PDPM: Interrupted Stay Policy

Skilled nursing facilities scramble to help staff understand new ‘Interrupted Stay Policy ‘ before Oct. 1

One of the several confusing aspects of Medicare’s new payment model for skilled nursing facilities is its new impact on “interrupted stays” –- or discharges resulting in readmissions within specific timeframes.

And with the clock ticking toward implementation of the new Patient-Driven Payment Model (PDGM) Oct. 1, there’s a growing sense of urgency for staff education.

“Skilled nursing facilities have only a few months left now to get all of their staff members on board with these extensive changes,” said J’non Griffin, owner and president of Home Health Solutions, a nationwide consulting and outsourcing firm which has served the home health and hospice industries since 2012.

Her Alabama-based company has launched a new long-term care solutions division known as LTC Solutions in anticipation of a PDPM-inspired need among skilled nursing facilities for training, consulting and outsourcing.

“We’re seeing a lot of questions recently about the new Interrupted Stay Policy which will be implemented along with PDPM,” J’non said. “Skilled nursing facility staff want to know how this new policy will affect the need for assessments and per diem rates.”

Case mix and per diem rates

The reason there is so much confusion about the new Interrupted Stay Policy is because per diem reimbursement under PDGM will fluctuate depending upon several factors, including how many days the resident has been at the skilled nursing facility.

“Whether a stay is considered an interrupted stay or a new admission can directly impact the amount of reimbursement under PDPM,” J’non said. “This is because per diem payment rates taper off throughout the length of the stay for many residents. New stays will pay higher per diem rates in some cases than interrupted stays."

Payment under PDPM will be determined by patient-specific characteristics such as primary diagnosis, comorbidities and functional impairment level, which will classify patients into five case-mix groupings: physical therapy, occupational therapy, speech-language pathology, nursing and non-therapy ancillary services.

Per diem rates may fluctuate throughout the stay depending upon the case-mix group and the length of stay.

Therapy per-diem rates, for example, will decrease over the length of the resident’s stay. Beginning on Day 21, per diem rates for physical therapy and occupational therapy will decrease by 2 percent every seven days until Day 100 of the stay.

The per-diem rate for non-therapy ancillary services will also fluctuate, tripling for Days 1-3 of the resident’s stay and returning to the base rate after Day 3.

Nursing and speech-language pathology rates will not fluctuate, however, remaining the same throughout the patient’s stay.

New or interrupted stay?

“Sometimes a patient may have multiple stays in the skilled nursing facility occurring in a single Part A benefit period,” J’non said. “Determining whether those multiple stays constitute one single ‘interrupted’ stay, or separate stays, is important for determining where the resident falls on the per diem pay scale.”

If the stay is considered “interrupted,” the per diem rate resumes upon readmission to the daily amount which was being paid from the point just prior to discharge. But if the stay is not considered interrupted, it is treated as a new admission and the per diem rate resets to the Day 1 amount.

As an example, reimbursement for an occupational therapy resident would be significantly less at Day 49 than on Day 1. If the resident was discharged on Day 49 and then readmitted days later on an “interrupted stay” basis, reimbursement would resume at the Day 49 per diem rate. However, if the resident was discharged and readmitted as a new stay, the per diem rate would reset to the Day 1 rate.

Assessments affected, too

The new Interrupted Stay Policy will affects assessments as well as per diem rates.

If a resident’s stay is determined to be an interrupted stay, there will be no need for the initial, five-day assessment. In the same manner that per diem rates resume where they left off, the schedule for continuing assessments will resume as if the “interruption” had never occurred.

However, all new stays will require the five-day assessment and the subsequent assessment schedule will reset as well.

For discharge assessments, CMS has clarified that in the case of an interrupted stay, no PPS assessments will be required, including a PPS Discharge assessment. However, OBRA assessment requirements still exist and an OBRA Discharge would need to be completed.

The optional Interim Payment Assessment (IPA) may be completed at the discretion of the skilled nursing facility.

The 3-Day Window

A three-day window will be the determining measure for whether a resident’s readmission is to be considered an “interrupted” stay or a new stay under the new policy.

The Centers for Medicare and Medicaid Services (CMS) defines an “interrupted” stay as one in which a patient is discharged from skilled nursing facility care and then readmitted to the same facility within three days of less after the discharge. It does not matter whether the resident is readmitted from a hospital, from home or from another type of healthcare facility.

The three-day window begins with the calendar day of discharge, and the resident must return to the same skilled nursing facility by midnight at the end of the third calendar day.

Admission to a different facility, however, will always be considered a new stay, and will reset the clock to Day 1

“This new policy for skilled nursing homes is consistent with the Interrupted Policies already used in Inpatient Rehabilitation Facilities and inpatient hospital settings,” J’non said. “Its implementation in skilled nursing facilities this October is just one more way we are seeing CMS standardize measures across the post-acute care industry.” We can help

Need help preparing for PDPM? Would you like to discuss how using coding and review services from HHS can improve your facility’s bottom line? Contact us today!