PDPM overview
Consists of 5 case-mix adjusted components
PT, OT, SLP, NTA, Nursing, and Non-Case Mix
What is the Patient Driven Payment Model?
PT/OT Component:
The 2 criteria that determines which case mix groups the resident will classify into for the PT/OT component.
What is primary clinical category and function score?
Considered the facility PDPM leader.
Who is the MDS Director?
A score compiled from assessment of ADL activities based on usual performance of the resident their first 3 days of the skilled admission to help determine payment category for PT, OT, and Nursing.
What is the function score (or GG score)?
MDS item: I0020B.
What is the SNF primary diagnosis coding question on the MDS?
This ICD-10 code determines the primary clinical category for the PT/OT components.
Oct 1, 2019
When does PDPM replace RUGSIV for Medicare A payers in PPS?
ST Component:
The 3 Tier 1 items used to classify the ST case mix groups in the ST component.
What is:
1. Acute Neurologic primary clinical diagnosis category
2. Cognitive Impairment
3. SLP comorbidities?
Completes functional ability assessments (section GG assessments) on residents.
Who are therapists and Nurses.
Therapists will complete for residents on rehab caseload and MDS nurses will complete for residents skilled for nursing.
Floor nurses will continue to do a functional ability assessment at admission and discharge to help cover weekend admissions/discharges.
Scored as "0" points in the function score calculation.
What is dependent?
Resident returns to SNF after a 2 day leave to daughter's house over the weekend and no new MDS is started upon return.
What is an example of the interrupted stay policy?
(3 midnight's is the rule)
Tripled for days 1-3 and then pays at the normal rate for the rest of the stay.
What is the NTA component?
A CNA reports observation of a resident dribbling coffee from mouth at breakfast this morning.
What is an example of a swallowing disorder (contributes toward ST component category if captured)?
As of Oct 1, leads and oversees the restorative nursing program.
Who is the DON
This "performance" of the resident is based on Direct Observation, resident self-report, qualified staff report, and/or qualified clinician documentation in the medical record during the assessment period.
What is the resident's usual performance coded on the functional ability assessment?
IDT discusses a residents changed medical and functional capacity due to new diagnosis and determines this optional assessment will be completed.
What is an IPA?
Interim Payment Assessment
New GG required.
Full component rate is received days 1-20 for these 2 components and then both of these components decrease by 2% every 7 days.
What is the Variable Rate Adjustment for the PT/OT components.
Used as an end split for Behavior and Reduced physical functioning Nursing Component case mix groups.
What is Restorative Nursing services?
(Must begin by day 3 to capture restorative services if using day 8 as ARD).
PPS meeting attendance to report on resident diagnoses, conditions, concerns, swallowing impairments, cognitive score, function score, etc. to predetermine component categories.
Who are the IDT to include: MDS, Unit manager, rehab director, social services, dietary, activities.
The calculated total score for Eating, Oral Hygiene, Toileting Hygiene, 2 bed mobility items, 3 transfer items, 2 walking items used 2 components in PDPM.
What are the section "GG" assessment items used in compilation of the function score for PT/OT?
Resident loves to attend groups in therapy and is monitored by the rehab director to comply with this new rule.
What is the concurrent/group therapy cap of 25%?
The Initial Medicare Assessment (5 day PPS assessment) and the Discharge Assessment.
What are the 2 types of mandatory MDS assessments that will be required under PDPM?
Ventilator or Respirator, post admission
Wound Infection Code (4 points)
Active DX: Diabetes Mellitus (2 points)
Active DX: Asthma, COPD, Chronic Lung Disease code (2 Points)
What are examples of NTA conditions with point values totaled into a NTA case mix group?
(6 groups: 0, 1-2, 3-5, 6-8, 9-11, and 12+)
Ensures receipt of hospital records and timely upload of information into the medical record for team review.
Who is the Admissions Director?
Oral Hygiene and Walking assessment items not used in the calculation of this PDPM component.
What are functional areas that are not included in calculation of the Nursing Function Score.
These 2 different restorative programs being performed and documented are actually just considered 1 restorative program when coded on the MDS.
What are:
1. Bed mobility and gait training
2. Active and Passive ROM
3. Scheduled toileting and bladder retraining
Only 1 pair required to earn the points