AAPACN's PDPM Game Plan-AAPACN's PDPM Game Plan

AAPACN's PDPM Game Plan
Pdf Summary
The "PDPM Game Plan" by AAPACN (updated January 2026) is a comprehensive resource designed to assist skilled nursing facility (SNF) professionals—including Nurse Assessment Coordinators, Directors of Nursing, and consultants—with operating under the Medicare Patient-Driven Payment Model (PDPM). PDPM, implemented in October 2019, replaces the prior RUG-IV system by focusing payment on resident characteristics rather than therapy volume, encompassing five case-mix adjusted components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillary (NTA), plus a non-case-mix component.

Key features include:

1. <strong>PDPM Basics and Assessments</strong>: PDPM requires a 5-Day PPS Assessment within days 1-8 of a Medicare Part A SNF stay and a Part A PPS Discharge Assessment. An optional Interim Payment Assessment (IPA) may be completed to adjust payment rates during the stay. The variable per diem (VPD) schedule adjusts payment rates over time, reflecting higher costs early in the stay, particularly for NTA, PT, and OT.

2. <strong>Interrupted Stay Policy</strong>: To prevent financial incentives to discharge and readmit residents to reset payment schedules, PDPM introduces an interrupted stay policy. A stay is considered interrupted if a resident returns to the same SNF within three days of discharge, continuing previous assessment and VPD schedules without a new 5-Day assessment.

3. <strong>Case-Mix Grouping and HIPPS Codes</strong>: Residents are classified into case-mix groups for each component based on clinical and functional data, including ICD-10-CM diagnoses, Section GG functional scores, cognitive impairments, and certain medical conditions. These groups determine the HIPPS billing code used for Medicare reimbursement.

4. <strong>ICD-10-CM Coding</strong>: Accurate, specific, and physician-documented ICD-10-CM codes are essential for correct PDPM classification and billing. The guide emphasizes common coding errors and provides best practices for diagnosis determination, including the need for provider queries and consistent documentation.

5. <strong>Tools and Audits</strong>: The resource includes tools like admission checklists, pre-admission record requests, cognitive level determinations, PDPM calculators, and audit forms (e.g., triple-check pre-billing reviews and MDS reimbursement audits) to support compliance and optimize reimbursement.

6. <strong>Section GG Functional Scoring</strong>: Section GG assessments measure residents’ functional status across self-care and mobility tasks, directly impacting PT, OT, and nursing case-mix group assignments.

7. <strong>Payment Implications and Compliance</strong>: The document outlines how HIPPS codes are constructed, default billing policies for late or missed assessments, and the financial impact of accurate PDPM implementation.

8. <strong>Medicare Coverage and Skilled Services</strong>: It details Medicare Part A eligibility criteria, skilled nursing and therapy service definitions, and the conditions under which residents qualify for Medicare benefits.

Overall, the AAPACN PDPM Game Plan is an essential 2026 guide for SNF professionals to navigate PDPM's complex reimbursement framework, ensuring accurate classification, documentation, billing, and compliance to support facility financial health and resident care quality.
Keywords
PDPM Game Plan
Medicare Patient-Driven Payment Model
Skilled Nursing Facility
5-Day PPS Assessment
Interrupted Stay Policy
Case-Mix Grouping
HIPPS Codes
ICD-10-CM Coding
Section GG Functional Scoring
PDPM Compliance and Billing