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  • SNF, IRF Final Rules Follow Through on Proposed Shifts in SNF Payment Systems, IRF Reporting Requirements

    The final 2019 rules for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) are substantially similar to what the Centers for Medicare and Medicaid (CMS) proposed in the spring, but that's not to say physical therapists (PTs) should assume it's a "same rule, different year" situation.

    In fact, the situation is far from a "same as usual" scenario—at least for PTs in SNF settings, who will be facing a dramatic change in how payment is determined.

    The new rules, set to go into effect in October of this year, include increases in payment of 2.4% for SNFS and 0.9% for IRFs, but the heart of the changes have less to do with payment increases and more to do with how payment will be determined and what needs to be reported. For PTs in IRFs, the reporting process could become a bit less burdensome, while PTs in SNFS will need to get up to speed with an entirely new payment system that does away with the Resource Utilization Groups Version IV (RUG-IV) process.

    SNFs: Hello Patient-Driven Payment Model (PDPM)
    The biggest takeaway from the proposed SNF payment rule was the adoption of the PDPM, and the same is true of the final rule. In doing away with the RUG-IV process, CMS adopted a model that bases payments on a resident's classification among 5 components, including physical therapy. Final payment is then calculated by multiplying the patient's case-mix group with each component (both base payment rate and days of service received) and then adding those up to establish a per diem rate. (Editor's note: more detail on the proposed rule appears in a PT in Motion News story published in April.)

    Between its release of the proposed rule and publication of the final version, CMS tweaked a few details—one around clinical categorization in the PDPM having to do with identifying surgical procedures that occurred during the patient's preceding hospital stay, and another related to a new assessment known as the Interim Payment Assessment (IPA), intended to accommodate reclassification of some residents from the initial 5-day classification. In the case of the IPA, CMS decided to make the assessment optional.

    IRFs: Goodbye Functional Independence Measure (FIM)
    As in the proposed rule, the final rule for IRFs drops the FIM and 2 quality-reporting measures related to methicillin resistant staph aureus (MRSA) infection and flu vaccine rates. According to CMS, data associated with FIM are being captured through other parts of assessment, while the costs of gathering data on MRSA and flu vaccines outweigh the benefits. (Editor's note: more detail on the proposed rule appears in a PT in Motion News story published in May.)

    The rule also allows for postadmission physician evaluation to count as one of the required face-to face physician visits and removes requirements for admission order documentation (but not the orders themselves). Additionally, under the new rule physicians will be allowed to lead team meetings remotely—a change that, when proposed, prompted APTA and others to ask CMS to extend that allowance to all team members. CMS stated in the final rule that it will evaluate how the new policy is working out and consider expanding flexibility.

    APTA comments on the proposed rules are available online (for SNF comments, visit APTA's Medicare Payment and Policies for Skilled Nursing Facilities webpage and look under APTA Comments; for IRF comments, look for the same header on the association Medicare Payment and Policies for Hospital Settings webpage). APTA summaries of the rules will be posted in the coming weeks.

    2018 State Policy and Payment Form Offers a Packed Agenda

    Issues that directly affect physical therapists (PTs), physical therapist assistants (PTAs), and society as a whole—population health, the opioid crisis, innovative delivery models, and much more—will be front and center at the 2018 APTA State Policy and Payment Forum. Registrations are now open for this important members-only gathering, to be held September 15–16 at the Westin Crown Center in Kansas City, Missouri.

    The forum is designed to increase PT and PTA involvement in and knowledge of state legislative and payment issues that have an impact on the practice of physical therapy, and to improve legislative, regulatory, and payment advocacy efforts at the state level.

    In addition to presentations on current advocacy efforts in the states, the forum will include information on federal regulatory issues; a presentation on state telehealth policy; and breakout sessions on state issues in pediatrics, value driving payment and contracting, and the physical therapy licensure compact. The event also includes a workshop for legislative chairs and lobbyists, and another aimed at payment chairs.

    Registration is online-only and is open through August 17—no onsite registrations will be offered. Visit the forum registration page to sign up and learn more about the event.

    Tiered Coding for PT Evaluations: New APTA Podcast Series Answers Common Questions

    As the payment landscape for 2019 comes into focus, it's becoming clear that physical therapists (PTs) will continue coding evaluations according to a 3-tiered system based on patient complexity. It's also clear that for now, at least, Medicare will not be using a tiered payment system, even as some commercial payers and state Medicaid plans adopt systems that reflect the complexity levels. Through it all, APTA continues to offer resources that help to reinforce accurate and consistent coding.

    CMS has indicated that its flat reimbursement policy, opposed by APTA from the start, will allow the agency to evaluate the distribution of utilization of the tiered codes in order to better determine the payment model. That distribution is beginning to come into focus: APTA research into nearly 4 million evaluations billed by providers across settings has revealed that 47% of evaluations were billed in the low-complexity category, 45% in the moderate-complexity category, and 8% in the high-complexity category.

    "At this point in time we have a sampling of baseline data that reflects practice in the first year of the tiered codes," said Alice Bell, APTA senior payment specialist. "CMS is also looking at this data and has indicated that they feel it will take 2 years of data to have an accurate representation. That means it's important that coding remain accurate and consistent."

    In its latest efforts to help underscore the importance of continued accurate coding, APTA produced a series of free podcasts on the CPT evaluation codes. The 5-part series covers a general overview of the coding change and addresses common questions related to determining levels of stability, documenting elements, the relationship of examination time to code selection, and coding in reevaluation. With episodes ranging from 5 to 8 minutes in length, the individual podcasts are convenient for quick listens on the go or during breaks at the clinic.

    "APTA is committed to supporting physical therapists through this transition to tiered coding in order to ensure that code selection truly reflects the level of complexity of the evaluation," Bell said. "Before we see further changes in reimbursement based on the tiered codes we want to make sure therapists have the tools and resources necessary to make the appropriate code selection. Accuracy in coding is critical if we are to make a compelling case for achieving our long-term goal of establishing reimbursement rates that truly reflect patient complexity."