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The Patient-Driven Payment Model (PDPM) was introduced by the CMS on October 1, 2019 as a way of improving how Skilled Nursing Facilities (SNFs) are reimbursed for services provided under Medicare Part A. With that change, PDPM training has become essential for long term care staff. 

PDPM marks a departure from the previous reimbursement model (RUG-IV), which was based on the number of therapy minutes a patient received. PDPM, meanwhile, asks caregivers to care for resident’s individual care needs instead of just the volume of services provided. 

Under PDPM, MDS nurses will assess each resident’s unique needs and then develop an appropriate care plan using their care plan software. And it only goes to follow that nurses who have undergone a PDPM training program are better equipped to understand and implement this new payment model.

Several institutions currently offer PDPM training programs for nurses, such as:

MDS nurse undergoing PDPM training.
There are several institutions such as AHCA and AAPACN that offer PDPM training programs.

The above PDPM training programs can help nurses and long term care administrators be better equipped to understand and implement the new PDPM payment model, which will ultimately lead to improved care for nursing home residents.

For those facilities looking to save on costs with free PDPM training and tips, Experience Care offers PDPM cheat sheets, a breakdown of the interrupted stay policy, PDPM FAQs, and most importantly, a PDPM Maximizer that ensures facilities will never miss reimbursement. 

The PDPM Maximizer automatically reviews PDFs of paperwork submitted by hospitals and identifies patterns to suggest diagnoses to the MDS coordinator. The MDS coordinator can then request that a physician review those items and potentially add a diagnosis to a patient’s chart, ensuring the nursing home will be sufficiently reimbursed. You can expect to see the release of Experience Care’s PDPM Maximizer later this year. 

PDPM Clinical Category Mapping

PDPM clinical category mapping is an essential part of PDPM training that should not be overlooked by MDS nurses. There are five case-mix components in PDPM, which are combined with the non-case-mix component. Together, these components determine an appropriate rate for a resident’s stay in a facility.

Each resident must be classified into one category for each of the five case-mix, adjusted components under PDPM. These five case-mix adjusted components are:

Nurse providing physical therapy to a SNF resident.
Each SNF resident must be classified into one category for each of the five case-mix, adjusted components under PDPM.
  1. Physical Therapy (PT): These are ICD-10-CM codes that include but are not limited to describing impairments in body movement and control, such as gait and balance disorders.
  2. Occupational Therapy (OT): These ICD-10-CM codes describe impairments in activities of daily living, such as dressing and grooming.
  3. Speech-Language Pathology (SLP): These are ICD-10-CM codes that describe impairments in communication, such as aphasia.
  4. Non-Therapy Ancillary (NTA): These ICD-10-CM codes describe ancillary services required for patient care, such as social work services.
  5. Nursing component: These ICD-10-CM codes include, but are not limited to codes that describe nursing diagnoses, such as pressure ulcers.

The case-mix index (CMI) is a measure used by the CMS to determine SNF reimbursement rates for care services provided to residents. The CMI is an aggregate value assigned to each resident in a long term care facility, and that in turn determines how much resources are allocated to the resident in the nursing home.

The non-case mix component includes services that do not change regardless of the clinical characteristics of the resident—services like laundry. MDS nurses with PDPM training will easily be able to distinguish between non-case mix and case-mix index (CMI) adjusted components.

The per diem rate, meanwhile, is the amount of money a nursing home receives from Medicare for each day a patient stays in the facility. The PDPM per diem rates are determined by the five case-mix adjusted components and the non-case mix component.

Understanding how PDPM clinical category mapping works is essential for nurses and long term care administrators, as it will impact how much reimbursement a skilled nursing facility receives for the care given to its residents. PDPM training can help nurses and long term care administrators better understand PDPM clinical categories, how they affect reimbursements, and how they can make better use of their nursing home software to maximize reimbursement.

Contact us here if you would like to test drive our user-friendly long term care software.

The Problem With PDPM Rate Calculator Excel Sheets

There are currently a lot of websites that provide downloadable PDPM rate calculator excel sheets. These sheets are a helpful tool for PDPM clinical category mapping, particularly for MDS nurses who have just completed their PDPM training. However, a PDPM cheat sheet presents the same problems that long term care nurses face when they employ the use of paper records instead of a long term care EHR.

Some associated problems with using PDPM rate calculator Excel sheets include:

MDS nurse filling in PDPM rate calculator excel sheets.
PDPM cheat sheets present the same problems that long term care nurses face when they employ the use of paper records.
  • The process is time-consuming: An MDS nurse has to fill in all the cells on the PDPM rate calculator sheet manually, which can take up a lot of time, especially with tens of residents.
  • It can be costly for the nursing home: Manual data entry can easily result in inaccurate or missed data entries, resulting in a nursing home receiving less reimbursement than it should. This can have a significant impact on the bottom line of the facility.
  • Security and resident privacy can be compromised: PDPM rate calculator Excel sheets often contain resident-identifiable information, which means they must be securely stored to maintain resident privacy. If the sheets are not fully secure, there is a potential risk that unauthorized individuals could access them, leading to potential HIPAA violations.
  • Changes may be hard to make: Once a PDPM rate calculator Excel sheet has been completed, it can be difficult to make changes if new information needs to be entered. This can result in nurses having to start from scratch, which can further add to the time-consuming nature of the task.

As a way of making the PDPM clinical category mapping process easier, Experience Care has developed a PDPM Maximizer tool. This software makes assigning PDPM clinical categories faster, easier, and more accurate for MDS nurses.

Typically, when an MDS coordinator receives a transfer patient from a hospital, they will also receive the patient’s medical information, which they manually enter into their EHR. They are responsible for reading through the documentation and suggesting possible missed diagnoses, a process that can take hours.

With Experience Care’s PDPM maximizer, MDS coordinators and nurses don’t have to check for resident diagnoses manually. They can simply upload the patient document into the PDPM Maximizer software and let the software scan for keywords using its AI database.

Any keywords found in the document will be matched with the related diagnosis, which the patient’s doctor can then review for final approval in the long term care EHR. This is a simple and quick process that can take as little as 30 minutes per patient.

Not only does Experience Care’s PDPM Maximizer save time, but it also prevents missed diagnoses in documentation, which can potentially increase reimbursements by thousands of dollars per patient. Facilities looking to increase their reimbursements should consider using this tool in their operations. Expect to see this revolutionary technology available in the coming months. 

PDPM Training and Why It Matters

PDPM represents a significant change to the way long term care facilities are reimbursed. Therefore, it is important for administrators and MDS coordinators to receive adequate PDPM training, enabling them to understand the intricacies of PDPM to ensure maximum reimbursement.

One way of making the PDPM clinical category mapping process easier is by using the PDPM Maximizer software by Experience Care, a user-friendly tool that can make assigning PDPM clinical categories faster, easier, and more accurate for MDS nurses. By preventing missed diagnoses in documentation, it can potentially increase reimbursements by thousands of dollars per patient.

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