Preparing for PDPM Scenarios

SNFs around the country are preparing for PDPM by receiving training, reading articles, talking to colleagues, and working with consultants, MDS trainers & more. After attending the Zimmet Healthcare Services Group conference earlier in August, I can attest to the degree of enthusiasm around PDPM that savvy SNF providers are feeling. I do think it makes sense to prepare for potential OUTCOMES of the transition.  No, I’m not referring to patient outcomes. In this article we will talk about the potential financial outcomes.

1. What happens if Medicare reimbursement under PDPM is higher than under RUG reimbursement?

I wouldn’t be surprised if that happens.  While CMS has been saying that PDPM will be budget neutral, there is more money in the system because the industry received a 2.4% rate increase for Fiscal Year 2020. SNFs could experience inflated reimbursements in FY 2020 similar to when MDS 3.0 was launched in FY 2011.  I’d recommend reserving some of the funds in preparation for a potential Medicare rate “adjustment” in FY 2021.  At the same time, drill down on the accuracy of reimbursement in each of the 5 individual PDPM components (PT, OT, Nursing, SLP, and Non-Therapy Ancillary).  Since each of the 5 components produce its own score, it is imperative that they are all accurate and optimal.

2. What happens if reimbursement is lower than expected?

In this scenario, I recommend beginning with your process for capturing ICD-10 codes aside from the patient’s primary diagnosis.  Next, look at your process and accuracy of coding Section GG.  Then, look at your marginon each of the PDPM components. In the PT & OT Category, there is very little reimbursement variation from top to bottom.  However, there is a great deal of variation in the SLP Component ($15.86 - $92.81ppd). Getting the SLP component 100% right with supportive speech documentationshould be very fruitful.

3. Is there enough data to come to any conclusions?

Maybe not, but there’s no sense in waiting.  We live in a data-centric society and the MDS itself provides a wealth of data to CMS. If a SNF submits 50 Medicare Part A claims worth $10,000 each, even a small margin of error will add up quickly. Start auditing the individual PDPM components right away.

Have any questions, or need a helping hand especially on the PDPM Speech-Language Pathology component? We are glad to help.

PDPMMatthew McGarveyComment