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In a proposed change strongly supported by APTA, skilled nursing facilities (SNFs) could see more flexibility when it comes to the number of residents considered acceptable for "group therapy" under Medicare. The loosened definition is part of the proposed fiscal year (FY) 2020 payment rule for SNFs recently issued by the US Centers for Medicare and Medicaid Services (CMS), a plan that also includes an overall 2.5% payment increase.

Currently, treatment of 4 patients performing same or similar activities qualifies as "group therapy" for purposes of Medicare payment in SNFs. The proposed FY 2020 rule—which would go into effect on October 1, 2019—would allow qualified rehabilitation therapists including physical therapists (PTs) to form groups with as few as 2 and as many as 6 patients. The change would make SNF group therapy rules more consistent with other care settings and "create opportunities for site-neutral payments," according to a CMS fact sheet on the proposed rule.

"The expanded definition of group therapy is very much in line with APTA's ongoing effort to advocate for the value of the PT's clinical judgment by allowing for more clinical flexibility in determining the most appropriate number of participants in a particular group," said Kara Gainer, APTA's director of regulatory affairs. "The change makes sense in terms of both payment and providing appropriate patient care."

The proposed rule would also boost payments to SNFs by about $887 million in FY 2020, with average increases varying depending on, among other things, the location of a particular SNF: facilities in urban areas would likely receive a 1.8% increase on average, while SNFs in rural areas could average a 6.4% increase.

PDPM System Moves Ahead—and Aims to Keep Up With ICD-10 Tweaks
As anticipated, the proposed rule proceeds with implementation of the Patient-Driven Payment Model (PDPM). The model is based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employs a per diem system that adjusts payment rates over the course of the stay. APTA has developed a number of resources on PDPM.

The CMS proposal also would allow the agency to use a "subregulatory" process to keep up with nonsubstantive updates to the ICD-10 codes used in PDPM, while substantive changes will be made through the traditional notice-and-comment rulemaking process. CMS writes that the change would "help ensure SNFs have the most up-to-date ICD-10 code information as soon as possible, in the clearest and most useful format."

Patient Assessment and Quality Reporting Data Requirements Expand
Also not much of surprise—CMS is proposing to continue its efforts to standardize patient assessment data collection across postacute care settings as required by the 2014 IMPACT Act.

Similar to its proposed FY 2020 rule for inpatient rehabilitation facilities (IRFs), CMS plans to require SNFs to report resident data on admissions and discharges in the following areas: cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidity; impairment; and a new category—social determinants of health. SNFs have been reporting on some components of these areas since 2018, mostly related to function, pressure wounds, and skin integrity.

In another proposed change that echoes the rule being considered for IRFs, the SNF Quality Reporting Program (QRP) would increase from 11 to 13 measures, adding assessments related to transfers of current reconciled medication lists at resident discharge or transfer; as well as the transfer of a similar list to the patient/resident, family, or caregiver upon discharge from a postacute facility.

The proposed rule also requires SNFs to collect and submit minimum data sets (MDS) on all SNF residents regardless of payer, a change that CMS says "may create additional burden" but would "ensure that Medicare residents are receiving the same quality of SNF care as other residents." As for MDS reporting related to post-hospital SNF care, the proposed rule clarifies that the "5-day assessment" requirement must be completed no later than the eighth day of the SNF stay, and that the requirement will go under a new name—"initial patient assessment"—beginning in FY 2020.

Amid all the additional requirements, CMS is proposing 1 reduction: baseline nursing facility residents would be excluded from the QRP related to discharge to community.

What APTA's Doing—and What You Can Do
The association will submit comments on the proposed rule by the June 18, 2019, deadline. Interested PTs, PTAs, students, and other stakeholders also are invited to provide comments, and will be able access information on how and where to submit comments at APTA's regulatory Take Action webpage in the coming days.

Members with an interest in postacute care are also encouraged to join APTA's online postacute care community on The Hub. The community is a staff-administered collaborative space for members to ask questions, share information, and identify areas of opportunity in relation to the new postacute care payment methodologies and other CMS postacute payment reforms. If you are interested in joining this online community, please email Kara Gainer at with “Join PAC Community” in the subject line and your member ID number in the body of the email.

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