Blue Sky Therapy Blog

CMS PDPM Presentation Highlights No Transition Period and Other Changes Coming

by Blue Sky Therapy

CMS-logoThe CMS Medicare Learning Network recently held a presentation on the Patient-Drive Payment Model. Check out the full presentation on the CMS website.


One major highlight from the presentation is that there will not be a transition period between the existing Resource Utilization Group, Version IV (RUG-IV) and the new system, Patient-Driven Payment Model (PDPM):

  • RUG-IV billing ends September 30, 2019
  • PDPM billing begins October 1, 2019

All residents on Medicare Part A will need a new MDS dated 10/1/2019 through 10/7/2019 to kick start their PDPM reimbursement:

  • October 1, 2019 will be considered Day 1 of the VPD schedule under PDPM, even if the patient began their stay prior to October 1, 2019.
  • Any “transitional IPAs” with an ARD after October 7, 2019, will be considered late and relevant penalty for late assessments would apply.

CMS also stressed that all RUG-IV rules continue to apply for all billing prior to PDPM’s October 1, 2019, start date.

Other areas of concern:

  • Medicaid:
    • To deal with any issues at the retirement of PPS assessments for capturing patient case-mix, CMS is introducing the Optional State Assessment (OSA) for providers to report on Medicaid-covered stays. The OSA allows providers in states using RUG-III or RUG-IV models as the basis of Medicaid payment to use them until Sept. 30, 2020.
  • Medicare Advantage:
    • A CMS spokesperson said that CMS cannot dictate if Medicare Advantage plans will participate in PDPM. Private plans will have the ability to choose how they pay.

CMS also noted that they will be closely monitoring therapy levels before PDPM officially begins.

Changes under PDPM are coming and they are coming quick. The first week of October will be essential for your staff to hit the ground running with PDPM. At Blue Sky, we are prepared to help lead your organization through this transition.

Contact us today to see how you should be preparing for PDPM.

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