The SNF Patient-Driven Payment Model (PDPM) began October 1 (the start of Medicare's fiscal year 2020), marking a significant difference in the SNF payment system. Below you can find resources explaining the new payment methodology, plus links to tools to demonstrate the value of physical therapy.
APTA is aware of the concerns being aired since the PDPM was implemented on October 1, including reports at some SNFs of immediate related layoffs and new requirements to use group therapy for 25% of services for all patients. Per a CMS fact sheet: "Skilled therapy services will still be reimbursed by Medicare under PDPM. While PDPM does change the manner in which patients are classified into payment groups under the SNF [prospective payment system], it does not change any of the coverage criteria or documentation requirements associated with the skilled therapy service coverage under PDPM. More important, PDPM does not change the care needs of SNF patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies, made on behalf of SNF patients."
APTA created this brief summary to give you the facts about the impact of PDPM in a format you can share with others:
How to Take Action if There Is a Problem
If you are engaged in or have witnessed a billing practice that you think is suspect, consider the following steps:
- Contact the facility's corporate compliance officer or administration point of contact for compliance issues.
- Immediately stop the questionable practice.
- Contact your professional association for guidance.
- When appropriate, consider reporting information to the Office of Inspector General or CMS, particularly if the compliance officer has not responded appropriately.
- Seek knowledgeable legal counsel as appropriate if other efforts are not successful.
The SNF PDPM replaced the case-mix methodology known as Resource Utilization Groups Version IV (RUG-IV). Under the PDPM, payments are based on a resident's classification among 5 components—physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillary (NTA) services, a category mostly related to drugs and medical supplies. PDPM classifies residents into a separate group for each of the case-mix adjusted components, which each have their own associated case-mix indexes. Additionally, PDPM applies variable per diem payment adjustments to 3 components—physical therapy, occupational therapy, and NTA— to account for changes in resource use over a stay. These adjusted per diem rates are then added together with the unadjusted speech-language pathology and nursing component rates and the non-case-mix component to determine the full per diem rate for a given resident.
The PDPM also restricts use of group and concurrent therapy, limiting these services to no more than 25% of a resident's total therapy minutes. Hearing that some SNFs have incorrectly used this provision to mandate 25% group therapy, APTA has developed guidance on when to use group therapy:
- Group vs Individual Care (.pdf)
When is it appropriate to provide group therapy versus individual—one-on-one—therapy? This decision tree can help you determine the approach you should take.
Preserving Access to Services: Demonstrating Your Value
These handouts and tips can help you understand and demonstrate the value your services bring to your facility or agency, and to your patients.