We’ve been digging into the CMS waivers updates and new policies to prepare our partners for the Patient Driven Payment Model (PDPM) and its components. This time, we are focusing on the Interrupted Stay Policy and the main adjustments you need to understand to ensure that it fits into your long-term care workflow.
What is the Interrupted Stay Policy?
The Interrupted Stay Policy is a part of the Patient Driven Payment Model as another CMS proposition to streamline facilities’ workflows and benefit residents. The policy sets out criteria for determining when Medicare will treat multiple SNF stays occurring in a single Part A benefit period as a single “interrupted” stay, rather than separate stays.
How Does It Affect LTC Reimbursements with Medicare?
To be more precise, let’s list some examples of stays Medicare would consider as interrupted to process Long-Term Care Facilities’ reimbursements.
A stay is considered interrupted when
- A resident leaves the facility and returns to that same SNF no later than the third calendar day after they left.
- The resident remains in the facility but is no longer under Medicare A coverage, and their Medicare A coverage needs to resume within three days.
A stay is not interrupted if
- The resident leaves the facility and returns more than three days calendar days later.
- If a resident leaves a facility and is admitted to a different SNF. Even if they leave one SNF and are admitted to another the same day, a new 5-day assessment is required, and the variable per diem schedule must reset to Day 1.
Why did CMS decide to always treat admissions to a different SNF as a new stay and exclude such cases from the Interrupted Stay Policy?
Based on regression analyses, the CMS found that a readmission to a different SNF, regardless of whether it was a direct SNF-to-SNF transfer or the beneficiary was rehospitalized or discharged to the community before the second admission, is more comparable to a new stay than an interrupted stay, particularly in terms of the three payment components relevant to the variable per diem adjustments.
Why Did the CMS Include The Interrupted Stay Policy in PDPM Criteria?
The Centers for Medicare & Medicaid Services established the protocol for the purposes of the assessment schedule and the variable per diem payment schedule. The assessment schedule makes it easier for the nurses because they don’t have to do a brand new admission assessment when the resident comes back. And as long as the stay is considered “interrupted,” the variable per diem does not stop. It starts its count over.
Bringing the resident back into the facility after a shorter than three days stay interruption doesn’t mean that much work for the facility. Now the long-term care industry is adapting to it because of the way that changes were made when PDPM came along.
What Is the VPD or Variable Per Diem?
The Variable Per Diem or VPD adjusts per diem rates over the course of a patient’s stay. The Skilled Nursing Facility Prospective Payment System (SNF PPS) is required to pay on a “per diem” basis. There is a payment rate associated with each day of the patient’s SNF stay. Since its inception, the SNF PPS has used a constant per diem rate, meaning that the payment rate for each day of the stay is the same, as long as the patient stays in the same payment group.
How Is the VPD Affected by PDPM?
Under PDPM, an adjustment is applied to certain PDPM components that vary the per diem payment throughout the stay.
NTAs (Non-Therapy Ancillaries)
The VPD (Variable Per Diem) seeks higher reimbursements for the first three days a resident is in the facility for the NTA (Non-Therapy Ancillaries).
PT (Physical Therapy) and OT (Occupational Therapy)
Additionally, the PT and OT reimbursements decrease by 2% starting on day 21 and decrease an additional 2% every seven days. With an Interrupted Stay, the VPD does not start the countdown over. With separate stays, the VPD would start over.
SNF PPS Assessments Under PDPM
There are three SNF PPS assessments under PDPM:
- The 5-day Assessment
- The PPS Discharge Assessment
- The Interim Payment Assessment (IPA)
Unlike the 5-day assessment and the PPS Discharge Assessment, the IPA is optional. It will be completed when the patient has undergone a clinical change that would require a new PPS assessment. The difference under PDPM is that an Interrupted Stay does not require a new admission assessment when the resident returns to the facility.
What Is the “Interruption Window” and How Is It Defined?
The interruption window is the maximum period of time that may elapse between discharge from an SNF and a subsequent readmission to the same SNF before the Interrupted Stay Policy no longer applies, and the subsequent stay is considered a new stay. CMS has defined this interruption window as three days or less.
Updating MDS Coordinators on PDPM
We have talked in previous interviews about what changes the long-term care industry is experiencing with the implementation of PDPM, but we will do a quick memorandum to have you on track while learning about its components.
What is PDPM?
The Patient Driven Payment Model (PDPM) is a new case-mix classification system for classifying skilled nursing facility (SNF) patients in a Medicare Part A covered stay into payment groups under the SNF Prospective Payment System. Beginning October 1, 2019, PDPM replaced the previous case-mix classification system, the Resource Utilization Group, Version IV (RUG-IV).
Why Did CMS Change From RUG-IV to PDPM?
The RUG-IV classified residents into therapy payment groups based on the volume of therapy services provided as the basis for payment classification. This created an incentive for SNF providers to furnish therapy to SNF residents regardless of the resident’s unique characteristics, goals, or needs.
PDPM eliminated this incentive and improves SNF payments’ overall accuracy and appropriateness by classifying residents into payment groups based on specific, data-driven resident characteristics while simultaneously reducing the administrative burden on SNF providers.
Hi, my name is Peter Lewis. I’m the director of marketing at Experience Care. Today I’m excited to interview our financial product manager, Sue Friesth. She’s been in long-term care since the 1980s/1990s. And worked in client services implementation and now in the financial area. Insiders call her the PDPM kind of sewer. Today, we’ll call her. Super excited to have you back to explore today’s interesting topic: PDMP and the Interrupted Stay. Let’s start with something that might seem simple, but let’s frame the conversation with what is the Interrupted Stay soon.
I don’t know if anybody would call it interesting. But the Interrupted Stay, if a resident leaves the facility while they’re in a PDPM coverage, an Interrupted Stay would mean that they left for less than three days. So it’s kind of it’s not a new state when they come back. It’s an interrupted, current PDPM stay.
Got you. And so, I asked you ahead of time why this is important. And you replied: Well, if the stay’s interrupted, then the variable per diem and the assessment schedule are not affected. Can you break this down a little bit for us? Just imagine that I’m a nurse on day one of training. What does interrupted mean? What is the variable per diem? Was it important, and why is affecting the assessment schedule matter? And then we’ll dive in deep a little later.
Okay. It would be interrupted, like I said, if they left the facility and came back in within three days. And the reason why Medicare came up with the policy is that there’s a variable per diem. And if it’s an Interrupted Stay, then that variable per diem does not stop, start its count over. And as far as the assessment schedule, it makes it a little easier on the nurses, they don’t have to do a brand new admission assessment when the resident comes back in isn’t interrupted today.
Got you. And I asked you to send over some documentation that our readers and watchers would have handy. And you track down some documents that I just want to share. And I’ll let everyone know that these will be available inside of the blog. And some of the documents you send over that you use to prepare for this are Interrupted Stay Factsheet, the Administrative Level of Care Presumption, PDPM payments for SNF’s patients with HIV/AIDS, Concurrent Group Therapy, Interrupted State Policy, MDS changes. So we’ll get to those in a little bit. But Sue, thank you for these documents and for organizing them. Now let’s dive into the topic a little bit more. When is a stay interrupted? And feel free to go into the nitty-gritty,
Okay. A stay is considered interrupted, like I said, if the resident leaves the facility for some reason. They may go home, they may go to the hospital. If they leave the facility and return to that same SNF facility within three days, no later than the third calendar day after they left, then that’s considered an Interrupted Stay. Another possible reason for an Interrupted Stay: The resident remains in the facility but they’re moved to a lower level of care. But within those three calendar days, they need to go back to skilled Medicare coverage. So, that would not be an Interrupted Stay. If the resident leaves the facility and returns more than three days later to that same SNF, that is not considered an Interrupted Stay. Additionally, if the resident leaves a facility and is admitted to another SNF, even if it’s the exact same day, that new stay at the new SNF is not considered an Interrupted Stay.
Is the three days arbitrary? Do you know where that comes from?
I’ve heard that it comes from the fact that if it’s less than three days, there’s not as much work that the facility has to do in order to bring the resident back into the facility. The acute care hospitals, rehab facilities, all have this same sort of three days Interrupted State Policy. So long-term care is now adapting to it because of the way that changes were made when PDPM came along.
Well, that leads me I guess to the next question, why did Medicare create this policy for PDPM.
So, previous to PDPM, we were paid on RUG scores. And it was just, you got paid the same every day for whatever RUG that resident was at. When PDPM came along, we now have a variable rate per day. So that’s why the three-day hospital stay, they had to determine some way, when would that day count start over?
And I know that you did an in-depth interview with our CEO, Jason Long about the change from RUG to PDPM. But could you refresh our memory, especially for those of us who might not have seen that interview? Why they moved from RUG to PDPM.
Yeah. They moved from RUG to PDPM. Which PDPM stands for Patient Driven Payment Model. So they wanted to focus more on the residents. Total condition, rather than RUG, really focused a lot on whether or not the residents were getting therapy and how much therapy they were receiving. PDPM now looks at more of the resident, it still looks at the therapy piece, but it looks at more of the other needs of the residents.
So I guess, let’s dive into the variable per diem. What is it and can you tease it out a little bit?
The variable per diem or VPD, as some sometimes referred to, gives a higher reimbursement. So for the first three days that the resident is in the facility. And it gives it a higher percentage on the non-therapy ancillary component of the whole PDPM score. So there are five, five components to the PDPM score. The non-therapy ancillary is the one, those are like the medications, things like that, it takes a little more of the nursing staff, time and effort those first three days to get a resident in the facility and settled. So they get paid, it’s actually three times more for that particular piece of the rate than on the fourth day and go back to just the normal rate for that piece. The other part of the variable per diem, the physical therapy components, and the occupational therapy components. On day 21 of the whole variable per diem day count, the therapies will start to decrease by 2%, their pieces of the rate will start to decrease by 2%. And that will continue to decrease every seven days by 2% until the resident either exhaust their days, or they leave the facility. So with an Interrupted Stay, the VPD does not start over. So if they’re out of the facility for two days and come back in, they don’t get that three times higher rate, the first three days, it just starts up from the day that they left. So if they left on day 20, they were gone three days, or two days, I guess. And then when they come back in the count itself starts on day 21, because it left off at 20. It now starts up again on the day 21 schedule. And if it’s not an Interrupted Stay, Then, when the resident comes back in, that whole day count starts over again. So the first three days there and they get the higher rate for the non-therapy ancillary.
So, I love how you bring it down. And even someone who works in marketing is able to understand this, but there has to be some confusion, I’m guessing when customers and facilities are going through the CMS regulatory updates, not all of this is so straightforward. Where would you say that facilities are getting confused or need the most amount of help or should pay the most amount of attention to make sure they’re, you know, they’re getting their reimbursements the best, the fullest potential? Right?
They probably, the most confusing part is that whole three-day thing, um, you know? Because prior to PDPM and this Interrupted Stay, when we had RUGs, if the resident left the facility for more than 24 hours, it was a whole new state. When they came back in they had to do all the assessments again. You know? It kind of all started over. So that’s a little bit of the confusing part because now we have this three-day piece. And so it’s, facilities just need to remember that if it’s three days, they don’t have to redo the Medicare assessment, you know? And their payments will not start over at the higher rate for those few days.
And I think we might have briefly touched upon this at the beginning. But you, you said that we should talk about the assessment schedule, can you kind of spell that out? And what is it under the PDPM?
Yeah, with RUG’s, there was a number of assessments, there is a five day, a 14 day, 30 days, 60 days. There were all these assessments that had to be done on a certain schedule. With PDPM, they’ve made that a lot easier on the facilities. Because there are just two that are required. An admission assessment needs to be done when the resident first comes in, under PDPM. And then, a discharge assessment when they actually leave or drop there, go to a lower level of care within the facility, they have to do a discharge assessment. There’s another type of assessment in PDPM. It’s called the interim payment assessment. I always call it an IPA. So it can be done if the residents’ condition changes while they’re in the facility. And so they can do this additional assessment to you know? Reevaluate, and maybe get a higher score, which means more reimbursement for the restroom for the facilities.
What would they define as a change in condition? Can you think of an example?
Um, well, if the residents in the facility, because they have a hip replaced, and maybe now they’ve contracted, you know? Pneumonia, or something like that. So the care has to really change. So we need to reassess the resident to see what’s the most important understand. And the Interrupted Stay, like I said, if it is an Interrupted Stay, you do not need to do another admission assessment. So it gives a little break to the MDS coordinators that you don’t have to redo one every time some resident comes back in from, you know? The hospital for a day or so, it saves them that time.
Great, this is a good overview. Is there anything that I didn’t ask or any extra points that you would like to include that you think that’d be helpful for facilities?
Yes. The important piece of the Interrupted Stay is that for the bill, the bill, billing would cover the whole period, whether most facilities will bill on a monthly basis. So if you have a resident who left for two days in the middle of the month, that Medicare bill would cover the entire month, but it would show that two days were not covered. It would just make that ah put those codes on there. And that said that the two days are not covered.
They’re very clear. I’m far from being a PDPM kind of sewer. But now I know why the inside is inside. Experience Care calling you that Sue. Thanks, service is detailed, helpful, actionable, full of easy to understand answers. Thank you for your time. Thank you for your passion and thanks for your hard work. Talk to you soon.