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In 2019, the Centers for Medicare and Medicaid Services (CMS) did away with the Resource Utilization Group-IV (RUG) classification model and replaced it with the Patient-Driven Payment Model (PDPM). That meant skilled nursing facilities had to learn a new method for calculating resident stays covered by Medicare Part A.

PDPM was designed with several goals in mind:

  • Improve reimbursement accuracy by focusing on appropriate patient treatment
  • Reduce the volume of unnecessary therapy services 
  • Reduce administrative duties for healthcare providers
  • Improve SNF payments without increasing Medicare payments
A new PDPM rate calculator tool that helps facilities to achieve accurate PDPM HIPPS scores while maximizing PDPM reimbursements.
PDPM rate calculator tools help to achieve accurate PDPM HIPPS scores while maximizing PDPM reimbursements.

One of the most significant changes after the move from RUG-IV to PDPM is that patients were no longer grouped into a single, volume-driven case-mix group. That removed the incentives for facilities to boost the number of therapy services unnecessarily to increase reimbursement payments. 

Instead, the PDPM system focuses on each patient’s needs and goals, making patient care the focal point. It asks caregivers to calculate payment by assessing clinical features, patient assessments, diagnoses, and resource needs. These factors form a cohesive care plan delivered to residents during their stay. 

Of course, the new model brought with it one major issue: calculating accurate PDPM reimbursements is no walk in the park. To help with this challenge, we developed the ultimate PDPM calculator that gives you an estimate of what you can expect when you do your formal MDS. This tool makes it far less likely that you will leave money on the table and takes just minutes to use.  

The Value of a HIPPS Code Calculator

Calculating HIPPS codes is tricky due to the variable outcomes. Furthermore, each letter is short-hand for a specific case mix-group and payment component. So it can be confusing to understand what each HIPPS code letter represents, especially for new nurses. A HIPPS code calculator makes this process far easier. 

An MDS nurse is spending quality time with a resident after using a HIPPS code calculator to determine the resident's PDPM HIPPS score.
A HIPPS code calculator makes it easier for MDS nurses to process PDPM HIPPS scores.

After an older adult is admitted into a long term care facility, an MDS nurse must determine the resident’s PDPM HIPPS score within three days of admission. This gives the facility an indication of what Medicare reimbursement they will receive while forming the basis of the resident’s personalized care plan. 

The MDS assessment, though, requires an average of four hours to complete. Additionally, there are many boxes to check, often by hand, which makes it easy for MDS nurses to forget or accidentally miss to check a box, leading to an incorrect diagnosis for a specific clinical condition. This affects the facility’s finances because these forgotten checked boxes will result in the facility being incorrectly reimbursed by Medicare. 

A PDPM calculator is a good way to get an idea of what you should expect in your official MDS assessment. By using such a resource, you will know if something is wrong in your MDS assessment, thus ensuring that you never leave money on the table. 

The CMS has created online training materials to aid the process of calculating PDPM rates. And some of the best long term care software vendors offer PDPM calculator cheat sheets that provide step-by-step guidance on calculating PDPM rates.

But perhaps most valuable resources are PDPM calculators that give you a projected HIPPS score before you do your MDS assessment. Experience Care, one of the most innovative nursing home management software vendors, has created an intuitive PDPM calculator tool with CMS data specifications in mind. Facilities can use this PDPM calculator to get HIPPS projections in just ten minutes. 

Contact us here to learn how our long term care software can help you calculate accurate PDPM reimbursements for your facility. 

The Features and Benefits of an Effective  PDPM Rate Calculator

PDPM rate calculator tools help you achieve accurate PDPM HIPPS scores while maximizing PDPM reimbursements. A PDPM-specific stay calculator tool should be able to determine the Day-Three admission HIPPS score, highlight essential areas for the facility to capture more diagnosis clarification points, and obtain the necessary documentation from other healthcare providers like hospitals. 

PDPM calculator tools that are to assist with reimbursements should offer the following features and benefits:

A physician is discussing PDPM payments with a patient's family by showing her how calculations are made with a PDPM calculator.
A PDPM calculator gives facilities an idea of what to expect when conducting their formal MDS.
  • Automated processes: The best PDPM calculator tools have built-in functions that calculate PDPM HIPPS scores once the questions have been answered. Afterward, the HIPPS code calculator will automatically cross-reference and determine the PDPM rate with precision and accuracy. 
  • Integrated into a single dashboard: Better conceptualized PDPM rate calculator tools allow users to create an account, which will save any previous scores. This will also allow users to log in and review all previous scores in a single dashboard, making comparing PDPM HIPPS scores for different residents easier. 
  • Improve workflow efficiency: An efficient PDPM calculator should require less than twenty clicks and less than ten minutes to complete. Any more time or clicks can become burdensome for the user, rendering the tool useless.  
  • Free Resource: Long term care facilities often have a tight budget, which is why PDPM calculator tools are often made accessible for free. While some paid HIPPS code calculator tools require membership fees, there are free options that accomplish the same thing.
  • Easy access to HIPPS codes: MDS nurses have a busy schedule, which means they will need to view and access a HIPPS code list quickly.
  • Easy to use: Even though it is primarily an MDS nurse’s responsibility to assess PDPM rates, there may be times when other staff need to determine PDPM scores. Therefore, any effective PDPM calculator should be usable by anyone, regardless if they are in the MDS department. 

The Cost Savings That Come With Using a PDPM Calculator 

Facilities need to calculate accurate PDPM scores because failure to do so will result in incorrect payments, impacting the facility’s finances. The long-winded MDS assessment process necessitates, by nature, that  PDPM errors will occur. Thankfully, innovative PDPM calculator tools minimize such human error. 

Facilities should take the time to educate their interdisciplinary team about PDPM rates and how to use a PDPM calculator. That way, if there are any discrepancies, the team will know how to monitor and identify them, making the MDS assessment and PDPM HIPPS process more efficient and effective across the team. 

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Cindy Wong
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