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Medicare Part A reimbursement was significantly changed beginning October of 2019, when the new Patient Driven Payment Model or PDPM reimbursement structure forced caretakers to on the complexity of care provided patients and a holistic approach to care as opposed to just therapy minutes. The goal was to provide more individualized care for patients and make it easier for SNF providers to accurately track patient progress. One major key to getting fully reimbursed is properly conducting the initial patient assessment.

One key change that came from PDPM was in the requirements for Minimum Data Set (MDS) Assessment. Previously, under RUG-IV, facilities had to assess patients on or around days 5, 14, 30, 60, or 90, depending on the length of their stay. PDPM reimbursement, though, shrinks this sequence down to three assessments:

  • Initial Medicare Assessment (required) – This is the most critical assessment for ensuring accurate PDPM reimbursement rates.
  • Interim Payment Assessment or IPA (optional) – This only occurs when a resident experiences a clinical change.
  • PPS Discharge Assessment  (required)

The Significance of Initial Medicare Assessments

Initial Medicare assessments can make or break the financial health of a facility. If they do not depict a resident’s full range of health concerns – from previous surgeries to comorbidities – the facility may end up losing money. SNFs will have an easier time ensuring the initial Medicare assessment accuracy if they gather complete resident profiles during, not after, the pre-admission process. We recommend using an integrated referral portal, as this allows clinical liaisons to accurately represent a resident’s needs from the start.

The goals of an intial payment assessment are: 

  • Identify the care needs of the resident – Knowing the state of a senior from the start will allow a facility to better reflect upon the care they provided and the improvement made in the resident’s health. 
  • Maximize reimbursement – If something is missed in the initial assessment, the facility will lose the opportunity to get reimbursed for the first week or two of care provided. 
  • Communicate needs to therapists and other caretakers  – The admissions coordinator must share the necessary info (including the most recent documentation) in order to help the various systems in place be on the same page. 

Under PDPM, several of these categories were updated and adjusted to fit modern patient needs. Some of the changes include updated language, the removal of certain indications, and the addition of new coding categories. Although it may seem like less data will be gathered due to the reduced content of a PDPM assessment, the data gathered at each assessment will need to be more thorough. This might seem overwhelming at first, but these changes and adjustments will help providers better track patient data and care – ultimately yielding better clinical outcomes.

A nurse walking with a senior using a walker in order to determine initial payment assessment.
Medicare assessments will help facilities with reimbursement.

Some of the items of an MDS assessment under PDPM include:

  • Identification Information
  • Hearing, Speech, and Vision
  • Cognitive Patterns
  • Mood
  • Behavior
  • Preferences for Customary Routine and Activities
  • Functional Status
  • Functional Abilities and Goals
  • Bladder and Bowel
  • Active Diagnoses
  • Health Conditions
  • Swallowing/Nutritional Status
  • Oral/Dental Status
  • Skin Conditions
  • Medications
  • Special Treatments, Procedures and Programs
  • Restraints
  • Participation in Assessment and Goal Setting
  • Care Area Assessment (CAA) Summary
  • Correction Request
  • Assessment Administration

Making the Switch to a PDPM Assessment Schedule

While any abrupt change in care can be difficult for a direct care team, reviewing handouts, literature, and online resources provided by the Centers for Medicare and Medicaid Services (CMS) can help a team transition to PDPM smoothly – as can our PDPM resource center. Being aware of the most important changes to the assessment schedule, new coding options and categories, and adjustments to various sections of the MDS. 

When making an initial assessment, you will have to add the scores of various components: 
1. Physical therapy and occupational therapy – The functional score for these two components (PT and OT) is calculated as the sum of the ten scores of mobility, transfer, eating, toileting, oral hygiene, and walking. 

2. Speech language therapy (SLP) – This uses a number of patient characteristics that were predictive of increased SLP costs, like nuerological clinical classification, related cormobidities, cognitive impairment, mechanically-altered diets, and swallowing disorders.

3. Cognitive score – This is either taken from the BIMS score or the CPS score. 

4. Nursing component – This takes into account the use of things like a tracheostomy and ventialor, the need for infection isolation, or other serious medical conditions like comatose, septicemia, or respiratory therapy. 

5. NTA component – This is based on the presence of certain comorbidities (like drug resistance, immunity disorders, or liver diseases) or the use of certain extensive services. 

There is also a variable per diem adjustment based on the number of days in stay. 

An initial patient assessment will greatly affect reimbursement under PDPM.
An initial patient assessment can impact care long-term.

5 things to remember about the Initial  Patient Assessment Under PDPM

  1. It’s the first of three patient assessments, and it’s required. Timeliness and a thorough evaluation during the initial Medicare assessment will lead to better clinical care for your residents and appropriate reimbursement for Medicare Part A SNF stays.
  2. Several changes have been made to MDS sections. Review each section of the MDS, as changes have been made to sections A, D, GG, I, J, K, O V, X, and Z – and it’s possible that more changes are on the way prior to PDPM implementation.
  3. It helps to paint a complete picture, and Non-Therapy Ancillary Services can greatly impact reimbursement rates. The new MDS is a more comprehensive clinical assessment and includes factors that impact everyday life. Coordinators will now have to understand many aspects of their residents’ clinical needs to receive reimbursements. For example, NTA factors can significantly bolster payments, but only if your facility successfully captures all of them on the initial Medicare assessment. For the first three days of the resident’s reimbursable care episode, the variable per diem adjustment for NTA factors will run at 300%.
  4. The initial Medicare assessment now covers all applicable standard Medicare payment days. Unless an IPA is completed due to a clinical change, the initial Medicare Assessment will pay for all covered Part A days until discharge.
  5. Reviewing CMS resources ahead of time will help your team transition smoothly to PDPM. Webinars, presentations, and literature are all available to help ensure SNF are well prepared for the change in MDS coding and timing. Ensure your whole staff has time for training – from nurses and physicians to administrators and beyond.

For many Skilled Nursing Facilities, the next few months will be spent preparing for the switch from RUG-IV to PDPM. Adapting to modern technology is one way to make a facility run smoother and more efficiently – starting with Cantata’s Referral Portal during the pre-admission process. With a more complete resident profile and by paying close attention to the changes coming to the initial Medicare Assessment, SNFs can be sure that they receive proper reimbursement for patient care.