HomeLatest NewsLong Term Care NewsCMS Holds Various SNF Claims to Refine PDPM

CMS Holds Various SNF Claims to Refine PDPM

As the Centers for Medicare and Medicaid Services (CMS) has undertaken the implementation of the Patient Driven Payment Model (PDPM), they are holding a limited number of Skilled Nursing Facility (SNF) claims while they make further refinements to the claims processing system.

PDPM (Patient Driven Payment Model) 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.​

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