Patient Driven Payment Model

Table of Contents

• Assessment Schedule
• Administrative Presumption
• Lookback Period (Observation Period)
  • Examples
• General PDPM Resources

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Assessment Schedule

Learn more about the Prospective Payment Systems’ Assessment Schedule by accessing valuable resources via the Medicare Learning Network®. Helpful tools such as a Scheduled Assessment Calendar MLN® Educational Tool: Medicare-Required SNF PPS Assessments can be found as well.

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Administrative Presumption

The SNF PPS includes an administrative presumption whereby a beneficiary who is correctly assigned one of the designated, more intensive case-mix classifiers on the initial five-day Medicare-required assessment is automatically classified as meeting the SNF level of care definition up to and including the ARD for that assessment, which must occur no later than the eighth day of the SNF stay. Administrative presumption only applies to beneficiaries who come directly from the hospital to the SNF and would not apply if they failed home discharge or transfer from another SNF.

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Lookback Period (Observation Period)

Active diagnosis is defined as physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the seven-day look-back period.

The standard look-back period for the MDS 3.0 is seven days unless otherwise stated, per the CMS’ Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual. The ARD is the reference point for determining the care and services captured on the MDS assessment. Anything that happens after the ARD will not be captured on that MDS.

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Examples

1. Seven-day look-back period: starts the day the ARD is completed and includes assessment information from six previous calendar days.
2. The look-back period includes observations and events through the end of the day (midnight) of the ARD.

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General PDPM Resources

Learn more about the Patient Driven Payment Model by accessing valuable resources via the links below; the resources include helpful tools and worksheets.

• Patient Driven Payment Model
• Patient Driven Payment Model Fact Sheet: Administrative Level of Care Presumption
• Patient Driven Payment Model Fact Sheet: NTA Comorbidity Score
• MLN® Educational Tool: Medicare-Required SNF PPS Assessments
• Fact Sheet: Administrative Level of Care Presumption under the PDPM
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance
• CMS’ Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual

Revised 6/26/2024