New Patient Driven Payment Model (PDPM) driving questions about therapy

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Providers on Tuesday began drilling down into the details of the Center for Medicare & Medicaid Services' new Patient Driven Payment Model, questioning how the 4-day-old reimbursement formula will influence therapy services.

CMS officials were asked to explain how patients receiving some types of therapy but not others — or none at all — would be categorized in the new case-mix classification during a SNF Open Door Forum conference call, according to attendees.

The proposed system, unveiled Friday in a 266-page document, reduces the number of classifications from a previously floated system by 80%.

If this system goes into effect as proposed in October 2019, skilled nursing providers will have to categorize residents across five categories, including two nursing case mixes (nursing and non-therapy ancillary) and one each for physical therapy, occupational therapy, and speech-language pathology.  

Regardless of whether a resident receives a certain therapy type, he or she would be rated in that category to create an aggregate mix and determine the corresponding reimbursement rate.

Providers also questioned the model's variable per-diem rate, which shifts downward over the length of a stay, starting after Day 20 for physical and occupational therapy patients.

“Constant per diem rates, by definition, do not track variations in resource use throughout a SNF stay,” the proposed rule reads. “We believe this may lead to too few resources being allocated for SNF providers at the beginning of a stay.”

The proposed model trims PT, OT and non-therapy ancillary pay over specific periods, while pay for speech language and nursing services would hold steady throughout a stay.

One provider questioned how the system would account for residents who suffer catastrophic events, such as strokes, that sometimes require more intense therapy days or weeks after admission, once the resident has regained strength.

CMS SNF team leader John Kane did not answer that specific query, but he encouraged providers to submit such questions as comments on the proposed rule, which will be taken through June 26.

In addition to per-diem variations for therapy services, providers in urban or rural settings would also have different rate factors. The system was tweaked to specifically help rural providers better, officials have said.

Additionally, CMS would add another 18% to the nursing per-diem payment for residents who have HIV/AIDS.

Those payments would then be added together along with the non-case-mix component to create a resident's total per-diem rate.

One thing that gets less focus in the new model — intentionally so — is billable therapy hours. According to listeners, Kane confirmed that hours would only need to be submitted as part of a discharge assessment, and would be used to determine whether the expected level of therapy falls off or increased after a switch to the PDPM.

The new system includes no minimum or maximum hours or artificial cut-offs.

“The minimum amount of therapy that should be delivered to SNF patients is the amount that they need,” Kane told conference call listeners.