CMS Issues PDPM Grouper Software Update to Fix Case Mix Errors

CMS; MDS; Medicaid; PDPM

Soon after the Centers for Medicare and Medicaid Services (CMS) implemented version 1.18.11 of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) on October 1, providers in states that use PDPM-based payment models under Medicaid noticed that the PDPM case-mix classification from OBRA assessments were incorrect. Specifically, incorrect case-mix assignments were occurring for the Nursing, Physical Therapy, and Occupational Therapy components on many OBRA assessments.  

On November 13, CMS issued the below notice of a software coding fix.   

The “PDPM Grouper JAR Package V2.2001 (ZIP)” is now available in the Downloads section below. This V2.2001 release is an update to adjust the OBRA logic for target dates on or after October 1, 2023.    

The logic for standalone OBRA assessments will be similar to the interim payment assessments logic. 

This means that:  

  •     If A0310A=01 and A0310B=99, use column 1 (GGxxxxx1)  

  •     If A0310A=02-06 and A0310B=99, use column 5 (GGxxxxx5)  

This change will affect Nursing, Occupational Therapy, and Physical Therapy logic. 

What’s Next: MDS software vendors will need to review the new instructions, implement the changes, and then deploy to provider software before the MDS generates the correct case-mix group assignment. Providers and their MDS staff should be on the lookout for information from their MDS software vendors about when the update has been applied.   

Providers with impacted OBRA assessments submitted prior to deployment of this software fix may want to contact their state Medicaid agency for guidance on whether correcting or resubmitting assessments will be necessary to update Medicaid PDPM payment rates.