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Medicare: Centers for Medicare & Medicaid Services (CMS) upcoming changes for Skilled Nursing Facilities (SNF) beginning October 1, 2019

The Patient-Driven Payment Model (PDPM) is a new case-mix classification system for classifying SNF patients in a Medicare Part A covered stay into payment groups under the SNF Prospective Payment System (SNF PPS). Beginning October 1, 2019, the PDPM will replace the current case-mix classification system, which is the Resource Utilization Group, Version IV (RUG-IV). RUG codes will be no longer applicable.

Please note:

  • This will impact all facilities reimbursed under the SNF PPS, specifically standalone SNFs and non-CAH swing bed units of hospitals.
  • Facilities reimbursed using Medicare Allowable methodology should not submit claims that span from one fiscal year to the next (e.g., September 2019 admittance to October 2019 discharge). Claims that span fiscal years need to be split. Facilities should bill one claim for each year’s services. 

Per diem adjustment

Under the PDPM, there is variable per diem adjustment, meaning the per diem rate for a given day of the stay may be different from that of the prior day, depending on an adjustment factor that may be applied against the SNF PPS rate connected with the HIPPS (Health Insurance Prospective Payment System) rate code.

More information
See MLN Matters, Implementation of the Skilled Nursing Facility PDPM
See MLN Matters, Medicare Part A SNF PPS Pricer Update FY 2020