Targeted Probe and Educate Review On-Demand Workshop-Patient-Driven Payment Model (PDPM): At-a-Glance

Patient-Driven Payment Model (PDPM): At-a-Glance

Pdf Summary

The January 2024 AAPACN update provides an overview of the Patient-Driven Payment Model (PDPM) for SNF (Skilled Nursing Facility) payment under Medicare Part A. PDPM determines a resident’s total Medicare reimbursement rate based on a 5-Day PPS assessment, incorporating five case-mix components—Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Nursing, and Non-Therapy Ancillary (NTA)—plus a non-case-mix component. Optional Interim Payment Assessments (IPA) may be completed to update the payment rate during a stay.<br /><br />Key components include:<br /><br />1. PT and OT: These share the same case-mix group determined by the resident's functional status via Section GG scores (ranging from independent to dependent on tasks such as eating, toileting, transfers, walking). Different case-mix indices apply to PT and OT, affecting payments.<br /><br />2. SLP: Case-mix groups for SLP are based on presence of acute neurologic conditions, SLP-related comorbidities (e.g., aphasia, stroke, tracheostomy), cognitive impairment, swallowing disorders, and diet modifications. Higher severity yields higher case-mix indices and payment levels.<br /><br />3. Nursing: The nursing component considers a function score derived from selected Section GG items and various clinical conditions such as pressure ulcers, feeding tubes, IV therapies, respiratory treatments, and cognitive/behavioral symptoms. Residents with higher function scores (15-16) or specific conditions qualify for the Clinically Complex group, which impacts payment multipliers.<br /><br />4. Non-Therapy Ancillary (NTA): This component scores based on presence of extensive services and comorbidities such as parenteral feeding, ventilator use, infections, transplants, and multiple chronic conditions. Points are assigned to conditions with cumulative scoring determining the NTA case-mix group and payment index.<br /><br />The PDPM HIPPS code encompasses case-mix group identifiers for PT/OT, SLP, Nursing, NTA, and the assessment type. These detailed scoring systems and clinical criteria, reflecting CMS FY 2024 updates, guide accurate case-mix classification and Medicare reimbursement in skilled nursing facilities. This summary serves as an educational tool and does not constitute legal or regulatory advice.

Keywords

Patient-Driven Payment Model

PDPM

Skilled Nursing Facility

SNF

Medicare Part A

5-Day PPS assessment

Case-mix components

Physical Therapy

Occupational Therapy

Speech-Language Pathology