A Clinician’s Guide to the new SNF Patient Driven-Payment Model … · 2018-10-29 · Lynda Jennings, OTR TOTA MCC 2019 –11/3/18 1 A Clinician’s Guide to the new SNF Patient

Lynda Jennings, OTRTOTA MCC 2019 – 11/3/18 1

A Clinician’s Guide to the new SNF

Patient Driven Payment Model

(PDPM)

Lynda Jennings, OTR

TOTA 2019 MCC Conference

November 3, 2018

Introduction• After over 20 years of skilled nursing facilities being reimbursed under the

Prospective Payment System, a major overhaul in reimbursement is around the corner significantly impacting therapy services.

• Effective October 1st, 2019 therapy minutes will no longer be utilized to classify skilled nursing facility resident’s into Resource Utilization Groups (RUGs).

• Counting of therapy minutes will be obsolete and therapy services will no longer be the primary driver of reimbursement.

• In it’s place will be a new model where the focus will not be on the number of minutes of service provided but, classifying the resident on patient characteristics, outcomes and quality versus quantity of rehab services.

2


Learning Objectives

• Understanding the legislative and regulatory changes to Medicare Part A policy impacting clinical perspective in skilled nursing facilities.

• Review how rehab services can influence positive outcomes through the new SNF Patient Driven Model (PDPM) landscape.

• Define the key components of the new SNF Patient Driven Model (PDPM) effective October 1, 2018.

• Review occupational therapy services distinct value to make an impact quality measures and patient outcomes.

3

Legislative Updates

• On July 31, 2018, the Center for Medicare and Medicaid Services (CMS)

issued a final rule (CMS-1696-F) outlining Fiscal Year (FY) 2019 Medicare

payment updates and quality program changes for skilled nursing facilities

(SNF’s).

• Additionally, CMS finalized a payment system called the Patient Driven-

Payment Model (PDPM) to replace the current RUGs-based SNF PPS.

• The implementation date for the final system is October 1, 2019 (FY 2020).

4


Payment Reform Provisions

• In the Balance Budget Act of 1997, Congress established a SNF prospective payment system (PPS) for Medicare Part-A fee for service (FFS) payment called Resource Utilization Group (RUGs) system.

• In April 2017, CMS released a regulatory update called the Advanced Notice of Proposed Rulemaking which outlined a new case-mix model called Resident Classification System ver. 1 (RCS-1) to replace the existing Medicare Part A FFS payment system.

• Based on feedback on RCS-1, CMS made significant revisions and released a new payment system in proposed and now final rule called Patient Driven Payment Model (PDPM).

5

Payment Reform Provisions

• PDPM is a fundamental shift from RUGs-IV and will replace RUGs entirely for Medicare Part A payment for SNFs.

• The new case-mix model, PDPM focuses on clinically relevant factors, rather than the volume –based services for determining Medicare payment by using ICD-10 diagnosis codes and other patient characteristics as a basis for patient classification. Therapy minutes will no longer drive payment.

• Under PDPM, Skilled Nursing Facilities (SNFs) reimbursement will provide a separate rate component for PT, OT, and ST services not based on therapy minutes for associated reimbursement. There will be an expanded nursing component to capture the clinical picture of the resident and a case-mix adjusted non-therapy ancillary component.

6


Key Elements of PDPM

• Payment is Per Diem Equal to the Sum of Component Rates.

• PDPM is Patient Characteristic-Based

• Variable Payment Schedule

• PDPM Finalized Elimination of Multiple Mandatory SNF PPS Assessments

• Interim Payment Assessment (IPA) – optional

• ICD-10 Diagnosis Coding on MDS and Related Coding becomes basis for payment

• Concurrent and Group Therapy Guidelines

7

RUGs IV vs PDPM

RUG IV ClassificationResource Utilization Grouper

• Per Diem based on a single RUG

• RUG uses service-based metrics to classify pts in a SNF into one of 66 possible groups that include two case-mix components:

1. Therapy

2. Nursing

PDPM - Patient Driven- Payment Model

• Per diem based on sum of six components

• PDPM groups pts into 10 primary classifications that include five case-mix index components:

1. Physical Therapy2. Occupational Therapy3. Speech Therapy4. Non Therapy Ancillary5. Nursing6. Non-Case Mix Component

8


RUGs IV vs PDPM

RUG IV Reimbursement

• RUG uses an index maximizing system which incentivizes higher therapy utilization.

• Rates are constant throughout patient lengths of stay, as long as services remain constant.

• Groups and concurrent therapy are financially discouraged.

PDPM -Patient Driven- Payment Model

• PDPM uses index combining system which financially incentivizes lower therapy utilization.

• Therapy minutes delivered has no impact on reimbursement.

• Rates decline after day 21 of a patient stay for the PT/OT component and after day 3 for the NTA component.

• Group and concurrent therapy are financially beneficial.

9

Index Maximizing vs. Combining

RUGs Index Maximizing

• The RUG model classifies every MCA resident into one of 66 RUGs levels. Most residents meet multiple categories, but the system applies patient to the group with the highest index, which correlates with the highest reimbursement.

• Since 90% of all MCA pt’s receive rehab services, daily reimbursement rates tend to be dominated by therapy services.

PDPM Index Combining

• Every MCA resident receives a calculated case-mix score in each of the five index components (PT/OT/ST/NTA/Nursing). The five indexes are combined with non-case mix components to determine the actual daily rate.

• PDPM Index combining increase the patient payment categories to 28,000+ levels.• PDPM removes therapy minutes as a means of classifying residents, which means it separates

therapy minutes delivered from the actual minutes. Instead it balances nursing and therapy case-mix classifications.

10


RUGs IV vs PDPMMDS assessments

RUG IV Current Assessments

• 5 scheduled assessments

• 5 day, 14-day, 30-day, 60-day, & 90 day

• Additional Assessments- OMRA, SOT, COT, EOT, EOT-R, Sign Change & PPS Discharge

PDPM Assessments

• Only 1 scheduled assessment – 5 day (Day 1-8) grace days eliminated

• EOT/COT, additional assessments eliminated

• 2 unscheduled assessments • Interim Payment Assessment (optional)• PPS Discharge Assessment

Adds Tracking PT/OT/ST– Therapy Start and End Date– Total Individual, Concurrent, and

Group Minutes– Total Days

11

Capturing the Clinical Picture

• Adapting to this substantial new CMS billing change will require highly accurate documentation and coding of each resident's medical condition, ADL status, and co-morbidities in order to receive compensation which most accurately reflects the resident's condition and the services provided to each resident.

• This will require medical and administrative teams to enhance their medical coding knowledge and skill in order to most accurately capture the data required to sufficiently document each resident's condition and avoid coding errors that can result in lower reimbursements to the facility.

12


Interim Payment Assessment (IPA)

• The Interim Payment Assessment (IPA) is an optional assessment that providers may determine whether and when an IPA is completed.

• The Assessment Reference Date (ARD) for the IPA will be the date the facility chooses to complete the assessment based on a triggering event that causes the facility to chose the IPA.

• Payment for the IPA will begin on the same day as the ARD.

• The IPA was placed into the payment system as a way to recognize changes in patient condition over the course of the stay.

• The variable rate is not impacted.

13

ICD-10 Diagnosis Coding on MDS

• The clinical reason for the resident’s SNF stay plays a critical

role in PDPM.

• We must ensure that the SNF has access to timely and accurate

information to complete this information.

• The selection of the appropriate ICD-10 diagnosis code plus

co-morbidities must be accurately capture to ensure appropriate

payment for services provided.

14


MDS Coding for PT/OT Components

• CMS finalized the proposed PT and OT components under the PDPM, as well as the methodology for classifying residents under the PT and OT components, with one important modification.

• The proposed rule required providers to record the type of inpatient surgical procedure performed during the prior inpatient hospital stay by coding an ICD-10-PCS code.

• In response to comments, CMS will instead require providers to select, as necessary, a surgical procedure category in a sub-item within MDS. This category will identify the relevant surgical procedure that occurred during the patient’s preceding hospital stay and will augment the patient’s PDPM clinical category.

SNFs will still need to be extremely knowledgeable on ICD-10 coding on the MDS as it determines the primary reason for the SNF stay.

15

Interrupted Stay PolicyInterrupted Stay Policy

• Medicare Part A covers a maximum of 100 days of SNF service per spell of illness or “benefit period”.

• A benefit period starts on the day the beneficiary begins receiving SNF benefits under MCA after a qualifying stay of at least 3 consecutive days duration.

• PDPM is proposing an interrupted stay policy to address discharges from a SNF setting during an active benefit period.

• Benefit Period would be consider a CONTINUATION if resident is discharged from a SNF and returns to SAME SNF by 12:00 am at the end of the 3rd day of interrupted window. Both resident classification and variable per diem adjustment schedule would continue.

• Benefit Period would be consider a NEW STAY if the resident is discharged from a SNF exceeds the 3 day interrupted window OR readmitted to a DIFFERENT SNF. Upon assessment the variable per diem adjustment schedule would reset to Day 1.

16


RUGs IV vs PDPMTherapy Delivery

RUGs IV

• Tracked by minutes on variety of therapy tracking assessments

• Minimum minutes required to meet each RUG level

PDPM

• No specific minutes are required

• Would allow up to 25% in group and concurrent combined

• Leave 75% for 1:1 treatment sessions

• Minutes reported on discharge MDS by modes of service

CMS has indicated that they do not anticipate a significant reduction in the amount of therapy provided to similar patients that were reimbursed under the RUGs-IV system.

17

Group and Concurrent Therapy

• Stated in the proposed rule (83 FR21066), to help ensure that SNF residents would receive the majority of therapy services on an individual basis, if the proposed PDPM was implemented, concurrent and group therapy combined should be limited to no more than 25 percent of a SNF resident’s therapy minutes by discipline.

• In combination, this limit would ensure that at least 75 percent of a resident’s therapy minutes are provided on an individual basis.

• For example, if a resident received 800 minutes of occupational therapy, no more than 200 minutes of this therapy could be provided on a concurrent or group basis.

18


Group and Concurrent Therapy

• Finally, we noted that under RUG–IV, we currently allocate minutes of therapy because we pay for therapy based on therapy minutes and not resident characteristics. We stated that given that therapy minutes would no longer be a factor in determining payment classifications for residents under the proposed PDPM, we would utilize the total, unallocated number minutes by therapy mode reported on the MDS, to determine compliance with the proposed limit.

• We explained that utilizing unallocated therapy minutes also serves to underscore the patient driven nature of the PDPM, as it focuses the proposed limit on concurrent and group therapy on the way in which the therapy is received by the beneficiary, rather than furnished by the therapist, and would better ensure that individual therapy represents at least a vast majority of the therapy services received by a resident.

19

Patient

Driven

Payment

Model

PT

OT

ST

Nursing

NTA

Non-Case Mix

These six components add up to a total rate. All

residents will be classified into a PT, OT, & SLP

classification regardless of whether they are receiving

services.

20


Component #Case Mix

Groups

Patient Characteristics Payment

Structure

PT 16 • Clinical category via primary dx

• Functional Score utilizing Sec GG

• PDPM PT Classification

Declining per diem after

day 21 using a variable

per diem payment

adjustment

OT 16 • Clinical category via primary dx

• Functional Score utilizing Sec GG

• PDPM OT Classification

Declining per diem after

day 21 using a variable

per diem payment

adjustment

SLP 12 • Clinical category via primary dx

• Determine one or more related SLP co-

morbidities

• Cognitive Impairment

• Number of conditions present

• Presence of a Swallowing disorder

• Presence of mechanically altered diet

• PDPM SLP Classification

Average daily per diem

throughout stay

PDPM

Payment

Components

21

Component #Case Mix

Groups

Patient Characteristics Payment

Structure

Nursing 25 • Nursing Function Score based on Sec GG• Eating, Toileting, Bed Mobility and Transfers

• Classify into the collapsed lower 43 nursing

RUGs• Extensive services

• Special Care High

• Special Care Low

• Clinically Complex

• Behavioral Symptoms/Cognitive Performance

• Reduced Physical Function

• Depression

• Restorative Nursing Count

• PDPM Nursing Classification

Average daily per

diem throughout stay

Non Therapy

Ancillary (NTA)

6 • Presence of HIV/AIDS

• Presence of Parenteral/IV Feedings

• High or Low Intensity

• NTA Comorbidities score calculation

• PDPM NTA Classification

Declining per diem

after day 3

Non-Case Mix N/A N/A Average daily per

diem throughout stay

PDPM

Payment

Components

22


PT and OT Case-Mix Classification

Clinical Categories- evaluated across 4 clinical categories

• Major Joint Replacement or Spinal Surgery

• Other Orthopedic

• Medical Management

• Non-Orthopedic Surgery and Acute Neurologic

23

PT and OT Case-Mix

Classification

Determine the resident’s primary diagnosis clinical category using the ICD-10-CM and ICD-10-PCS codes recorded on the MDS.

To do so, refer to the PDPM clinical category mapping at:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

Which maps a resident’s primary diagnosis to the 10 PDPM primary diagnosis clinical categories.

Note: Multiple ICD-10-CM codes may point to more than one Clinical category.

In these cases, providers will select a surgical procedure category which would identify the relevant surgical procedure that occurred during the pt’s preceding hospital stay and which would augment the pt’s PDPM category.

24

Primary Diagnosis Clinical

Category

PT and OT Clinical Category

Major Joint Replacement or

Spinal Surgery


Spinal Surgery

Orthopedic Surgery (Except

Major Jt. Replacement or Spinal

Surgery)

Other Orthopedic

Non-Orthopedic Surgery Non-Orthopedic

Acute Infections Medical Management

Cardiovascular and Coagulations Medical Management

Pulmonary Medical Management

Non- Surgical

Orthopedic/Musculoskeletal

Other Orthopedic

Acute Neurologic Acute Neurologic

Cancer Medical Management

Medical Management Medical Management



PT and OT Function

Score Based on Section GG

Section GG Score

Self-Care: Eating 0-4

Self-Care: Oral hygiene 0-4

Self-Care: Toileting hygiene 0-4

Mobility: Sit to lying

Mobility: Lying to sitting on side of bed

0-4

(avg. of 2 bed

mobility items)

Mobility: Sit to Stand

Mobility: Chair/bed-to-chair transfers

Mobility: Toilet transfer

0-4

(avg. of 3

transfer items)

Mobility: Walk 50 ft. with 2 turns

Mobility: Walk 150 ft.

0-4

(avg. of 2

walking items)

Scoring Response for Section GG

Items

Functional

Score

05, 06 Set-up assist, Indep. 4

04 Supervision or CGA 3

03 Partial/Mod A 2

02 Substantial/Max A 1

01, 07, 09,

10, 88

Dep., refused, N/A, not

attempted

0

25

Functional Impairment (Section GG)

• For purposes of calculating the function score, all missing values for section GG assessment items will receive zero points. Similarly, the function score will incorporate a new response “10. Not attempted due to environmental limitations” and CMS will assign it a point value of zero.

• The final rule further states:

• Furthermore, consistent with a commenter’s suggestion, we will adopt MDS item GG0170I1 (Walk 10 feet) as a substitute for retired item GG0170H1 (Does the resident walk), and we will use responses 07: “resident refused,” 09: “not applicable,” 10: “not attempted due to environmental limitations,” or “not attempted due to medical condition or safety concerns” from MDS item GG0170I1 to identify residents who cannot walk.

• These technical changes point out the importance of mastering Section GG, which also plays a role in SNF quality metrics under the Quality Review Program (QRP).

26


Clinical Category Section GG

Function Score

PT/OT

Case-Mix

Group

PT Case-

Mix

Index

OT

Case-

Mix

Index


Spinal Surgery0-5 TA 1.53 1.49

6-9 TB 1.69 1.63

10-23 TC 1.88 1.68

24 TD 1.92 1.53

Other Orthopedic 0-5 TE 1.42 1.41

6-9 TF 1.61 1.59

10-23 TG 1.67 1.64

24 TH 1.16 1.15

PT/OT

PDPM

ClassificationTable 21-Federal Register/Vol. 93, No.89.

27

Clinical Category Section GG

Function Score

PT/OT

Case-Mix

Group

PT Case-

Mix Index

OT Case-

Mix Index

Medical Management 0-5 TI 1.13 1.17

6-9 TJ 1.42 1.44

10-23 TK 1.52 1.54

24 TL 1.09 1.11

Non-Orthopedic

Surgery and Acute

Neurologic

0-5 TM 1.27 1.30

6-9 TN 1.48 1.49

10-23 TO 1.55 1.55

24 TP 1.08 1.09

PT/OT

PDPM


28


Variable Per Diem Adjustment (VPDA)

• PDPM incorporates variable per diem payment adjustment to

account for changes in resource use over the course of a stay for

PT/OT and NTA components.

• Variable Per Diem Adjustment (VPDA), utilizing the adjustment

factors and schedule for the PT and OT components, drops 2%

every 7 days starting on day 21.

• The adjustment factors and schedule for the NTA component

reduce this component starting on day 4.

29

Calculation of the Variable Per Diem

Payment Adjustment

PT and OT

Day in Stay PT and OT

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 .086

70-76 0.84

77-83 0.82

84-90 0.80

91-97 0.78

98-100 0.76

To calculate the per-diem rate for these

components, multiply the components of the base

rate by the case-mix index associated with the

resident’s case-mix group and the adjustment

factor based on the day of the stay.

Component Per Diem Payment =

Component Base Rate x Resident Group CMI x

Component Adjustment Factor

30

Table 30-Federal Register/Vol. 93, No.89.


ST Case-Mix Classification

5 Key Characteristics determine the ST component

• Acute Neurologic or Non-Neurologic

• SLP-Related Comorbidity

• Cognitive Impairment

• Mechanically Altered Diet

• Swallowing Disorder

31

ST Case-Mix Classification

Determine the resident’s primary diagnosis clinical

category using the ICD-10-CM and ICD-10-PCS codes

recorded on the MDS.

To do so, refer to the PDPM clinical category mapping

at:

https://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/SNFPPS/therapyresearch.html

Which maps a resident’s primary diagnosis to the 10

PDPM primary diagnosis clinical categories.

32

Primary Diagnosis Clinical

Category

PT and OT Clinical Category


Spinal Surgery

Non-Neurologic

Orthopedic Surgery (Except

Major Jt. Replacement or Spinal

Surgery)

Non-Neurologic

Non-Orthopedic Surgery Non-Neurologic

Acute Infections Non-Neurologic

Cardiovascular and Coagulations Non-Neurologic

Pulmonary Non-Neurologic

Non- Surgical

Orthopedic/Musculoskeletal

Non-Neurologic

Acute Neurologic Acute Neurologic

Cancer Non-Neurologic

Medical Management Non-Neurologic



Presence of Acute

Neurologic Conditions,

SLP Related

Comorbidities, or

Cognitive Impairment

Mechanically Altered Diet

or Swallowing Disorder

SLP Case-

Mix Group

SLP

Case-Mix

Index

None

Neither SA 0.68

Either SB 1.82

Both SC 2.66

Any one

Neither SD 1.46

Either SE 2.33

Both SF 2.97

Any two

Neither SG 2.04

Either SH 2.85

Both SI 3.51

All three

Neither SJ 2.98

Either SK 3.69

Both SL 4.19

SLP PDPM


33

Aphasia Laryngeal Cancer

CVA, TIA, or Stroke Apraxia

Hemiplegia or Hemiparesis Dysphagia

Traumatic Brain Injury ALS

Tracheostomy Care (while a

resident)Oral Cancers

Ventilator or Respirator (while a

resident)Speech and Language Deficits

SLP Related

Co-

Morbidities

34


Cognitive Function Score (CFS)

CMS Propose blending BIMS and CPS to get a CFS score

CFS Cognitive Scale BIMS Score CPS Score

1. Cognitively intact 13-15 0

2. Mildly impaired 8-12 1-2

3. Moderately impaired 0-7 3-4

4. Severely impaired - 5-6

35

Nursing Case-Mix Classification

• CMS reduced the number of Nursing RUGs from 43 to 25

• Nursing will use Section GG to capture the Nursing Function Score

Section GG Score

Self-care: Eating 0-4

Self-care: Toileting Hygiene 0-4

Mobility: Sit to lying 0-4 (Average of 2 items)

Mobility: Lying to sitting on side of bed

Mobility: Sit to stand 0-4 (Average of 3 items)

Mobility: chair/bed-to-chair transfer

Mobility: Toilet transfer

36Table 25-Federal Register/Vol. 93, No.89.


ResidentGG-based Function

Score

Nursing

Classification

Nursing Case-Mix

Index

Extensive Services

0-14 ES3 4.04

0-14 ES2 3.06

0-114 ES1 2.91

Special Care High0-5/6-14 HDE2/HBC2 2.39/2.23

0-5/6-14 HDE1/HBC21 1.99/1.85

Special Care Low0-5/6-14 LDE2/LBC2 2.07/1.71

0-5/6-14 LBE1/LBC21 1.72/1.43

Clinically Complex

0-5/6-14 CDE2/CBC2 1.86/1.54

0-5/6-14 CDE1/CBC1 1.62/1.34

15-16 +CA1/CA2 0.94/1.08

Behavior

Symptoms/Cognition

11-16 BAB1/BAB2 0.99/1.04

Reduced Physical Function

0-5 PDE2/PBC2 1.57/1.21

6-14 PDE1/PBC1 1.47/1.13

15-16 PA1 0.66

Nursing

PDPM


37

Non-Therapy Ancillary (NTA)

Comorbidity Score Calculation

Determine if resident has one or more NTA-related

comorbidities.

• Does resident have HIV/AIDS?

• Presence of Parental/IV Feeding? High/Low

Determine the resident’s has any additional NTA-related

comorbidities.

To do so, review the 50 conditions and services in the

table for NTA Comorbidities. (Partial table shown on

right for reference)

https://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/SNFPPS/therapyresearch.html

38

Condition/Extensive Services Points

HIV/Aids 8

Parental IV feeding: high 7

Special Treatments/Programs: Intravenous

Medication Post-Admit Code

5

Special Treatment/Programs: Ventilator or

Respirator Post-Admit Code

4

Parental IV feeding: low 3

Special Treatments/Programs

• Transfusion

• Major Organ Transplant except Lungs

• Active Diagnosis – Multiple Sclerosis

• Wound Infection

• Active Diagnosis: Diabetes Mellitus

• Etc.

2

• Morbid Obesity

• Chronic Pancreatitis

• Inflammatory Bowel Disease

• Etc.

1



Non-Therapy Ancillary (NTA)

Comorbidity Score Calculation

Calculate the resident’s total NTA score using the NTA

Comorbidity Scale. Total NTA score, summing the

points for all conditions or services present.

39

Condition/Extensive Services Points

HIV/Aids 8

Parental IV feeding: high 7

Special Treatments/Programs: Intravenous

Medication Post-Admit Code

5

Special Treatment/Programs: Ventilator or

Respirator Post-Admit Code

4

Parental IV feeding: low 3

Special Treatments/Programs

• Transfusion

• Major Organ Transplant except Lungs

• Active Diagnosis – Multiple Sclerosis

• Wound Infection

• Active Diagnosis: Diabetes Mellitus

• Etc.

2

• Morbid Obesity

• Chronic Pancreatitis

• Inflammatory Bowel Disease

• Etc.

1

NTA Score

Range

NTA Case-

Mix Group

NTA Case-

Mix Index

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

Table 28-Federal Register/Vol. 93, No.89.Table 27-Federal Register/Vol. 93, No.89

Calculation of the Variable Per Diem

Payment Adjustment

Non-Therapy Ancillary

Day in Stay NTA

Adjustment Factor

1-3 3.00

4-100 1.0

To calculate the per-diem rate for these

components, multiply the components of the base

rate by the case-mix index associated with the

resident’s case –mix group and the adjustment

factor based on the day of the stay.

Component Per Diem Payment =

Component Base Rate x Resident Group CMI x

Component Adjustment Factor

40

Table 31-Federal Register/Vol. 93, No.89.


Non Case-Mix Component

• Flat rate

• Non case-mix Adjustment

41

PT

OT

ST

Nursing

NTA

Non-Case Mix

Total PDPM

Case-Mix

Adjusted Per

Diem Rate

These six components add up to a total rate. All

residents will be classified into a PT, OT, & SLP

classification regardless of whether they are receiving

services.

42


43

Urban Case Mix

Index

(CMI)

Adjustment Factor Component Per

Diem calculation

Component Per

Diem

PT $59.33 TA-TP (16) Day 1-20

1.0

Day 21 & forward see Table

30

Urban rate X CMI

X Adjustment

factor

$

OT $55.23 TA-TP (16) Day 1-20

1.0


30

Urban rate X CMI

X Adjustment

factor

$

ST $22.15 SA- SL (12) N/A Urban rate X CMI $

NTA $78.05 NA-NF (6) Day 1-3

3.0

Day 4-100

4.0

Urban rate X CMI

X Adjustment

factor

$

Nursing $103.46 ES3-PA1

(25)

N/A Urban rate X CMI $

Non Case

Mix

$92.63 No CMI

Flat Rate

N/A Flat rate $ 92.63

TOTAL PER

DIEM

$

Table 12 FY 2019 PPDM Unadjusted Federal Rates-Federal Register/Vol. 93, No.89.

How to calculate

the SNF daily

rate – (Urban)

44

Urban Case Mix

Index

(CMI)

Adjustment Factor Component Per

Diem calculation

Component Per

Diem

PT $59.33 TA-TP (16) Day 1-20

1.0


30

Urban rate X CMI

X Adjustment

factor

$

OT $55.23 TA-TP (16) Day 1-20

1.0


30

Urban rate X CMI

X Adjustment

factor

$

ST $22.15 SA- SL (12) N/A Urban rate X CMI $

NTA $78.05 NA-NF (6) Day 1-3

3.0

Day 4-100

4.0

Urban rate X CMI

X Adjustment

factor

$

Nursing $103.46 ES3-PA1

(25)

N/A Urban rate X CMI $

Non Case

Mix

$92.63 No CMI

Flat Rate

N/A Flat rate $ 92.63

TOTAL PER

DIEM

$

Table 12 FY 2019 PPDM Unadjusted Federal Rates-Federal Register/Vol. 93, No.89.

How to calculate

the SNF daily

rate – (Urban)


Case Examples

45

Therapy Considerations

Review Therapy Contract Agreements

• Existing agreements for Medicare Part A will need to be updated to reflect PDPM reimbursement guidelines

• Review agreements with Managed Care providers as they may adopt “PDPM like” reimbursement for Medicare replacement policies, continue with RUGs or change all together

• MCB currently will remain the same however, effective January 1, 2022 per the Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount.

46



Therapy Utilization may go down

• Demand for services may go down

• Outcomes should drive service delivery and modes of treatment

• If a patient misses or refuses a treatment, no urgency to “get your minutes”

• Must still follow MD orders

• Must still meet daily skilled requirement

• Must still meet customer service expectations

• Medicare regulation still apply

47


Industry Impact

• Demand for therapist may decline

• May impact therapist/assistant wages, benefits, etc.

• May impact mix of therapist to assistants

• Revisit use of rehab aides

• SNFs may evaluate contract versus in-house models

• Service delivery – 5/6/7 day week of services especially in first 20 days

48


Therapy Services Billing

How will SNF’s be billed for therapy services? Possible methodologies:

• Per Diem• Flat fee per day for every MCA pt in a SNF, regardless of whether they are

receiving services.

• Percentage of Reimbursement• The therapy company would bill the SNF an agreed upon percentage of the

reimbursement allocated for therapy to each resident.

• Per Minute• The therapy provider would bill the SNF on a per minute basis. Since, the

reimbursement for therapy is fixed for each individual patient, there would

presumably be a cap on the number of minutes that the SNF would be billed

based on the patient’s PDPM classification and therapy reimbursement.49

Therapy PDPM Preparedness• Identify distinct value added services and specialized skills

• Focus on functional and outcome based therapeutic activities

• Identify department inefficiencies and streamline services

• Review staffing skill sets and mix

• Review and educate evaluating therapist primary diagnosis selections/ICD-10 coding

• Validate accuracy of Section GG key functional components

• Ensure assessments capture skilled needs of resident and comorbidities accurately

• Review therapy services role in treatment of depression, behaviors, and special care

• Identify opportunities to begin to incorporate group and concurrent services as clinically appropriate

• Develop clinical pathways

50


51

Questions

52

References and Resource

FY 2019 SNF PPS Final Rule

https://www.federalregister.gov/documents/2018/08/08/2018-16570/medicare-program-prospective-payment-

system-and-consolidated-billing-for-skilled-nursing-facilities

Federal Register Vol.83, No. 153/Wednesday, August 8. 2018/Rules and Regulations

https://www.gpo.gov/fdsys/pkg/FR-2018-08-08/pdf/2018-16570.pdf

PDPM Calculation Worksheet for SNFs

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf

SNF PPS Payment Model Research


• CMS Advanced Notice of Proposed Rulemaking: Revision of SNF PPS Case-Mix Methodology (Resident

Classification System, Version 1 or RCS-1)

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/RCS_I_Logic-

508_Final.pdf

https://www.federalregister.gov/documents/2018/08/08/2018-16570/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities

https://www.gpo.gov/fdsys/pkg/FR-2018-08-08/pdf/2018-16570.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/RCS_I_Logic-508_Final.pdf


53

References and Resource

• Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT ACT)

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Medicare/Improving-Medicare-Post-Acute-Care-

Transformation.aspx

• Medicare proposes fiscal year 2019 payment & policy changes for skilled nursing facilities

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-04-27-4.html?DLPage=1

• Medicare Says It Heard OT Loud & Clear on Proposed SNF Payment Model

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2018/Medicare-Hears-OT-Loud-Clear-Proposed-SNF-

Payment-Model.aspx

• CMS Adopts New SNF PPS Patient-Driven Payment Model (PDPM): Important Highlights From the SNF PPS 2019

Final Rule

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2018/CMS-SNF-PPS-Patient-Driven-Payment-Model.aspx

• Acumen Skilled Nursing Facilities Patient-Driven Payment Model Technical Report

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf

• New Patient-Driven Payment Model Will Change SNF PPS Payment

https://www.aota.org/publications-news/otp/archive/2018/patient-driven-payment-model-snf-pps.aspx

Contact Information

Lynda Jennings, OTR

Chief Operating Officer

Touchstone Rehabilitation

[email protected]

210-301-1511

54

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Medicare/Improving-Medicare-Post-Acute-Care-Transformation.aspx

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-04-27-4.html?DLPage=1

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2018/Medicare-Hears-OT-Loud-Clear-Proposed-SNF-Payment-Model.aspx

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2018/CMS-SNF-PPS-Patient-Driven-Payment-Model.aspx

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf

https://www.aota.org/publications-news/otp/archive/2018/patient-driven-payment-model-snf-pps.aspx

mailto:[email protected]

Documents

A Clinician’s Guide to the new SNF Patient Driven-Payment Model … · 2018-10-29 · Lynda Jennings, OTR TOTA MCC 2019 –11/3/18 1 A Clinician’s Guide to the new SNF Patient