QUIZ: 2023 Medicare Part A Reimbursement – The Patient Driven Payment Model

The Patient Driven Payment Model was created for and will drive reimbursement for residents in the SNF with which active primary payer:

The main reason CMS decided to retire the RUG-IV system and transition to the new PDPM model on 10/1/19 was:

What were the main therapy trends for Medicare Part A residents that CMS was concerned about?

The RUG-IV system still exists for all OBRA MDS’s. MDS scoring only allows for 1 main RUG score in either a therapy or nursing group. PDPM allows for individual case mix group scores for each of the 5 components. The 5 components are:

The PDPM will allow the Medicare Part A covered resident to score in each of the 5 case mix component groups AND the SNF will receive payment for each group even if the resident is not on an active therapy program.

Both the Nursing Function Score and the Therapy Function Score are derived from what Section of the MDS?

Which statement(s) about Section GG are true?

The Nursing Function Score uses 4 Sections from GG: Eating, Toileting Hygiene, Bed Mobility and Transfers. The Therapy Function Score uses these same 4 Sections, and also uses 2 additional questions/sections from GG. These are:

A Nursing Function Score ranges from 0-16 and a Therapy Function Score ranges from 0-24. A resident with a score of 24 would represent a resident with what type of function in the Self Care and Mobility items?

Using your PDPM Green Sheet handout, how would you code the following resident for the Nursing Case Mix Group Component:

• Respiratory Therapy for 7 days of the look-back period coded in Section O
• PHQ-9 Score (Mood Interview) of 0 = Not depressed
• Nursing Function Score of 10

Using your NTA Point Sheet handout, how many points would a resident with the following receive?

• IV Feedings/Fluids for dehydration received in the HOSPITAL
• IV Medication while a resident
• COPD
• Malnutrition

The Main Clinical Categories for PDPM ICD-10 Codes are:

1. Major Joint Replacement or Spinal Surgery
2. Other Orthopedic
3. Medical Management
4. Non-Orthopedic Surgery or Acute Neuro

How do you know which Clinical Category the main ICD-10 code selected by your SNF will fall into?

True or False: PT and OT will always share the Case Mix Group (ie: TA, TB, TC…). However, the total daily reimbursement rate for PT and OT will always be different because the Case Mix Index values and unadjusted per diem Federal Rates for each discipline are different.

Using your PDPM Case Mix Group Green Sheet, how would you code the following resident for PT and OT:

• Total Knee Replacement
• Therapy Function Score of 8

Which one of the following is NOT a factor in determining the Speech Therapy Component under PDPM?

CMS stated Group Therapy need, type and size should be determined ONLY by the clinician and have supporting documentation in the record as to why Group is needed vs Individual. CMS redefined Group Therapy for Medicare Part A to be defined as how many residents in the Group?

The total combined amount of Concurrent and Group Therapy provided over the course of a residents Medicare Part A coverage per discipline is:

Using your Non-Therapy Ancillary print-out, what would be the total number of points and the resulting Case Mix Group for a resident with the following:

• COPD
• Diabetes

Total payment to the SNF per day is determined by:

The resident Case Mix Groups and resulting daily reimbursement rate for the entire Part A stay will be determined by 1 MDS assessment (assuming no IPA’s are done). What is this assessment?