PDPM Claims Issues 

PDPM Claims Issues 

CMS has identified bumps in the road during PDPM implementation. We wanted to share with you this notice that CMS just put out via the Medicare Learning Network. If you have or are experiencing issues with your October claims, it would be helpful if you could share specifics with is to that we can have accurate information to communicate with CMS to identify the scope and magnitude of issues occurring with claims. Useful data points include:

  • the number of October claims submitted with percentage having multiple PDPM HIPPS codes;
  • the total amount billed for using claims with multiple PDPM HIPPS codes; and 
  • the MAC’s narrative claim status reason code if placed on hold, not paid accurately, or otherwise producing an unexpected result. 

Please let us know if you are experiencing issues, you can send me an email directly (atripp@leadingage.org). We want to let CMS know how LeadingAge members are experiencing the PDPM rollout.

Here is the text of CMS’ recent message:

Skilled Nursing Facility Claims Hold

As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), we are holding a limited number of Skilled Nursing Facility (SNF) claims while we make further refinements to our claims processing system.

PDPM is a historic reform of the SNF prospective payment system. PDPM focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. PDPM was effective on October 1, 2019.

Specifically, CMS is holding claims with:

  • Dates of service October 1, 2019 or later and
  • Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF Patient Driven Payment Model (PDPM) and
  • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).

Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. We anticipate releasing the remaining held claims in late November, once CMS completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.

In addition, we underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. We are automatically reprocessing those claims; no provider action is needed.

CMS will continue to provide updates as further information develops.

Aaron Tripp | Vice President for Reimbursement and Financing Policy |  LeadingAge

P 202.508.9433 | F 202.939.5822 | LeadingAge.org | atripp@LeadingAge.org