PyPDPM

Tools for working with the CMS case-mix classification model, payment driven payment model (PDPM). Details about PDPM can be found here: https://www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/pdpm.

If you are interested in helping contribute to this repository, or have any questions, feel free to send me an email.

Usage

Basic usage includes three primary tasks:

• Retrieving reimbursement amounts for specific HIPPS codes (whether for a specific day or from the admit date to a specific day in the stay)
• Generating HIPPS codes from patient information (either using payment groups or specific patient PHI)
• Generating patient information from HIPPS codes

To get a PDPM HIPPS code from a patient's payment groups and then get the reimbursement amount for accumulated for days 0 to 30 of their stay, you can write:

from PyPDPM import HIPPS

code = get_PDPM_HIPPS_code('TK', 'SB', 'LBC1', 'NE', 1)
reimbursement = calculateTotalReimbursement(code, 30)

If you instead want to get the reimbursement about for a specific day, you could instead write:

reimbursement = getReimbursementAmount(code, 30)

The reimbursement functions assume an urban facility in the year 2022, but these can be adjusted by changing the values for the 'urban' and 'year' parameters.

It is important to note that you do not need to provide the payment groups for get_PDPM_HIPPS_code if you do not have them. You can instead pass:

• ICD10CM_primaryDiagnosisCode (str)

  Primary diagnosis of the patient

• section_GG_function_score (int)

  The section GG functional range score (standardized tool that measures the functional status and goals of the resident in various areas, including self-care, mobility, and communication)

• ICD10CM_SLP_Codes (list)

  List of ICD-10-CM does that are potential comorbidities

• cognitiveImpairment (bool)

  Boolean value representing whether a patient has cognitive impairment

• acuteNeurologicalCondition (bool)

  Boolean value representing whether a patient has an acute neurological condition

• mechanicallyAlteredDiet (bool)

  Boolean value representing whether a patient has a mechanically altered diet

• swallowingDisorder (bool)

  Boolean value representing whether a patient has a swallowing disorder

• ICD10CM_Codes (list)

  list of secondary diagnoses associated with a patient for NTA payment group calculation

• nursingPaymentGroup (str)

  The CMG for a particular patient

• assessmentType (str)

  'IPA', 'PPS 5-day', or 'OBRA' representing the assessment type

And the payment groups will be generated for you.

PDPM Mappings

Revenue per diem for Medicare patients is calculated through PDPM HIPPS codes. The table below summarizes each component of the HIPPS codes where columns 1 to 4 represent the payment groups for characters 1-4 (of five) in the PDPM HIPPS code:

PT/OT	SLP	NURS	NPG	Code Value
TA	SA	ES3	NA	A
TB	SB	ES2	NB	B
TC	SC	ES1	NC	C
TD	SD	HDE2	ND	D
TE	SE	HDE1	NE	E
TF	SF	HBC2	NF	F
TG	SG	CBC2		G
TH	SH	CA2		H
TI	SI	CBC1		I
TJ	SJ	CA1		J
TK	SK	BAB2		K
TL	SL	BAB1		L
TM		HBC1		M
TN		LDE2		N
TO		LDE1		O
TP		LBC2		P
		LBC1		Q
		CDE2		R
		CDE1		S
		PDE2		T
		PDE1		U
		PBC2		V
		PA2		W
		PBC1		X
		PA1		Y

The fifth character is represented by the assessment type, demonstrated by the following table:

Assessment Type	Code Value
Initial Patient Assessment	0
PPS 5-Day Assessment	1

Using the above tables, it is clear that the code 'KBQE1', for example, can be broken down into its unique payment groups. In this case, TK-SB-LBC1-NE using PPS 5-Day Assessment. For more information on what these payment groups mean and how they are selected, continue on to the following section.

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Case-Mix Index (CMI) values for each character

It is important to note that 'clinical category' originally has ten unique categories based on primary diagnosis. These ten categories are then grouped into four PT/OT categories (shown below in the leftmost column).

The following table shows, for the clinical category and PT/OT function score of a patient, which PT/OT payment group they fall into as well as their PT and OT CMI values:

Clinical Category	PT & OT Function Score	PT & OT Case Mix Group	PT CMI	OT CMI
Major Joint Replacement or Spinal Surgery	0-5	TA	1.53	1.49
Major Joint Replacement or Spinal Surgery	6-9	TB	1.69	1.63
Major Joint Replacement or Spinal Surgery	10-23	TC	1.88	1.68
Major Joint Replacement or Spinal Surgery	24	TD	1.92	1.53
Other Orthopedic	0-5	TE	1.42	1.41
Other Orthopedic	6-9	TF	1.61	1.59
Other Orthopedic	10-23	TG	1.67	1.64
Other Orthopedic	24	TH	1.16	1.15
Medical Management	0-5	TI	1.13	1.17
Medical Management	6-9	TJ	1.42	1.44
Medical Management	10-23	TK	1.52	1.54
Medical Management	24	TL	1.09	1.11
Non-Orthopedic Surgery and Acute Neurologic	0-5	TM	1.27	1.30
Non-Orthopedic Surgery and Acute Neurologic	6-9	TN	1.48	1.49
Non-Orthopedic Surgery and Acute Neurologic	10-23	TO	1.55	1.55
Non-Orthopedic Surgery and Acute Neurologic	24	TP	1.08	1.09

The following table shows, based on the presence of an acute neurological condition, SLP-related comorbidity, cognitive impairment, or mechanically altered diet or swallowing disorder, which SLP payment group a patient falls into as well as their SLP CMI value:

Presence of Acute Neurological Condition, SLP-Related Comorbidity, or Cognitive Impairment	Mechanically Altered Diet or Swallowing Disorder	SLP Case Mix Group	SLP CMI
None	Neither	SA	0.68
None	Either	SB	1.82
None	Both	SC	2.66
Any One	Neither	SD	1.46
Any One	Either	SE	2.33
Any One	Both	SF	2.97
Any Two	Neither	SG	2.04
Any Two	Either	SH	2.85
Any Two	Both	SI	3.51
All Three	Neither	SJ	2.98
All Three	Either	SK	3.69
All Three	Both	SL	4.19

The following table shows, based on extensive services, clinical conditions, depression status, restorative nursing services, and function score, which NURSING payment group a patient falls into as well as their NURSING CMI value:

RUG-IV Nursing RUG	Extensive Services	Clinical Conditions	Depression	Restorative Nursing Services	Function Score	CMG	CMI
ES3	Tracheostomy & Ventilator	---			0-14	ES3	4.04
ES2	Tracheostomy or Ventilator	---			0-14	ES2	3.06
ES1	Infection Isolation	---			0-14	ES1	2.91
HE2/HD2		Serious medical conditions e.g. comatose or respiratory therapy	Yes		0-5	HDE2	2.39
HE1/HD1		Serious medical conditions e.g. comatose or respiratory therapy	No		0-5	HDE1	1.99
HC2/HB2		Serious medical conditions e.g. comatose or respiratory therapy	Yes		6-14	HBC2	2.23
HC1/HB1		Serious medical conditions e.g. comatose or respiratory therapy	No		6-14	HBC1	1.85
LE2/LD2		Serious medical conditions e.g. radiation therapy or dialysis	Yes		0-5	LDE2	2.07
LE1/LD1		Serious medical conditions e.g. radiation therapy or dialysis	No		0-5	LDE1	1.72
LC2/LB2		Serious medical conditions e.g. radiation therapy or dialysis	Yes		6-14	LBC2	1.71
LC1/LB1		Serious medical conditions e.g. radiation therapy or dialysis	No		6-14	LBC1	1.43
CE2/CD2		Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns	Yes		0-5	CDE2	1.86
CE1/CD1		Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns	No		905	CDE1	1.62
CC2/CB2		Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns	Yes		6-14	CBC2	1.54
CA2		Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns	Yes		15-16	CA2	1.08
CC1/CB1		Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns	No		6-14	CBC1	1.34
CA1		Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns	No		15-16	CA1	0.94
BB2/BA2		Behavioral or cognitive symptoms		2 or more	11-16	BAB2	1.04
BB1/BA1		Behavioral or cognitive symptoms		0-1	11-16	BAB1	0.99
PE2/PD2		Assistance with daily living and general supervision		2 or more	0-5	PDE2	1.57
PE1/PD1		Assistance with daily living and general supervision		0-1	0-5	PDE1	1.47
PC2/PB2		Assistance with daily living and general supervision		2 or more	6-14	PBC2	1.21
PA2		Assistance with daily living and general supervision		2 or more	15-16	PA2	0.7
PC1/PB1		Assistance with daily living and general supervision		0-1	6-14	PBC1	1.13
PA1		Assistance with daily living and general supervision		0-1	15-16	PA1	0.66

The following table shows, based on NTA score range, which NTA payment group a patient falls into as well as their NTA CMI value:

NTA Score Range	NTA Case Mix Group	CMI
12+	NA	3.25
9-11	NB	2.53
6-8	NC	1.85
3-5	ND	1.34
1-2	NE	0.96
0	NF	0.72

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Additionally, for reimbursement calculation, the unadjusted federal rates per diem are taken into account (for both urban and rural facilities) as shown below:

Urban:

Rate Component	PT	OT	SLP	Nursing	NTA	Non-Case-Mix (NCM)
Per Diem Amount	$62.84	$58.49	$23.46	$109.55	$82.64	$98.10

Rural:

Rate Component	PT	OT	SLP	Nursing	NTA	Non-Case-Mix (NCM)
Per Diem Amount	$71.63	$65.79	$29.56	$104.66	$78.96	$99.91

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Finally, there is an adjustment factor applied per-diem:

Day in Stay	Adjustment Factor
1-20	1.00
21-27	0.98
28-34	0.96
35-41	0.94
42-48	0.92
49-55	0.90
56-62	0.88
63-69	0.86
70-76	0.84
77-83	0.82
84-90	0.80
91-97	0.78
98-150	0.76

as well as an NTA component adjustment factor:

Day in Stay	Adjustment Factor
1-3	3.00
4-150	1.00

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Total daily price computation

Using the above values, we can calculate the per-diem reimbursement from day 0 to n using the following formula:

(\sum_{i=0}^n BaseRate_i * CMI_i * AdjustmentFactor_i) + NonCaseMix