PDPM vs. PPS: Understanding the presumption of skilled coverage

CMS' new Patient-Driven Payment Model (PDPM) doesn’t change Medicare’s basic requirements for skilling a resident. However, due to the change in resident care classifications, the rule specifies the new PDPM categories that will qualify for the presumption of skilled coverage. The new model focuses less on the number of therapy minutes and more on residents’ clinical characteristics.

Effective Oct. 1, 2019, under PDPM, the presumption of skilled coverage concept will continue but will be modified for various PDPM classifications. Beneficiaries who are “correctly assigned one of the designated case-mix classifiers on the initial 5-day, Medicare-required assessment are automatically classified as meeting the SNF level of care definition up to and including the assessment reference date on the 5-day Medicare required assessment” (CMS-1696-F, Part V, paragraph G).

The new PDPM model focuses less on the number of therapy minutes and more on residents’ clinical characteristics.

Residents who aren’t automatically eligible will remain subject to the existing level of care determination process. (42 CFR Part 409, Subpart D.)

The presence of any of the following classifiers will qualify a resident for the administrative presumption that the SNF level of care requirements have been met under PDPM:

• Nursing case-mix groups: Extensive Services, Special Care High, Special Care Low, and Clinically Complex
• PT and OT groups: TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO
• SLP groups: SC, SE, SF, SH, SI, SJ, SK, and SL
• The NTA component’s 12-plus comorbidity group

To compare how presumption of skilled coverage is changing under the new model, the prospective payment system (PPS) includes an administrative presumption based on a beneficiary’s initial classification in the Resource Utilization Grouper (RUG-IV) system to assist in making level of care determinations. Under PPS, if a resident’s initial classification is in one of the upper 52 RUGS of the 66-group RUG-IV system, then the resident is deemed to have met the level of care requirements.

While PDPM will create plenty of change for providers, it was developed with an important goal shared by SNFs: to stay focused on the fundamental clinical reasons to skill a patient.

As always, feel free to contact a Plante Moran healthcare industry specialist if you have any questions.