PPS-PDPM. Patient Driven Payment
Model
Medicare Part A - answer-Created by Congress in 1965 as part of the Social Security
Amendment
-Hospital insurance benefit for individuals over 65 or disabled that covers: 1. Hospital
(Acute/LTACH) Care 2. Acute Inpatient Rehabilitation Care 3. Skilled Nursing Facility
Care 4. Home Health Care 5. Hospice Care
Medicare Part A Eligibility - answer-Age 65 or older
-Individuals under the age of 65 with certain disabling conditions:
1. Resident of a long term care facility for 2 consecutive years
2. End stage renal disease
3. Accidental disability after 24-29 months, cognitive impairment, psychiatric conditions)
4. Generally, under the age of 65, individuals with health issues prohibiting participation
in the open market may apply for state Medicaid benefits
Medicare A SNF Benefit Eligibility - answer Technical Requirements:
-Benefit Availability: Enrolled in Medicare Part A and have days available to use
-Three day qualifying hospital stay (3 midnights, Must be ADMISSION, not
OBSERVATION)
-Timing of Services: Admission for SNF level services is within 30 days of discharge
from an acute care stay or within 30 days of discharge from a SNF level of care (30-day
rule)
Clinical Requirements:
-Patient needs and receives medically necessary skilled care on a daily basis (at least 5
out of 7 days) ->For therapy to count as skilled care, the treatment must exceed 15
minutes in length
-The care is provided under the direct supervision of skilled nursing or rehabilitation
professionals (PT, OT, ST or RN)
-Services can only be provided in a SNF (Must be reflected in the documentation)
Any of the following conditions would render services necessary in a SNF:
-Outpatient services are not available where the individual lives
-Outpatient services are available but... (Transportation is an excessive physical
hardship, Outpatient care is more costly than SNF placement)
-If the use of alternative services would adversely affect the patient's condition, the
services are skilled
Services must be for a condition:
-For which the resident was treated during the qualifying hospital stay (i.e. hip
replacement)
OR
, -That arose while the resident was in the SNF for treatment of a condition for which
he/she was previously treated in a hospital (i.e. develops pneumonia, DVT, or infection
as a complication of the hip replacement)
Med A SNF Coverage Requirements - answerServices must:
-Be ordered by a physician
-Be reasonable and necessary for the medical condition
-Require the skills of a qualified individual (PT, OT, SLP, RN)
-Have a reasonable expectation that progress will be made
SNF Eligibility - answerWhat if the patient cannot reside at home because there are
insufficient caregiving resources?
-The presence of a willing, competent, and available caregiver has a huge impact on
clinical outcomes.
-The absence of an appropriate caregiver is NOT a clinical indicator that qualifies an
individual for SNF coverage under Medicare A. Insufficient caregiving resources can
necessitate SNF placement to maintain patient safety, but does not dictate coverage.
Example: Joe is a 67 year-old male who was admitted to your SNF on a Friday
afternoon (4/1) at 4:15 pm from an acute care hospital. His insurance is Medicare A. He
has not otherwise been hospitalized within the past year. He is s/p an elective R THA on
Monday of this week (3/28).
-Enrolled in Medicare part A and has days available to use (hasn't been hospitalized this
year), has had a recent 3 day hospital stay, the condition that is being treated is the
same that was treated in hospital, coming to SNF for rehab after THA, these services
are reasonable and medically necessary for PT, reasonable to assume they will make a
full recovery
PPS - answer"A Prospective Payment System (PPS) is a method of reimbursement in
which Medicare payment is made based on a predetermined, fixed amount. The
payment amount for a particular service is derived based on the classification system of
that service (for example, diagnosis related groups for inpatient hospital services). CMS
uses separate PPS's for reimbursement to acute inpatient hospitals, home health
agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient
rehabilitation facilities, long term care hospitals, and skilled nursing facilities."
-The PPS system follows the same basic structure in all post acute models reimbursed
by Medicare A. The data collection tool varies from setting to setting.
-Data -> Classification System -> Estimation of Cost
-SNF: Data => MDS (PDPM) => Reimbursement
-Rehab: Data => IRF-PAI => Reimbursement
-Home Health: Data => OASIS (PDGM) =>Reimbursement
History of PPS - answerThe RUG system was cumbersome and relied heavily on the
volume of therapy provided to the patient as the determinant of reimbursement. Factors
stressed included the number of:
-Minutes of therapy provided
-Days of therapy provided
Model
Medicare Part A - answer-Created by Congress in 1965 as part of the Social Security
Amendment
-Hospital insurance benefit for individuals over 65 or disabled that covers: 1. Hospital
(Acute/LTACH) Care 2. Acute Inpatient Rehabilitation Care 3. Skilled Nursing Facility
Care 4. Home Health Care 5. Hospice Care
Medicare Part A Eligibility - answer-Age 65 or older
-Individuals under the age of 65 with certain disabling conditions:
1. Resident of a long term care facility for 2 consecutive years
2. End stage renal disease
3. Accidental disability after 24-29 months, cognitive impairment, psychiatric conditions)
4. Generally, under the age of 65, individuals with health issues prohibiting participation
in the open market may apply for state Medicaid benefits
Medicare A SNF Benefit Eligibility - answer Technical Requirements:
-Benefit Availability: Enrolled in Medicare Part A and have days available to use
-Three day qualifying hospital stay (3 midnights, Must be ADMISSION, not
OBSERVATION)
-Timing of Services: Admission for SNF level services is within 30 days of discharge
from an acute care stay or within 30 days of discharge from a SNF level of care (30-day
rule)
Clinical Requirements:
-Patient needs and receives medically necessary skilled care on a daily basis (at least 5
out of 7 days) ->For therapy to count as skilled care, the treatment must exceed 15
minutes in length
-The care is provided under the direct supervision of skilled nursing or rehabilitation
professionals (PT, OT, ST or RN)
-Services can only be provided in a SNF (Must be reflected in the documentation)
Any of the following conditions would render services necessary in a SNF:
-Outpatient services are not available where the individual lives
-Outpatient services are available but... (Transportation is an excessive physical
hardship, Outpatient care is more costly than SNF placement)
-If the use of alternative services would adversely affect the patient's condition, the
services are skilled
Services must be for a condition:
-For which the resident was treated during the qualifying hospital stay (i.e. hip
replacement)
OR
, -That arose while the resident was in the SNF for treatment of a condition for which
he/she was previously treated in a hospital (i.e. develops pneumonia, DVT, or infection
as a complication of the hip replacement)
Med A SNF Coverage Requirements - answerServices must:
-Be ordered by a physician
-Be reasonable and necessary for the medical condition
-Require the skills of a qualified individual (PT, OT, SLP, RN)
-Have a reasonable expectation that progress will be made
SNF Eligibility - answerWhat if the patient cannot reside at home because there are
insufficient caregiving resources?
-The presence of a willing, competent, and available caregiver has a huge impact on
clinical outcomes.
-The absence of an appropriate caregiver is NOT a clinical indicator that qualifies an
individual for SNF coverage under Medicare A. Insufficient caregiving resources can
necessitate SNF placement to maintain patient safety, but does not dictate coverage.
Example: Joe is a 67 year-old male who was admitted to your SNF on a Friday
afternoon (4/1) at 4:15 pm from an acute care hospital. His insurance is Medicare A. He
has not otherwise been hospitalized within the past year. He is s/p an elective R THA on
Monday of this week (3/28).
-Enrolled in Medicare part A and has days available to use (hasn't been hospitalized this
year), has had a recent 3 day hospital stay, the condition that is being treated is the
same that was treated in hospital, coming to SNF for rehab after THA, these services
are reasonable and medically necessary for PT, reasonable to assume they will make a
full recovery
PPS - answer"A Prospective Payment System (PPS) is a method of reimbursement in
which Medicare payment is made based on a predetermined, fixed amount. The
payment amount for a particular service is derived based on the classification system of
that service (for example, diagnosis related groups for inpatient hospital services). CMS
uses separate PPS's for reimbursement to acute inpatient hospitals, home health
agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient
rehabilitation facilities, long term care hospitals, and skilled nursing facilities."
-The PPS system follows the same basic structure in all post acute models reimbursed
by Medicare A. The data collection tool varies from setting to setting.
-Data -> Classification System -> Estimation of Cost
-SNF: Data => MDS (PDPM) => Reimbursement
-Rehab: Data => IRF-PAI => Reimbursement
-Home Health: Data => OASIS (PDGM) =>Reimbursement
History of PPS - answerThe RUG system was cumbersome and relied heavily on the
volume of therapy provided to the patient as the determinant of reimbursement. Factors
stressed included the number of:
-Minutes of therapy provided
-Days of therapy provided
