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:

Significance of Cognitive Function Under PDPM SNFs have been using the BIMS interview since the implementation of MDS 3.0, however, it generally hasn’t played a key role in impacting reimbursement for Medicare A residents - unless the resident was skilled in a Nursing category of impaired Cognitive Performance. Under PDPM, the BIMS or Cognitive Performance Scale will be used to determine payment under the ST component. This gives reason for a facility to evaluate their current process and policy for the completion of the BIMS interview. 

On 4/11/19 CMS updated their PDPM Frequently Asked Questions (FAQ) document 5.4 by adding ‘If neither the BIMS nor the staff assessment is completed, then the patient will not be classified under PDPM and a PDPM HIPPS code will not be produced for this assessment.' 


Section GG: Self-Care & Mobility Items Impacting Reimbursement Under PDPM:

The ADL score that has historically been captured in section G of the MDS is going to no longer be used under PDPM. Instead, CMS will utilize section GG: Self-Care and Mobility items to determine two separate function scores: a score for the Nursing component and a score for the PT and OT components of PDPM.  The GG items that will determine these function scores include: ​


Learn more about Section GG under PDPM by clicking here.


Diagnosis Coding Under PDPM: Diagnosis coding under PDPM is one of the most significant area of impact which will require accurate, timely and comprehensive coding.  The diagnosis entered in I0020B will determine the Clinical Category of a resident under PDPM and will play a significant role in determining reimbursement of the PT, OT and ST components.  Additionally, diagnosis codes entered in section I: Active Diagnoses, will impact Nursing components, ST co-morbidities, and the NTA component of PDPM. For additional information on diagnosis coding, access the Quick Reference Guides here.


Section K & PDPM: Under PDPM, payment will be increased if a resident is noted to have signs and symptoms of a swallowing disorder, and if given the nutritional approach of a mechanically altered diet during the 7-day look back period of the MDS. Education and training will be essential to Nursing and the IDT members to monitor for these symptoms of possible swallowing disorders and to ensure documentation is accurate.   Learn more about Section K & PDPM by clicking here.

Steps to Take Now: Ensure your staff are trained and prepared for PDPM. While it is intended to be budget neutral, there will ultimately be winners and losers.  The key will be being prepared and knowledgeable about the reimbursement changes coming with the MDS assessment and documentation requirements for coding the MDS.  Follow the link below to access our 6-month implementation timeline which will help guide your efforts in preparing for PDPM.



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