The Prospective Payment Process

The actual procedures needed to implement the PPS are very simple - in fact, simpler than the old process of daily skill level determination. The primary process necessary is performing an accurate assessment!

The essential steps in PPS are:

1. Perform a preliminary assessment to determine initial qualification.
2. Schedule assessments according to the PPS rules (5, 14, 30, 60, 90 day)
3. Collect data and complete the assessments on time with clinical accuracy.
4. Encode the MDS data into MDS computer software, which calculates the RUG-III scores.
5. Pass the resident's RUG-III score, assessment reference date, and the MDS "reasons for assessment" to the business office.
6. The business office places a HIPPS code (which incorporates the RUG-III score and the
7. reason for assessment) onto the claim, with the days covered by the assessment(s).
8. The business office submits the claim to the Medicare fiscal intermediary.
9. The Medicare fiscal intermediary calculates the payment due and transfers the money to the nursing facility.

That really is all there is to it! The key points are the MDS schedule, and the accurate completion of the MDS.