On October 1 the Patient-Driven Payment Model (PDPM) became the Medicare Part A fee-for-service payment system for skilled nursing facilities (SNFs). Check out resources and information on

• a system bug identified late last week,
• how to handle Part A crossovers, and
• additional implementation support and tools AHCA is providing members.

PDPM replaces the Resource Utilization Group IV (RUG IV) payment system in its entirety with no transition period. If you have not done so already, now is the time to make sure your contracts are up-to-date and appropriate with all payers impacted by PDPM, including Medicaid, Medicare Advantage, the US Department of Veterans Affairs (VA), and TRICARE. It is important that your legal counsel also reads any contracts closely before entering into them, particularly with the VA.

CMS PDPM Bugs Identified

AHCA was informed September 30 that CMS has identified and is working to fix a new bug with the system. Here’s what you need to know: 

• Last Friday, September 27, CMS issued updates to the PDPM DLL Package (V 1.0002 FINAL). This is the software code that SNF software vendors use as part of the PDPM classification Grouper programs within the MDS software packages to generate the PDPM billing case mix codes (physical therapy, occupational therapy, speech-language pathology, non-therapy ancillary, and nursing).  
• This past weekend, software vendors identified problems with the released DLL package. CMS has privately acknowledged that additional updates are needed to make the PDPM Grouper operate correctly.  
• The date for the corrected software code fix is still to be determined.

AHCA is in communication with CMS to seek further guidance for providers. The PDPM DLL software is necessary to properly classify a resident under PDPM, and CMS is working to fix the problem. We have also been made aware that some vendors are instructing SNFs to delay marking a PDPM MDS Assessment (5-Day or IPA) with a reference date beginning October 1 and beyond as complete until this data issue can be resolved. AHCA will share updates as they become available.

Info on Part A Crossovers under PDPM

Virginia Medicaid must modify the way the Medicaid’s payment for claims under Part A for dual eligible individuals in nursing facilities is determined once PDPM goes live. Currently, Medicaid uses a crosswalk from the Medicare RUG system to the Medicaid RUG system to determine if Medicaid will pay any amount on the claim. Under Medicare’s PDPM system, there is no practical way to crosswalk to a Medicaid RUG.

DMAS has determined that both fee-for-service and managed care (through the six CCC Plus MCOs) will follow a simpler methodology in determining the Medicaid liability, if any, for these claims. Specifically, if a Medicare Part A claim for a dual eligible indicates a coinsurance amount due, the process below will determine if additional payment must be made by the Medicaid program:

1. Add together the Medicare payment amount and sequestration adjustment to determine the total Medicare payment for the entire service date span (not just the coinsurance days).
2. Calculate the Medicaid allowance by multiplying the relevant nursing facility’s Case Mix Neutral Rate by the number of covered days (again, not just the coinsurance days) on the Medicare claim.
3. Compare the total Medicare payment to the Medicaid allowance:

• • If the total Medicare payment is greater than the Medicaid allowance, no Medicaid payment is due. The payer will populate the appropriate bad debt denial code and other relevant variables to the Medicaid remittance advice (or the quarterly spreadsheets if not yet available on the remittance); or

• • If the total Medicare payment is less than the Medicaid allowance, the difference is due from the Medicaid program. Patient pay must be applied in part or in full if the entire DSS-calculated patient pay has not already been applied to a separate claim for the same month of service. To the extent the full Medicare coinsurance is not paid by Medicaid under this approach, the payer will populate the appropriate bad debt denial code and other relevant variables to the Medicaid remittance advice (or the quarterly spreadsheets if not yet available on the remittance) for the remaining amount.

DMAS has indicated a Medicaid Bulletin on this topic is in development but is not yet ready for publication. While we do not expect the bulletin to stray from the process outlined above, it is important to note that DMAS has yet not reviewed the language above. These steps represent VHCA-VCAL’s understanding of the process based on multiple discussions with DMAS and the call held with the agency on Friday, September 27. If you have any additional questions, please contact Steve Ford.

Help Us Understand How Implementation Is Working, Use the PDPM Resource Navigators for Help

AHCA has worked closely with members over the past year to provide resources and ensure you are prepared for success under the new payment model. These efforts will continue into post-implementation.

Please provide valuable, real-time information to AHCA on how PDPM implementation is working by completing this survey each week. This will help AHCA address your needs through member education, resources, and advocacy with the CMS on regional or national issues.

AHCA is introducing PDPM Resource Navigators who are trained to help you find existing AHCA and CMS resources and guidance. They can be reached by email at pdpm@ahca.org or by calling (202) 842-4444 and asking to speak with an AHCA PDPM Resource Navigator. If you have technical questions, PDPM Resource Navigators will record your information and question(s) and submit them to in-house PDPM technical experts. Members will receive a same day response to questions and requests. You will be notified if additional technical research or clarification from CMS is required, and a projected response date will be provided.

AHCA offers resources and is prepared to answer PDPM policy and operational questions. If you need intensive, hands-on assistance, such as claims submissions, we can refer you to a vetted consultant.

Additional Resources

• AHCA PDPM Resource Center
• ACHA PDPM Academy Resources (available only to participants of the PDPM Academy)
• ICD-10 NTA Mapping Guide
• AHCA/AHIMA ICD-10 Training for PDPM – Coder
• AHCA/AHIMA ICD-10 Training for PDPM – Non-Coder