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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. 

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.

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). 


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