SNF PPS Payment Model Research

Patient Driven Payment Model

In May 2017, CMS released an Advanced Notice of Proposed Rulemaking (ANPRM) which outlined a new case-mix model, the Resident Classification System, Version I (RCS-I), that would be used to replace the existing RUG-IV case-mix model, used to classify residents in a covered Part A stay into payment groups under the SNF PPS. Since the ANPRM, we continued our stakeholder engagement efforts to address the concerns and questions raised by commenters with RCS-I. This resulted in significant changes to the RCS-I model, which have prompted us to rename the proposed model discussed in the FY 2019 SNF PPS Notice of Proposed Rulemaking (NPRM) the SNF Patient Driven Payment Model (PDPM). Below are several items we have posted concurrent with the FY 2019 SNF PPS NPRM to assist stakeholders in reviewing and commenting on the proposed PDPM. 

 

SNF PDPM Technical Report

With release of the ANPRM in May 2017, we released an accompanying technical report, which described all of the research and analyses conducted to develop the RCS-I model. Similarly, the SNF PDPM Technical Report discusses the additional analyses conducted, many in response to stakeholder feedback on the ANPRM, in development of the proposed PDPM. We would note that, as described in the FY 2019 SNF PPS NPRM, we make use of both the SNF PDPM and SNF PMR technical reports in our discussion of the proposed PDPM.

SNF PDPM Technical Report (PDF)

 

SNF PDPM ICD-10 Diagnosis and Procedural Code Crosswalk

As discussed in Section V.D.3.b, the proposed PDPM would use ICD-10 diagnosis and procedural codes in order to classify SNF residents into one of ten PDPM Clinical Categories, which would then be used to further classify the resident for payment purposes under PDPM. These files provide a crosswalk between the ICD-10 diagnosis and procedure codes and the ten PDPM clinical categories.

All ICD-10-CM diagnosis codes have been assigned to a default clinical category shown in column C in the diagnosis clinical category file. For a subset of these ICD-10-CM diagnosis codes, the clinical category will be modified if there were specific related surgical procedures performed in the hospital stay immediately preceding admission to the skilled nursing facility. There are three surgical clinical categories where this may occur; major joint replacement or spinal surgery, orthopedic surgery (except major joint replacement and spinal surgery) and non-orthopedic surgery. The surgical procedure code lists provided will be used as a reference by the skilled nursing facility staff to augment the resident’s clinical category classification. The staff would review the information sent by the preceding hospital stay to identify any procedures defined in these surgical clinical categories. For these situations, the alternative clinical category is shown in columns D and E in the diagnosis clinical category file. This process is further discussed in the FY 2019 SNF PPS NPRM. 

SNF PDPM Clinical Category Mapping (ZIP)

Note: For the most current PDPM ICD-10 code mapping, please refer to the PDPM Resources section of the Patient Driven Payment Model webpage.

SNF PDPM Classification Logic

To assist stakeholders in understanding the process by which SNF residents would be classified into PDPM payment groups, we are providing three files. The first file provides a narrative step-by-step walkthrough that would allow stakeholders to manually determine a resident’s PDPM classification based on the data from an MDS assessment. The second file is a spreadsheet-based grouper tool which can be used to test certain combinations of MDS items used to classify residents under the proposed PDPM, and observe their impact on the resident’s PDPM classification. These files should be used in conjunction with the discussions found in the FY 2019 SNF PPS NPRM and accompanying files to better understand the process for resident classification under PDPM. The third file is a mapping, referenced in the narrative walkthrough file, between ICD-10-CM codes and the comorbidities used for resident classification under the NTA component.

SNF PDPM Classification Walkthrough (PDF)

SNF PDPM Grouper Tool (ZIP)

SNF PDPM NTA Comorbidity Mapping (ZIP)

06/08/2018 Update: A few typographical and usability issues were recently identified by certain stakeholders with SNF PDPM the classification logic (SNF PDPM Classification Walkthrough, Grouper Tool, and NTA Comorbidity Mapping).  In order to address these issues, we have posted revised versions of the three files below. Stakeholders should use these revised SNF PDPM files (Version 2) to inform their comments on the proposed rule.

SNF PDPM Classification Walkthrough (PDF), Version 2

- Corrected typo on page 23 in definition of Extensive Services category “ES2”

SNF PDPM Grouper Tool (ZIP), Version 2

- Corrected typo in ES1 and ES3 labels on the nursing tab
- Added D0600 logic to depression flag
- Added support item "did not occur" logic to ADL construction
- Improved clinical category logic so that the tool assigns the default clinical category for patients who have procedure info that will not impact category assignment
- Corrected GG-based function score rounding
- Updates final payment calculation to include proposed 18% nursing add-on for patients with HIV/AIDS

SNF PDPM NTA Comorbidity Mapping (ZIP), Version 2

-Added ICD-10 code mapping for category “Major Organ Transplant Status, Except Lung”

06/14/2018 Update: An additional typographical issue was recently identified by certain stakeholders with the SNF PDPM Grouper Tool. In order to address this issue, we have posted a revised version of that file below. Stakeholders should use the revised SNF PDPM Grouper Tool (Version 3).

SNF PDPM Grouper Tool (ZIP), Version 3

- Corrected typo in minimum point value thresholds used to classify patients into groups “NA” and “NB” under the NTA component

SNF PDPM Provider-Specific Impact File

To assist stakeholders in understanding the potential impacts of the proposed PDPM, we are providing a provider-specific impact analysis file, which details the estimated impact of the PDPM model discussed in the FY 2019 SNF PPS NPRM on Medicare Part A payments to each SNF in the country. We would note that, as discussed in the file and in the proposed rule, the provider and resident data is for fiscal year 2017 and represents estimated payments under PDPM, assuming no changes in provider behavior or resident case-mix.

SNF PDPM Provider Specific Impact Analysis (ZIP)

 

Analysis of Medicare Part A SNF PPS Payment Model

In an effort to establish a comprehensive approach to Medicare Part A SNF payment reform, we are expanding the scope of the SNF Therapy Payment Research project.  Although we always intended to ensure that any revisions to therapy payment would consider an integrated approach with the remaining payment methodology, we now plan to examine potential improvements and refinements to the overall SNF PPS payment system. This expansion will allow for improving the ability for Medicare to pay adequately and appropriately for all services provided during a Medicare Part A SNF stay.  

Overview

Since 1998, Medicare has paid for services provided by skilled nursing facilities (SNFs) under the Medicare Part A benefit on a per diem basis through the skilled nursing facility prospective payment system (SNF PPS). Currently, therapy payments under the SNF PPS are based primarily on the amount of therapy provided to a patient, regardless of the specific patient characteristics and care needs. CMS has contracted with Acumen, LLC to identify potential alternatives to the existing methodology used to pay for services under the SNF PPS. Below, we will post information about this project as it progresses.
  

Phase One

In the first phase of the project, the contractor reviewed past research studies and policy issues related to SNF PPS therapy payment and options for improving or replacing the current system of paying for SNF therapy services. The following report summarizes the analysis and findings from this first phase of the project:

SNF Therapy Payment Models – Base Year Final Summary Report, April 2014 (PDF)

 

Phase Two

In the second phase of the project, which is now in process, the contractor is using the findings from this Base Year Final Summary Report as a guide to identify potential models suitable for further analysis.  We have considered stakeholder comments and concerns as we continue to investigate alternative therapy payment approaches and plan to solicit additional feedback on this aspect of our SNF payment research.  As noted above, we expanded the scope of this project during this phase to include ideas for revising the overall SNF PPS and plan to include additional and separate opportunities to obtain stakeholder input on non-therapy related refinement possibilities.  

As the contractor began the process of further narrowing the scope of therapy payment models in this second phase of the project, Acumen hosted a Technical Expert Panel in February 2015 to discuss questions and issues related to the therapy payment research. The slides used during this TEP, as well as a report that summarizes the discussion and recommendations of the Technical Expert Panel, may be found below:

Skilled Nursing Facility Therapy Payment Models Technical Expert Panel Presentation (PDF)

Skilled Nursing Facility Therapy Payment Models Technical Expert Panel Summary (PDF)

Additionally, Acumen hosted a second Technical Expert Panel in November 2015 to discuss questions and issues related to the nursing component of the SNF PPS, as well as issues around Non-Therapy Ancillaries. The slides used during this TEP, as well as a report that summarizes the discussion and recommendations of the Technical Expert Panel, may be found below:

Skilled Nursing Facility Payment Models Nursing Component Technical Expert Panel Presentation (PDF)

Skilled Nursing Facility Payment Models Nursing Component Technical Expert Panel Summary (PDF)

Acumen hosted a third Technical Expert Panel in June 2016 to provide an outline of basic payment structure for a revised SNF PPS, including the various new components of the revised SNF PPS and a discussion of potential pricing schedules which may be incorporated. The slides used during this TEP, as well as a report that summarizes the discussion and recommendations of the Technical Expert Panel, may be found below:

Skilled Nursing Facility Payment Models Technical Expert Panel Presentation (PDF)

Skilled Nursing Facility Payment Models Nursing Component Technical Expert Panel Summary (PDF)

Acumen hosted a fourth Technical Expert Panel in October 2016 to provide an outline of the recommended alternative payment model for a revised SNF PPS, including the various new components of the revised SNF PPS and a discussion of potential pricing schedules which may be incorporated. The slides used during this TEP, as well as a report that summarizes the discussion and recommendations of the Technical Expert Panel, may be found below:

Skilled Nursing Facility Payment Models Technical Expert Panel Summary Report (PDF)

Skilled Nursing Facility Payment Models Technical Expert Panel Presentation (PDF)

Technical Report

Based on the work conducted by Acumen during the second phase of the project, which included substantial feedback from stakeholders and four Technical Expert Panels, the contractor drafted a Technical Report (PDF), which discusses the research conducted by the contractor on developing an alternative to the existing methodology used to pay for services under the SNF PPS. The report identifies all of the relevant data and methodologies used in creating the contractor’s recommended alternative to the current case-mix classification system, RUG-IV, which they have named the Resident Classification System, Version I (RCS-I).

Provider-Specific Impact Analysis

To assist stakeholders in their review of the RCS-I model, as discussed in the SNF PPS Advance Notice of Proposed Rulemaking (ANPRM) and Technical Report provided above, we are providing a provider-specific impact analysis file, which details the estimated impact of the RCS-I model discussed in the ANPRM on Medicare Part A payments to each SNF in the country. We would note that, as discussed in the file, the provider and resident data is for fiscal year 2014 and represent estimated payments under RCS-I, assuming no changes in provider behavior or resident case-mix.

Provider Specific Impact Analysis (ZIP)

RCS-I Classification Logic

To assist stakeholders in their review of the RCS-I model, as discussed in the SNF PPS Advance Notice of Proposed Rulemaking (ANPRM) and Technical Report provided above, we are providing a narrative discussion of the resident classification logic used under the RCS-I model discussed in the ANPRM. This file provides a step-by-step walk-through that allows stakeholders to manually determine a resident’s RCS-I classification based on the data from an MDS assessment. This document should be used in conjunction with the discussions found in the ANPRM and accompanying Technical Report to better understand the process for resident classification under RCS-I.

RCS-I Model Calculation Worksheet for SNFs (PDF)

 

The contractor is continuing with further refinements and considering potential improvements to the overall SNF PPS payment structure, and we welcome your comments and feedback. Comments on the SNF PPS payment methodology may be submitted anytime to:

PDPM@cms.hhs.gov