The transition from the Resource Utilization Groups (RUGs) system to the Patient-Driven Payment Model (PDPM) in Skilled Nursing Facilities (SNFs) has brought about significant changes in how facilities are reimbursed for the care provided. One of the critical tools in optimizing reimbursement under PDPM is the Interim Payment Assessment (IPA). When used correctly, the IPA can play an important role in ensuring that SNFs receive the appropriate reimbursement to reflect the level of care provided to its residents.

When used appropriately, the IPA is a beneficial tool that allows a SNF to adapt to changes in resident care needs and modify the reimbursement—especially when those needs increase unexpectedly after the initial 5-day assessment. This adaptability ensures SNFs are prepared and proactive in providing the necessary care.

What is the SNF PDPM IPA?

Under the PDPM, the IPA is an optional, unscheduled, and stand-alone assessment (not combined with other assessments). Its purpose is to allow SNFs to update their reimbursement to reflect significant changes in the resident’s condition or care needs that would support a higher reimbursement.

The payment rate will change starting on the Assessment Reference Date (ARD) and will remain in effect throughout the resident’s Part A stay unless a new IPA is completed or the resident is discharged. Remember that the Variable Per Diem (VPD) rate will not be affected by completing an IPA.

Why is the IPA important?

By submitting an IPA, the SNF can have a recalculation of the reimbursement rate, which ensures that the SNF receives compensation that reflects the change in the level of care being provided. This becomes crucial in cases where a resident has a significant change in health or requires intensive services that were not initially captured in the 5-day assessment. The IPA plays a role in ensuring that the SNF’s efforts are compensated.  

The IPA provides a mechanism to update the resident’s case-mix classification, which determines the reimbursement rate if the resident’s clinical picture changes during the SNF stay.

The takeaway is that the IPA allows for timely updates, helping ensure SNF is reimbursed at a level that reflects the resident’s current care needs starting on the IPA’s Assessment Reference Date (ARD). It’s especially valuable when a resident’s condition changes after completing the 5-day assessment.

How can the IPA be beneficial?

To help clarify when an IPA might be appropriate, let us consider several common scenarios where the IPA can play a role in adjusting reimbursement where there is a change in the resident’s condition.  Remember, an IPA can also be completed any time after the 5-day assessment if the SNF realizes that they forgot to code an existing condition on the assessment that would impact payment.

Significant Change in a Resident’s Condition

If a resident experiences a significant decline in their health after the 5-day assessment—whether due to a worsening of a pre-existing condition or the onset of a new one—the IPA allows the SNF to adjust the payment to reflect the increased level of care.

Example:

  • Initial condition – A resident is admitted with a diagnosis of a hip fracture and their medical condition supports an orthopedic HIPPS category. .
  • Change in condition – After the 5-day assessment had been completed, the resident tested positive for COVID-19, and the physician ordered single-room isolation, which severely impacted their ability to perform daily activities. They now require intensive nursing care and therapy.

IPA – Add the COVID-19 diagnosis in MDS Section I—Check MDS O0110M1b, Isolation.

The infection changes the resident’s clinical complexity, directly impacting the reimbursement categories under PDPM—which will most likely increase the resident’s Nursing case-mix group (CMG) and the NTA classification. The IPA ensures that the SNF receives reimbursement at a higher level corresponding to the increased care needs.

Example:

  • Initial condition – A resident is admitted with a relatively mild condition and is classified under a low-care reimbursement group—Nursing component: Reduced Physical Function Category.
  • Change in condition – During the SNF stay, the resident’s condition worsens due to a sudden medical complication, such as an exacerbation of a chronic condition or a new acute issue requiring intravenous (IV) medication—for instance, Pneumonia, which was not an active diagnosis during the lookback period of the completed 5-day assessment.

IPA –  Checking MDS items I2100, Pneumonia, and O0110H1b, IV medications.

In this case, the SNF can complete an IPA to reflect the change in the resident’s condition. The IPA would reassess the resident’s clinical characteristics, including their primary diagnosis, comorbidities, and functional status—which may increase the resident’s Nursing CMG and increase the NTA points to classify to a reimbursement rate.

Example:

  • Initial diagnosis: A resident is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) and requires moderate respiratory support, which is documented during the 5-day assessment.
  • Change in diagnosis: A few days into their stay, the resident develops respiratory failure and dyspnea when lying flat, which leads to increased respiratory therapy needs and close monitoring by nursing staff.

IPA – Checking MDS Items J2100C, Shortness of breath or trouble breathing when lying flat, and I6300, Respiratory failure, listing the respiratory failure diagnosis (which is documented by the physician) in MDS I8000, and the additional nursing interventions in MDS Section O (e.g., respiratory therapy, oxygen therapy, etc.).

Submitting an IPA may lead to a higher Nursing CMG and increase the NTA classification due to the need for additional treatments, increasing reimbursement.

Cognitive or Behavioral Changes

Residents with dementia or other cognitive impairments can experience changes in condition, requiring more nursing or behavioral support. Suppose the resident experiences a decline in mental function or exhibits challenging behaviors that require more intensive intervention. In that case, the IPA can adjust the reimbursement to reflect these needs.

Example:

  • Initial cognitive and behavior status: A resident’s 5-day assessment had a score of 13 on the BIMS and no behavioral issues.
  • Change in condition: During the SNF, the resident’s cognitive status declines significantly, and begins exhibiting aggressive behavior that requires increased supervision, psychiatric care, and medication management

IPA – MDS Section C – the resident scores eight (8) on the BIMS; the behavioral symptoms are coded in MDS Section F.

The IPA allows the SNF to capture these cognitive and behavioral changes often associated with higher resident needs. As a result, the resident may be reassigned to a different SLP and Nursing CMGs, reflecting an increased reimbursement.

Swallowing issues or Changes in Diet Consistency

There are instances where a resident may develop swallowing difficulties, which can make eating and drinking unsafe or uncomfortable.

Example:

  • Initial swallowing and diet: The resident had no swallowing difficulties and was on a regular diet, as reflected in the 5-day assessment.
  • Change in condition: During the SNF stay, the resident reports experiencing difficulty and some pain with swallowing. The dietician was consulted, and the physician ordered the evaluation and, if needed, treatment by the Speech-Language Pathologist (SLP), who noted mild oropharyngeal dysphagia with minimal food pocketing. The Dietitian and SLP collaborated on changing diet consistency modifications, which might include adjusting the texture of foods (like serving pureed or soft foods) or thickening liquids to make swallowing easier and safer.

IPA – Check MDS items K0100B: Holding food in mouth/cheeks or residual food in mouth after meals; K0100D, Complaints of difficulty or pain with swallowing; and K05203C, Mechanically altered diet.  

The IPA allows the SNF to capture these swallowing changes and interventions, supporting the change to a different SLP CMG and maximizing reimbursement.

How to Utilize the IPA Correctly?

The IPA must be used correctly and strategically to maximize reimbursement. Below are key steps for making the most of the IPA:

  • When deciding to complete an IPA, it is essential to compare this to another PPS assessment (i.e., the 5-day or the most recent IPA). Use the PDPM Calculation Worksheet for SNFs, Chapter 6 of the RAI Manual, as a reference. Use of a worksheet is critical because, since the decision to complete an IPA is optional, if the reimbursement does not change, or goes down, the SNF should not choose to complete an IPA.
  • Timely and Accurate Documentation – The most important factor in using the IPA effectively is to ensure that changes in the resident’s condition are documented clearly and accurately. When a significant clinical or functional change is identified, the Interdisciplinary Team (IDT) must review and update the resident’s medical records and assessment forms to reflect this change. Clear and accurate documentation will help support the IPA, reflecting the need to maximize appropriate reimbursement. This includes:
    • Revisiting the primary diagnosis and noting any new or more severe conditions.
    • Updating the Section GG functional scores based on the resident’s current level of independence.
    • Reviewing the residents’ needs and interventions.
  • IDT Collaboration—The IDT must regularly review a resident’s clinical status and functional abilities. Any changes should be communicated and discussed with the team responsible for completing and submitting assessments. Regular updates can help prevent missed opportunities to adjust payment through the IPA.
  • Stay Educated on PDPM Categories – Understanding how each PDPM category—PT, OT, SLP, Nursing, and NTAs—affects reimbursement is essential. Know that changes in your residents’ conditions may trigger changes in these categories.
  • Timely Submission – The IPA must be submitted within 14 days after the ARD (ARD + 14). Ensure that this timeframe is followed for the reimbursement to be adjusted beginning on the ARD of the IPA.

The SNF PDPM IPA is an important tool for SNFs to utilize to maximize reimbursement rates based on their residents’ evolving needs. Whether due to changes in health or clinical presentation, increased needs and interventions, new diagnoses, cognitive or behavioral changes, or even a missed coding event, the IPA allows SNFs to capture these changes and ensure that reimbursement aligns with the care being provided.

By implementing these strategies, documenting changes accurately, submitting IPAs promptly, and working collaboratively with the IDT, SNFs can maximize their reimbursement under the PDPM system while meeting the changing needs of their residents and receiving the appropriate compensation for the care provided. Staying proactive and knowledgeable about the PDPM system and its requirements and complexities, SNFs can navigate these changes successfully and ensure that their reimbursement reflects the true care provided to their residents.

If you are not completing any IPA assessments at your SNF and wonder if you should be, reach out to the consultants at LWCI. We will be happy to assist you with more specific review of your PDPM coding and billing practices.  Contact Kay Hashagen, PT, MBA, RAC-CT  at [email protected] or (410) 777-5999.