CMS Confirms Some PDPM Claim-Processing Errors,
Promises Fix by October

The federal government on Thursday acknowledged some errors in processing Medicare claims under the new payment system for nursing homes, promising to make a full correction by the start of its next fiscal year.

The main issue has to do with the sequence of initial claim filings for Patient-Driven Payment Model (PDPM) reimbursements, the Centers for Medicare & Medicaid Services (CMS) announced in a release from the Medicare Learning Network.

SNF PDPM Claims Issue

Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) initial claims that are processed out of sequence are not paying the correct Variable Per Diem (VPD)-adjusted rate. Also, all adjustment claims are not processing correctly. Claims need to process in date of service order for each stay for the VPD to calculate correctly. We will correct this issue in October. In the interim:

  • Submit claims in sequence by waiting at least 2 weeks before billing subsequent claims
  • To adjust claims, cancel the initial claim and all subsequent claims in the SNF stay then rebill in sequential order; or, hold adjustments (when allowable) until October when they will process correctly
  • Submit a complete bill at the time of entry