PDPM - Highlights

We're nearing a significant milestone in Part A skilled nursing reimbursement. For roughly 10 years, the most important factors in your Part A reimbursement have been therapy minutes and ADL scores. When CMS released the RCS-1 proposal, therapy minutes were completely removed as a driver of reimbursement but ADLs still played a role. It was a much lesser role but it was still section G.

In the proposal released on April 27th CMS is proposing that not only do we abandon therapy minutes but also Section G. Instead we'll use the relatively new section GG. That means that the two largest drivers for Part A reimbursement could be effectively gone in less than 18 months.

Some important notes about this change:

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  1. We'll be using all of Section GG, not just late loss ADLs like we did with Section G.
  2. Section GG is used for PT/OT AND nursing.
  3. The rules for Section GG are completely different than Section G. We'll no longer be coding "what actually occurred" but "what usually occurs". This is subjective in my opinion but we'll get used to it.
  4. Under PDPM ADLs will not be nearly the financial driver they are right now. 
  5. The scales for Section G and GG are not only different, they're reversed. (A high score on Section G means higher acuity, the reverse is true for Section GG. Most of you probably know that but for those of us that are not clinical, Section GG is a little foreign to us.)
  6. If you live in a case-mix state, you will still need to train/deal with Section G AND Section GG. This will be tricky.

The PDPM manual is useful.