UNDER PDPM, WHAT AREAS OF THE MDS WILL IMPACT REIMBURSEMENT THAT DIDN'T BEFORE?

Updated: Jul 29, 2019


While the MDS form itself will not be changing significantly on October 1, 2019 with the implementation of PDPM, the methodology in how payment is calculated will be significantly different from what we know and practice today.  In our current RUGS-IV model, if a patient is receiving therapy services, only two areas are used to determine a resident’s RUG category: four questions from section G0110- Activities of Daily Living Assistance and section O0400-Therapies. 


​With the payment calculation changes of PDPM, there will now be a significant increase in the number of questions on the MDS that have the potential to impact reimbursement.  This brings a heightened awareness and significance to the accuracy of the MDS coding.  Greater attention and detail is required to ensure the MDS is coded accurately to ensure the facility will receive reimbursement for all of the conditions, complexities and care being provided [especially since the 5-day MDS with PDPM will set the payment rate for the entire stay; with the exception of when an optional IPA (Interim Payment Assessment) is completed].  


Scheduling Changes PDPM will continue to utilize MDS 3.0 as the basis for patient assessment and classification. The assessment schedule is more streamlined under PDPM with only 2 required assessments: 5-day scheduled PPS assessment and the PPS Part A Discharge Assessment.  The 5-day assessment will determine payment for all covered days until Part A Discharge, unless the provider chooses to complete a new assessment type, an IPA (Interim Payment Assessment). The IPA is an optional assessment and can be used to report a change in a patient PDPM classification.


MDS Sections That Impact Reimbursement Under PDPM The following list highlights key areas of the 10/1/19 MDS 3.0 form that will play a significant role by impacting reimbursement in PDPM. These include: