Under PDPM, going into effect October 2019, there won’t be any changes to Medicare Part A coverage in the SNF setting, but the payment methodology for these services will change. Since the changes will impact MDS schedules and reimbursement, your whole team should be aware of the policy and its effects on your organization.
An “interrupted stay” policy has been developed under PDPM to determine how payments will be made when residents are discharged and re-admitted during a benefit period. The policy is necessary due to the tapering of payment rates under PDPM. The “interruption window” has been defined as the three-day period starting with the calendar day of discharge and includes the two calendar days immediately following.
If a resident is re-admitted to the same SNF during the interruption window, the payment continues where it left off under the variable per diem rate. If the interruption window is exceeded, or the resident is admitted to a different SNF, the per diem payment is reset to day one, and a new five-day admission assessment is required. The re-admission source is irrelevant — it can be from a hospital, home, or other type of healthcare facility.
Medicare beneficiaries are still entitled to a maximum of 100 days of SNF services per spell of illness or benefit period. The benefit period begins on the day a beneficiary begins receiving SNF benefits under Medicare Part A. A prior qualifying three-day inpatient hospital stay is also required to receive SNF Medicare Part A benefits.
Discharge from the SNF doesn’t necessarily mark the end of the benefit period. A resident can be re-admitted multiple times and still be within the same benefit period. A new benefit period can’t begin unless a period of 60 consecutive days elapses without an inpatient hospital or SNF stay. A new three-day hospital stay is required prior to any new benefit period.
By comparison, payment under PPS is made based on RUG-IV classification. If a resident’s RUG-IV category doesn’t change, the payment rate remains the same for all days a resident is classified within that RUG-IV category during the benefit period.
With PDPM, a variable per diem payment rate will be implemented. Early days will be paid at higher per diem rates, which will decrease as the length of stay progresses. The per diem payment rate that’s applied during a benefit period will not only depend on acuity, but on the actual day of the stay.
The Federal Register, CMS-1696-F, provides the following clarifications of the new interrupted stay policy.
Resident is Discharged from a SNF, and Readmitted to the SAME SNF
When a resident is discharged from a SNF and returns to the same SNF by 12:00 a.m. at the end of the third day of the interruption window, the readmission is treated as a continuation of the previous stay. Days are not reset and no new 5-day admission assessment is required. If the resident was discharged on day seven of their stay, then the date of readmission will start at the rate in effect on day seven.
If the 3-day interruption window is exceeded, the readmission is a new stay, and the per diem rate is reset to Day one. A new 5-day admission assessment is required.
Resident is Discharged from a SNF, and Admitted to a DIFFERENT SNF
When a resident is discharged from a SNF, and admitted to a different SNF by 12:00 a.m. at the end of the third day of the interruption window, this is treated as a new stay. Days are reset to Day 1 and a new 5-day admission assessment is required.
If the 3-day interruption window is exceeded AND the resident does not return to the discharging facility but is admitted to a different SNF, the readmission is a new stay, and the per diem rate is reset to Day 1. A new 5-day admission assessment is required.
CMS’ plans to monitor this new interrupted stay policy for abuses, giving special attention to facilities with frequent re-admissions that just exceed the interruption window.
The interrupted stay policy is new and will require some attention from staff across your entire organization to assess how it will impact MDS assessment schedules and reimbursement. Planning ahead will ensure your organization thrives under the new PDPM model come October 2019.
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