The Centers for Medicaid Services (CMS) updated their online PDPM resources to align with July’s Final Rule. Here is a summary of these important updates.
The ICD-10 mapping tool has been updated, including the maps for clinical category placement into OT, PT, and SLP, as well as the comorbidity maps for NTA and SLP.
Within these maps, CMS added a significant number of codes. The clinical category map has increased to 72,184 codes including 34,872 RTP codes. The NTA comorbidity map now contains 1,806 codes, an increase of 271 codes.
PDPM fact sheets
CMS updated five of the nine PDPM fact sheets.
Concurrent and Group Limit Fact Sheet – The definition of group therapy has been updated to reflect the definition that was finalized in the Final Rule: “Group therapy is defined for Part A as the treatment of 2-6 residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals.”
Functional and Cognitive Scoring Fact Sheet – The necessity of a BIMS score to the SLP category calculation has been revised to indicate: “In cases where neither the BIMS nor the staff assessment is completed, the patient will be considered ‘cognitively intact’ for classification purposes under PDPM.”
Interrupted Stay Fact Sheet – The definition of the interruption window has been revised relative to the new Interrupted Stay Policy: “The interruption window is a 3-day period that begins on the first non-covered day following a Part A-covered SNF stay and ends at 11:59 p.m. on the third consecutive non-covered day. It should be noted that the first non-covered day may be different depending on if the patient leaves the facility or simply leaves Part A coverage.”
MDS Changes Fact Sheet – The use of the optional state assessment has been clarified and the time limitation on the use of the OSA has been removed: “Second, for states that rely on the RUG-III or RUG-IV assessment schedules for calculating case mix group for NF patients, CMS has created the optional state assessment (OSA) so that Medicaid payments are not adversely impacted when PDPM is implemented as of October 1, 2019. States will have the ability to determine the policy associated with this assessment to meet your Medicaid payment needs.”
PDPM Patient Classification Fact Sheet: The PDPM classification group tables have been updated to reflect the revised case mix weights that were published in the Final Rule.
CMS updated and added more questions and answers to their PDPM Q&A document.
Q 1.5: CMS clarified which assessments will be used for Part A billing. “How do providers bill for services under PDPM? Providers would bill for services under PDPM using the Health Insurance Prospective Payment System (HIPPS) code that is generated from a 5-day PPS assessment and Interim Payment Assessment (IPA) with an ARD on or after October 1, 2019.”
NEW Q 1.9: “Is it required that the SNF primary diagnosis match the primary diagnosis reported for the qualifying hospital stay? No, the primary diagnosis for the SNF stay may differ from the primary diagnosis reported for the hospital stay that serves as the qualifying hospital stay necessary for SNF coverage.”
Q 5.4 has been revised to reflect a crucial update as to how the BIMS score will impact the SLP classification. “How is the patient classified under PDPM if neither the BIMS nor the CPS staff assessment is completed to determine cognitive level? If neither the BIMS nor the staff assessment is completed, then a patient will be classified under PDPM as if the patient were ‘cognitively intact.’ In other words, even if the patient has a cognitive impairment, without the BIMS or staff assessment completed, the cognitive impairment will not be considered as part of the patient’s PDPM classification. An IPA may be done to reclassify the patient in such scenarios to capture the cognitive impairment.”
Q 11.2 has been corrected to appropriately refer to MDS item I0020B.
Q 12.10 has been revised to clarify the concept that while an EOT is not necessary under PDPM, a daily skilled care requirement is. “If there is a three-day break in therapy, will an EOT be required under PDPM? Under PDPM, there are not a required number of days of treatment per week in order to receive a certain therapy component classification (thus no EOT will be required); however, there is still a daily skilled care requirement for SNF Part A patients, as discussed in Chapter 8 of the Medicare Benefit Policy Manual, specifically section 30.6.
Q 13.3 “When is a stay considered ‘interrupted’ under the Interrupted Stay Policy?” The answer to this question has been revised to include reference to the revised definition of the interruption window that can be found in the Interrupted Stay Fact sheet.
Q 13.7 “What is the “interruption window?” The answer to this question has been revised to include an expanded definition of the interrupted stay that is found in the Interrupted Stay Fact Sheet. Old Q 13.9, which contained the previous definition of the interrupted window, has been removed. Q 13.10, 13.13 and 13.16 have been edited to remove portions of the old interruption window definition. The revised expanded definition is: “…beginning on the first non-covered day following a covered SNF Part-A stay and ends at 11:59 p.m. on the third consecutive non-covered day. It should be noted that the first non-covered day may be different depending on if the patient leaves the facility (facility discharge) or merely is discharged from Part A but continues in the facility under a different payer (Part-A discharge).”
NEW Q 14.15 has been added: “I have questions about the OSA. To whom should I direct these questions? Any questions regarding the OSA should be directed to the relevant state agency governing the state’s Medicaid policy issues.”
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