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Medicare Reimbursement

The intersection of quality and payment in the Medicare program continues to advance at a rapid pace. IHCA/INCAL team is committed to help our members learn and adapt to these changes.

CMS Updates Nursing Home Care Compare Staffing and Quality Measures

The Centers for Medicare & Medicaid Services (CMS) released QSO-23-21-NH regarding updates coming in April 2024 to Nursing Home Care Compare Staffing and Quality Measures. The updates accommodate previously announced changes to the Minimum Data Set (MDS) taking place October 1, 2023. This includes changes to the staffing level case-mix adjustment methodology from RUG-IV to PDPM. Additionally, CMS announced it will be removing the CMS-672 form (Resident Census and Conditions of Residents).



Beginning October 1, 2019, the methodology for nursing facility reimbursement rates changed significantly.  replaced the RUG-IV system with a completely new way of calculating reimbursement. Under PDPM, therapy minutes are removed as the basis for payment in favor of resident classifications and anticipated resource needs during the course of a patient’s stay. PDPM assigns every resident a case-mix classification that drives the daily reimbursement rate for that individual.

PDPM Resources

AHCA/NCAL and IHCA/INCAL have put together a number of valuable resources to help facilities and their partners navigate PDPM.

MDS PDPM On-Demand Series

This six-week, six session webinar series provides MDS section-by-section coding guidance under PDPM and insights for optimal data collection, supportive documentation, and consistent coding accuracy.


A-la-carte PDPM-Related Best-Practice CE Eligible PDPM Academy Webinars

The AHCA Patient Driven Payment Model (PDPM) Academy provides AHCA provider members with a suite of original content, tools, and training options and resources to assist providers in how to be successful in  implementing the new Medicare Part A PDPM SNF PPS.

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ICD-10 Online Training through ahcancalED

The AHCA ICD-10 PDPM training is an online training that is designed to position SNF professionals to be successful in a PDPM environment. The ICD-10 content, while PDPM specific, is complex.

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Skilled Nursing Facility Value Based Purchasing (SNF VBP) Program

The SNF VBP Program rewards skilled nursing facilities (SNFs) with incentive payments based on the quality of care they provide to Medicare beneficiaries, as measured by a hospital readmissions measure.

Section 215 of the Protecting Access to Medicare Act of 2014 (PAMA) added sections 1888(g) and (h) to the Social Security Act, which required the Secretary to establish a SNF VBP Program.

PAMA specifies that under the SNF VBP Program, SNFs:

  • Are evaluated by their performance on a hospital readmission measure;
  • Are scored on both improvement and achievement;
  • Receive quarterly confidential feedback reports containing information about their performance; and
  • Earn incentive payments based on their performance.

Quality Reporting Program (QRP)

On September 18, 2014, Congress passed the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). The IMPACT Act requires the submission of standardized data by Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs). The IMPACT Act establishes a quality reporting program (QRP) for SNFs.

The IMPACT Act added section 1899B to the Social Security Act (Act) and requires the reporting of standardized patient assessment data with regard to quality measures and standardized patient assessment data elements (SPADEs). It requires the submission of data pertaining to quality measure, resource use, and other domains. Through the use of standardized quality measures and standardized data, the intent of the IMPACT Act, among other obligations, is to be standardized and interoperable to allow for exchange of the data among post-acute providers and other providers. The IMPACT Act intends for standardized post-acute care data to improve Medicare beneficiary outcomes through shared-decision making, care coordination, and enhanced discharge planning.

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