Physical therapy services represent a significant portion of Medicare expenditures in postacute care settings—services provided in inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), skilled nursing facilities (SNFs), and via home health agencies (HHAs) under Medicare Part A. PTs practicing in postacute care are integral to improving the quality of care provided to patients while reducing overall costs. This is particularly true under new value-based payment initiatives such as bundled payment models, accountable care organizations, and patient-centered medical homes.
APTA supports health care payment reforms in postacute care when they ensure access to physical therapy services that focus on the unique needs of patients. However, changes being made to the payment systems for IRFs, SNFs, LTCHs, and HHAs could have a drastic impact on the profession. The resources on this page will help you prepare for the postacute care reforms that are being implemented now and over the next several years.
Combined Postacute Care Reform Information
This Medicare Postacute Care Reform webpage hosts resources and updates on payment reform efforts that affect all postacute care settings—IRF, SNF, LTCH, and HHA. This reflects Medicare's desired move toward a unified payment system that eventually would replace the existing 4 individual systems. On the individual APTA webpages for each setting under Medicare Coding & Billing, you'll continue to find links to APTA comments and fact sheets specific to the regulations that govern those settings, which can be accessed by clicking on the appropriate link below:
Ongoing IMPACT Act Implementation
On September 18, 2014, Congress passed the Improving Medicare Postacute Care Transformation Act of 2014 (IMPACT Act). The Act requires the submission of standardized data by LTCHs, SNFs, IRFs, and HHAs. Additionally, the Act requires the development and reporting of measures pertaining to resource use, hospitalization, and discharge to the community. Through the use of standardized quality measures and standardized data, the intent of the Act, among other obligations, is to enable interoperability and access to longitudinal information for such providers to facilitate coordinated care, improved outcomes, and overall quality comparisons.
In implementing the IMPACT Act, CMS established quality-reporting programs for HHAs, IRFs, LTCHs, and SNFs. Additional information about the IMPACT Act and each setting-specific quality-reporting program can be found below.
2018: What You Need to Know
The Medicare payment system is in the midst of a paradigm shift—away from the fee-for-service payment structure, in which providers are rewarded solely by the volume of services provided, and toward a structure that holds providers accountable for patient outcomes and costs. This move to value-based care is intended to advance the goals of health care's "triple aim"—improving the patient experience of care (including quality and satisfaction), bettering the health of populations, and reducing the per-capita cost of health care.
As part of this effort, CMS is proposing significant changes that will affect the home health and skilled nursing facility payment systems, beginning as soon as 2019. These new payment systems would eliminate the connection between therapy use and reimbursement. CMS formally proposed the Home Health Groupings Model (HHGM) proposed earlier in 2017, but chose not to finalize it for 2018 after heavy opposition from groups including APTA. However, Congress is expected pursue legislation that makes at least partial reforms to home health payment that could begin as early as 2020. It also appears likely that CMS will work with stakeholders to develop a more patient-centered model that does not impose barriers to access, as the HHGM would have. A future home health payment model could mirror some aspects of the proposed HHGM. Accordingly, we encourage members to get to know the basic concepts of the HHGM.
The potential revisions to case-mix classifications chart outlines the potential revisions CMS was considering, as compared to the SNF RCS-I model, discussed below.
CMS released a less-formal Advanced Notice of Proposed Rulemaking for its SNF Resident Classification System Version 1 (RCS-I) and continues considering the initial comments it received earlier this year. CMS has indicated that it will continue to accept comments on the proposed RCS-I model. If you would like to provide feedback on the proposed model, please submit comments to: SNFTherapyPayments@cms.hhs.gov. While there is no deadline for comments, APTA recommends submitting them as soon as possible.
Because provisions in the proposed HHGM and RCS-I overlap between the 2 settings, APTA has developed a table showing their similarities and differences:
Potential Revisions to Medicare Case-Mix Classification Systems for Home Health and Skilled Nursing Facilities: A Comparison (.pdf)
How to Learn More:
This Could Impact You in the Coming Years
Although neither the HHGM (or alternative version) nor RCS-I model will be implemented in the foreseeable future, it is imperative that physical therapists and physical therapist assistants begin thinking about the implications of these types of proposals and prepare for the possibility that new systems could be effective by 2019 or 2020.
CMS's goal is to improve payment accuracy for patients in HHAs and SNFs. In future payment systems, it is likely we will see the connection between therapy utilization and payment eliminated. With the potential for therapy utilization no longer being connected to payment, it is imperative that you are able to understand and demonstrate the value your services bring to your facility or agency and, as important, to your patients.
To demonstrate the value of your services to the health care system and determine how your individual and group performance may affect payment within these new payment models, you need to know your outcome and cost data at the facility or agency levels.
For guidance on acquiring this data and working with your agency or facility administrators, please visit the APTA Quality webpage.
Documentation and Billing: What You Need to Know
Review information on coding and billing on APTA's Coding and Billing webpage.
Review the list of ICD-10-CM codes to be used for discharges and patient encounters occurring from October 1, 2017, through September 30, 2018. (Discharge is the point at which the patient leaves the setting and either returns home or is transferred to another facility. The term "encounter" is used for all settings, including hospital admissions, and describes an interaction between a patient and health care provider (ie, a visit).
Postacute PPS Assessments Guidance Manuals
Postacute PPS assessment manuals provide guidance for facilities and agencies on collecting accurate data through the assessment tool. These tools include both general data-collection conventions and item-specific guidance, as well as links to quality-related resources for agencies and facilities.