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Updated: Apr 25, 2019

In August CMS inked PDPM as the innovative new payment methodology for Medicare Part A. Since that time a flurry of information has been inundating our in boxes leaving some SNF providers scratching their heads over the correct strategic plan of action.  With just under ten months before the go-live date, one thing is certain: it’s time to start preparing!

Here are the Top 3 drivers for success and accurate reimbursement under PDPM:

ICD-10 Diagnostic Coding The diagnosis entered in the MDS section I0020B will determine the Clinical Category which is the major payment component under PDPM. MDS staff will need to be highly skilled to ensure the diagnosis entered maps to the proper clinical category or reimbursement could be adversely impacted. 

What to do now: Begin assessing current MDS competency and seek education for staff as neededReview current transition/admission process and develop efficient and interdisciplinary process for accurate codingBegin identifying the primary reason for the SNF stay ICD-10 code for all Medicare A patients now and determine which clinical category it maps to Download Concept Rehab’s ICD-10 Coding Simplified Cheat Sheet

Section GG Completion This section of the MDS was previously not used to drive reimbursement. Under PDPM it becomes a major player for accurate payment. The GG functional scoring varies from the therapy case mix groups to the nursing group so collaboration will be key.

What to do now:Understand how the assessment look-back period works for Section GGGather information from all sources prior to coding the MDSDevelop a process for identifying “usual function” that is collaborative in natureBegin using Section GG as if it impacted payment now

Length of Stay Practices PDPM begins to feel a little like managed care when variable per diem rates that decrease over the length of stay seem to incentivize a shorter stay. However, we must not lose sight of best patient care practices and excellent quality outcomes.

What to do now:

  • Determine your current average length of stay by payer type.

  • Understand that a 2% decrease in the variable rate over the course of a stay is less of a financial hit than an empty bed.

  • Evaluate risk for readmission with decreased length of stayImplement Care Pathways to manage length of stay while mitigating risk of readmission.

Analyze, develop, educate and understand the primary impacts of PDPM by tackling these 3 drivers and you will be on the road to a successful implementation.                  



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