Most of you who choose to read this blog have been preparing for the CMS Patient-Driven Payment Model (PDPM) for a long time. Rehabilitation Manager Matt Williams’ preparation started over a year ago. I sat down with Matt to dive into the reality of PDPM.
Matt also joined me for a myPTpodcast. To listen, click here and select Episode 13.
Be sure to subscribe wherever you get your podcasts so you don’t miss an episode.
I’ve listened to webinars and read APTA and CMS reports but wanted to get a “boots on the ground” view of how PDPM will affect the delivery of Physical, Occupation and Speech Therapy services in the skilled nursing environment.
I started with a list of questions for Matt and then he provided his own insightful reflections on PDPM.
How will the removal of the minutes-driven Resource Utilization Groups Version IV (RUG-IV) system to PDPM change the delivery of rehab care in your facility?
Matt: “We always wrestled with how to deliver what was the best level of care for the patient. Over time we chose to focus on what level of minutes was best for the patient and chose not to push people into the higher RUG categories.“ Matt continued, “We believe that the PDPM puts an emphasis on delivering care at a level based on patient need, and away from revenue based on the level of PT, OT and SLP provided.” Matt reflected, “I actually think that the change to PDPM is a step in the right direction.” Matt said the change is not drastic for his facility
How will the change to PDPM affect revenue for your facility?
“CMS has provided an easy to use tool to access the projected revenue for your facility.” Our projections are favorable.”
Matt hypothesized, “Our projections appear positive because I believe we have not been over-utilizing the higher RUG categories.”
In PDPM we will not be rewarded with the level of PT, OT and SLP services we deliver. Instead, payment will be driven by patient admitting diagnoses and on the relevant MDS 3.0 data- the functional score for each discipline.
How does the GG score affect the payment group mix?
Matt started by reviewing the five factors affecting per diem payment in PDPM. “Physical Therapy, Occupational Therapy, Speech and Language Pathology, Nursing and Nontherapy ancillary services all affect per diem payment. PT, OT, SLP, and Nursing will report through the GG scores the initial functional level.
The functional level is then is paired with the admitting diagnoses. The two factors combined determine the “Case Mix Group.” Matt emphasized that identifying the correct functional level for the patient will be best identified from an interdisciplinary approach.
For example, on a physical therapy evaluation, a patient may present a sit to stand transfer where the amount of physical assist is less than 50%. This identifies that patient as level 3. This may be in contrast with how the patient presents in the evening. The nurse assistants may report that due to fatigue or confusion the patient may require to assist greater than 50% putting the patient with a chair stand score of 2. However, you factor your GG code level Matt recommended that you be consistent and gain input across disciplines.
How will PDPM affect your staffing levels?
“We do not anticipate any reduction or addition to our PT, OT or SLP staff,” Matt stated.
A Rehab Manager’s Review
“Since patient diagnoses significantly impact case group mix and therefore payment, it is crucial that the PT, OT, and SLP dialogue with coding and billing to identify what diagnoses they will be “treating” in physical therapy.
Matt presented this example: A patient is admitted with a diagnosis of low back pain which falls into the clinical category as “other orthopedic.” In addition, the patient, while hospitalized, received a new diagnosis of Parkinson’s Disease, which falls into the clinical category “Non-Orthopedic and Acute Neurologic.”
Which is the correct case mix? Each case mix has a specific per diem reimbursement rate. How do you choose? Matt believes in this case the patient went into the hospital due to acute low back pain. Most of the functional deficits that physical therapy will be addressed were due to the acute low back pain not the Parkinson’s Disease. Therefore, in this case, the most applicable case-mix per their facility would be the “other orthopedic” case-mix group.
Second Reflection – How will CMS utilize Discharge information in the future?
Matt is curious about how CMS will utilize discharge information. For example, SNF is required to provide the following discharge statistics:
1. The total number of therapy minutes provided.
2. Group therapy minutes.
3. Concurrent therapy minutes.
4. GG score the last 3 days.
He anticipates that CMS will be utilizing the discharge data in the future. “I would not be surprised that CMS will evaluate the number of therapy minutes and the GG scores to monitor the value of service provided. For example, I think that CMS may consider changing payment if a person stays 20 days and does not change in functional status.”
Matt also voiced concern over sticky moral dilemmas. Once a patient is assigned a case group for PT and OT, the facility will be receiving per diem reimbursement for the entire stay. However, what if the discipline discharges before the patient is discharged home? For example, consider a patient with a total knee joint diagnosis is placed in the total joint case-mix group for occupational therapy and physical therapy. After seven days Occupational therapy goals have been met. However, the patient continues to require skilled physical therapy through day 11. The facility receives occupational therapy per diem rates but is not providing the occupational therapy service. Matt wonders if CMS will adjust payments in the future if the services are not provided.
Third Reflection – Be Kind to your RN colleagues!
The discipline that PDPM may be affecting the most is nursing. Until now, only Physical, Occupation and SLP had to document skilled services to justify the payment. Under PDPD nursing will also have to provide documented justification for skilled nursing services. For example, nurses will need to provide documentation that the CHF patient requires skilled nursing services such as oxygen perfusion and edema assessments to justify the skilled nursing service. So, Matt said we need to work together to make sure that each discipline is documenting the skilled services that they are receiving payment for. Matt encouraged everyone to have consistent interdisciplinary meetings to ensure that each discipline is providing the documentation to justify the case-mix you are receiving.
I agree with Matt’s assessment of the PDPM. I believe the PDPM correctly focuses payment based on the diagnoses and needs of the patient. As PDPM is implemented we will experience its weaknesses. However, I believe we as rehabilitation providers have more than likely pushed CMS to make these changes. Our service levels did not change based on patient diagnoses and initial functional presentation. Hopefully, we can now demonstrate that we have the patient’s best interest in mind.
I would love to hear how the PDPM has affected your Skilled Nursing Facility – pros and cons. Please leave a comment below!