With exactly three months until the launch of a groundbreaking new payment methodology, many in the long-term care industry are still looking for answers to key questions about coding and therapy services that could dramatically influence reimbursements.

The changing definition of “group” therapy, ICD-10 codes that are missing or mapped incorrectly, and confusion over whether an optional interim payment assessment will be truly optional are among the widespread concerns about the Patient-Driven Payment Model. Skilled nursing operators, employee groups and advocacy organizations recently included requests for further details in their comments on the proposed 2020 rules for Medicare. 

In its comments, posted in the Federal Register, Genesis Healthcare said it backed the Centers for Medicare & Medicaid Services’ proposed shift to therapy provided in groups of two to six residents.

“It provides standardization across the Post-Acute Care setting and is consistent with the definition of group therapy provision in Inpatient Rehab Facilities,” Genesis wrote. “We believe a standard definition across all settings would reduce administrative burden on providers and provide more consistency in treatment plans as a patient transitions from one setting to another.”

The provider said the new approach would improve flexibility so residents in SNFs without exact groups of four — the current standard — could still work with fellow residents. LeadingAge took a similar stance in its comments.

CMS has imposed a 25% cap on concurrent and group therapy under PDPM. 

But Service Employees International Union cautioned that major SNF companies have been quoted “touting expected PDPM success that is based on a reduction of individual therapy in favor of group and concurrent therapy services.” They argued some might take advantage of larger group sizes to “maximize cost savings and potential profits, which could lead to residents not receiving the individualized therapy that is preferred.”

The union also noted that there is no financial penalty for exceeding the six-resident limit.

Missing codes

Other organizations remain concerned about ICD-10 codes, which will be used to set each resident’s primary diagnosis at admission. The proposed rule uses a diagnosis and procedural code crosswalk to map all possible diagnoses to 10 PDPM clinical categories. Those categories help set reimbursement rates.

The American Association of Post-Acute Nursing identified a page worth of codes that do not map appropriately or that are missing in some places. On their list for revision or correction are codes for malignant primary vs. malignant secondary oral cancers; aftercare following surgery for circulatory, gallbladder or coronary artery issues; and additional dysphasia diagnoses.

Both AAPACN President and CEO Tracey Moorhead President and LeadingAge have backed updates to those ICD-10 codes at the sub-regulatory level, which would speed changes. LeadingAge, however, in its comments, requested that CMS roll out updates on a predictable schedule.

“Continuously checking the PDPM website to ensure accurate coding would substantially increase providers’ administrative burden, an outcome that conflicts with one of the intents of PDPM,” wrote Jodi Eyigor, LeadingAge’s Director of Nursing Home Quality & Policy.

Both organizations also asked CMS for clarification on the interim payment assessment, which is the only opportunity under PDPM to show a change in patient status and seek the adjusted reimbursement. Text in the final proposed rule muddled previous interpretations that IPAs would be voluntary, commenters said. 

“This proposed rule states, ‘the SNF’s responsibility in this context would include recognizing those situations that warrant a decision to complete an IPA in order to account appropriately for a change in patient status,’” Eyigor noted. “This seems to indicate that a SNF could be held accountable if an IPA is not completed on a patient who is determined to have experienced a change in status.”

Earlier this spring at LeadingAge and AAPACN conferences, CMS SNF Team Leader John Kane went to great lengths to emphasize that IPAs would be fully optional.