Skip to main content

4 smart ways to prepare for PDPM

The Patient-Driven Payment Model (PDPM) that goes into effect on October 1 is the largest financial change the industry has seen in 20 years.

The Centers for Medicare and Medicaid Services (CMS) changed the fee-for-service reimbursement model to a fee-for-performance model, also known as value-based care.

CMS objective with PDPM is to remove the financial incentive to provide routine therapy to patients regardless of their unique characteristics, goals or needs. Instead, PDPM classifies patients into payment groups based on specific, data-driven patient characteristics.

When the new structure goes into effect later this year, all skilled nursing facilities will be expected to comply immediately. How you fare during the transition depends on how well you plan ahead. Read on for four smart ways to prepare for PDPM.

1. Prioritize staff training

The implementation of PDPM will make it more important than ever to complete accurate and detailed Minimum Data Set (MDS) assessments. The initial diagnoses will set the bar for payments going forward and must be supported by clinical documentation each step of the way.

An application like ABILITY CAREWATCH® can help ensure accuracy by catching inconsistencies in your assessments before they are submitted. Providers can also analyze this data to improve care plans and locate reimbursement opportunities that may have been missed.

One such opportunity that PDPM incentivizes is accepting more medically complex patients, since reimbursement will be more closely aligned with their elevated care needs. Your staff must be equipped to deliver that level of care.

Expect that some staff training will be required prior to meeting the updated requirements for both the MDS assessments and the needs of patients requiring enhanced care.

2. Become or enlist an ICD-10 coding specialist

CMS FAQs note that ICD-10 codes will be used in two ways: First, providers will be required to report the patient’s primary diagnosis on the MDS. The diagnosis will be mapped to a clinical category and then further classified into therapy components.

Second, ICD-10 codes will be used to capture additional diagnoses and comorbidities of the patient, which factor into further classifying them into speech-language pathology and non-therapy ancillary components.

Many skilled nursing facilities don’t have certified coders on staff. Coding will be even more demanding under PDPM, and providers have a choice: either train key staff on the new requirements or consult with a certified coder.

3. Prepare to step down therapy use

One of the largest changes in the shift to PDPM is that reimbursements will no longer pay per therapy minute. Skilled nursing operators might consider renegotiating with their current therapy partners.

The new rules also limit group and concurrent therapies to no more than 25 percent. CMS considers this an important step to help ensure that patients receive the highest level of personalized care.

4. Don’t forget about your vendors

Skilled nursing facilities rely on many other service providers to run smoothly. Therapy providers, electronic health record vendors and others should be knowledgeable of the upcoming changes that PDPM will bring. Check in and make sure these providers are preparing diligently and sharing their progress and insights along the way.

One of the best ways to succeed under PDPM is to stay informed and prepare, so that when October comes, your facility can hit the ground running.

To ensure your team is prepared every step of the way, discover what our care quality management software can do.

Inovalon and design®, Inovalon® are trademarks of Inovalon, Inc.

About the author

Michelle Karl, Solution Architect