On April 8, 2021, CMS released the new Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Proposed Rule which, once finalized, is effective October 1, 2021. This proposed rule updates Medicare payment policies for facilities under SNF PPS for fiscal year 2022. The proposed rule also includes information for the SNF Quality Reporting Program (QRP) and SNF Value-Based Program (VBP) for FY 2022.

See below for the most significant areas of updates:

  1. FY 2022 updates to the SNF payment rates
  2. Methodology for recalibrating the PDPM parity adjustment
  3. Rebase and revision of the SNF market basket to improve payment accuracy under the SNF PPS
  4. New Blood Clotting Factor Exclusion from SNF Consolidating Billing
  5. Changes in PDPM ICD-10 Code Mappings – The ICD-10 code mappings and lists used under PDPM are available on the PDPM Website at: https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/SNFPPS/PDPM
  6. SNF QRP update – modification to the public reporting SNF quality measures
  7. SNF VBP Program proposal to suppress the SNF readmission measure

For more information on this proposed rule, please visit the Federal Register’s Public Inspection Desk under “Special Filings,” at http://www.federalregister.gov/inspection.aspx.


By: Sheena Mattingly, Director of Clinical Outcomes

In case you are in need of a recap, let’s start from the beginning. PDPM came into our lives on October 1, 2019. IDT processes and collaborative effort toward patient-centered care became even more imperative. Therapy remained a necessity in the recovery process under the methodology. The Centers for Medicare & Medicaid Services made it clear as mud that they will be looking at provision of services and outcomes. Presumably, medical review will surround any substantial changes in these areas. Let us also not forget that outcomes are publicly reported and impact quality measures, QRP, VBP, five-star, and so much more. Now that you are all caught up, let’s get to the good stuff!

HTS has shown improved Section GG outcomes when FY2019 is compared to the first six months post PDPM implementation.

So, what does this mean? If outcomes are equal to or above historic values, there is less risk for medical review and it means patient care and delivery is not compromised under PDPM. Also, improved outcomes provide further evidence of the great care HTS therapists deliver…even during a Public Health Emergency!

The proof is in the GG but in case you want more, check out the list below to see just a few more accomplishments from the past couple months:

  • Outpatient clinics are back up and running at almost full capacity!
  • Therapists are now equipped to use two new delivery service modes: telecommunication technology and telehealth.
  • Procedures such as cleaning, disinfecting, and sanitizing have been successfully implemented company-wide in order to mitigate risk of exposure to COVID-19.
  • Therapists have utilized a new Treatment Hierarchy Guide provided by HTS to help prioritize the treatment visits and provide services in a sequential manner according to priority level to further mitigate risk of exposure.
  • The Breathe Program introduced in April has improved pulmonary intervention for patients.
  • Therapists have demonstrated commitment to best practice by accommodating new regulation and compliance standards due to the public health emergency with quick turnaround time! This has allowed HTS to continue to provide services to patients in need during uncertain times.

The Bottom Line… HTS therapists have been rocking it out even harder than ever before and for that we thank you!

SNF PEPPER summarizes data statistics which are obtained from paid SNF Medicare UB-04 Claims for SNF episodes of care that end in the most recent three federal fiscal years (the federal fiscal year spans October 1-September 30). The current version of PEPPER now available reviews episodes of care through quarter 4 of FY2019 including statistics for 2017, 2018, and 2019. SNFs are compared to other SNFS in three comparison groups: nation, MAC, and state. These comparisons enable a SNF to determine if their results differ from other SNFs and whether it is an outlier and/or at risk for improper payments.

Target Area Updates

The following RUGs focused target areas will be phased out for FY2020 as a result of PDPM: Therapy RUGS with High ADL, Nontherapy RUGs with High ADL, Change of Therapy Assessment, & Ultrahigh Therapy RUGS. These target areas are included in the current FY2019 report along with the target areas: 20-day episodes of care, 90+ day episodes of care, and a new target area: 3-5 day readmissions which reviews readmissions to the SNF following a 3-5 calendar day gap. Please note this target area will not reflect claims until FY2020 and is intended to give providers information on readmission practices before and after PDPM implementation in order to assess the level to which facilities “may attempt to circumvent interrupted stay rules.”

Please click here for a table of target area definitions and suggestions.

Accurate coding for the SLP Component under the PDPM reimbursement methodology has been an area of opportunity across the industry. HTS has uniquely positioned itself with a team of seasoned therapists and nurses to analyze data and trends to optimize systems and processes to assure a smooth transition into PDPM. Now that we have three months of PDPM under our belt, here is what we have learned:

  • A tool to communicate SLP evaluation findings to the IDT will streamline the process and optimize IDT collaboration. Our MDS coordinators have enough on their plates. Let’s make it as easy as possible to present them with information so they can make the best coding decisions. HTS has created a tool for this, “HTS IMA SLP Component Communication Tool.” This tool is completed by the SLP and/or OT to provide information regarding sections B, C, I, and K related to the SLP therapy PDPM component. The tool is also equipped with a coding reference to assure that therapists are familiar with the RAI language and coding instructions.
  • Best practices when administering the BIMS is an area of opportunity. HTS recommends reviewing interview guidelines from the RAI, coding tips, and BIMS basics. Use HTS’ “Cognitive Assessment Quick Reference” for a guide to optimize practices in these areas. Also, remember the BIMS is a brief test and is not sensitive enough to capture some cognitive deficits such as executive functioning impairments. Even if a patient is “cognitively intact” (BIMS score of 13, 14, or 15), they still may benefit for cognitive-communicative therapy. The SLP will have formal testing to identify these areas of deficit and create short term goals associated with these areas.
  • If a patient scores in the SA case mix group indicating there are no items coded for the SLP component, the patient can still qualify and benefit from therapy. As mentioned in #2, the formal testing selections by a SLP will be more sensitive to cognitive impairment and therefore capture deficits more brief tests will not. However, if a patient is coded as “SA” and would benefit from speech-language therapy, HTS recommends going over the patient record to assure coding accurately reflects the patient’s medical complexities. Often times aphasia in section I4300 of the MDS may be a coding opportunity but also may require querying the physician. Additionally, section K coding best practices could also result in a more accurate SLP case-mix group.
  • Section K coding and optimization requires IDT collaboration. 2017 CMS data analytics revealed that section K coding was also an area of opportunity. In the past many have relied solely on the dietary department for section K coding. We’ve learned the SLP observations are also an important factor when coding section K accurately. For this reason, HTS created a “Quick Reference Optimize Coding in Section K” and “RAI Instructions for Completion of Section K.” Additionally, a webinar is available on the partner portal, “PDPM: SLP Component and Accurate Reporting of SLP Comorbidities.”

As we continue to navigate new waters under the PDPM methodology, we have adapted and modified our systems and processes to assure patient-centered care is at the forefront and best practices are in place. Accurate SLP component coding allows us the opportunity to more accurately depict the patient’s medical status and individualized needs. HTS will continue to provide the resources and tools to achieve IDT collaboration for the best patient outcomes possible so together we can drive quality improvement.

Written By: Sheena Mattingly, M.S., CCC-SLP, RAC-CT, Director of Clinical Outcomes

Article by James M. Berklan, www.mcknights.com

Journalists are supposed to be “words” men and women, but to be honest, I love a good set of numbers as much as anything. Especially when they’re tied to a pertinent analysis.

That’s why I find this period of transition with the Patient Driven Payment Model intoxicating. There’s mystery (Will providers fare well under the drastic overhaul?), cunning (How might providers get the best bang for their buck?) and suspense (What will regulators yank back if they don’t like what they’re seeing?).

And numbers. Lots and lots of numbers.

Wednesday I got a chance to talk initial PDPM numbers with three of the biggest LTC numbers crunchers around, Marc Zimmet, Vince Fedele and Steven Littlehale. We talked about Zimmet Healthcare Services Group’s initial PDPM reimbursement analysis of October Medicare claims.

The overall impression coming out of it? You’re going to be alright, providers. Just as many had predicted, those who did their homework — and vow to keep getting better — should be just fine.

In fact, as colleague Danielle Brown writes in today’s top Daily Update news item, many providers who paid attention in their PDPM educational classes are making, on average, more than $50 more per patient day then they would have under the old RUGs-IV system. When adjusted for one-time exceptions, it’s about half that, but it’s still a big positive. In addition, Zimmet estimates that providers can gain another $40 per patient day more once they get better at coding and, well, simply remembering to claim what they have coming.

While OT and PT therapy pay rates won’t necessarily budge much, better can be had in speech language therapy, nursing and non-therapy ancillary services, Zimmet explained.

A big caveat here: The analysts were clear that theirs was not a random sample and should not be taken as an ironclad predictive argument. The sample included a lot of East Coast clients, and they tended to be on the larger size, but it was still significant and close to what others should be finding.

The biggest worry isn’t so much what PDPM will do to providers’ bottom lines, but, much as I predicted a few weeks ago after talking to a long time marketplace exec: What the Centers for Medicare & Medicaid Services will do to the flow of cash when it eventually recalibrates pay rates. Because we can assume with these kinds of cheery numbers Uncle Sam will want to get back what he feels is rightly his.

Zimmet predicted with “95% confidence” that a rate readjustment will be coming, eventually. Providers will know in “less than a quarter” how finances will shake out, but CMS will likely take about six months before it makes any pronouncements about rate readjustments.

Make no mistake: This is good. It means you’re not getting riffed right now, wondering how to make ends meet. The CMS policy is not going to be budget neutral — but in a good way.

And the best thing of all is, you can do even better at it once you get better at coding and stop leaving money on the table.

Click here to continue reading this blog.

Exclusive PDPM Training For HTS Partners

We are committed to supporting our partners by offering exclusive PDPM webinar and live trainings in critical areas to foster success as we “Power through PDPM.”

Moving From RUG-IV to PDPM:  The Transitional IPA

Wednesday, September 25, 10:00 a.m. – 11:00 a.m.

Join us for the 1st High Impact PDPM Workshop where we will review how to successfully navigate the upcoming transition from RUG-IV to PDPM. This webinar will focus on completion of the required transitional Interim Payment Assessment (IPA) for current Medicare Part A beneficiaries including gathering quality assessment data and considerations for ARD scheduling.

Presented by: Eleisha Wilkes, RN, RAC-CT


PDPM Billing Processes

Wednesday, October 23, 10:00 a.m. – 11:00 a.m.

The importance of billing accuracy becomes more important than ever under the PDPM (Patient-Driven Payment Model) effective October 1, 2019. This session will focus on tools and strategies to establish a robust Triple Check process that providers cannot afford to overlook.

Presented by: Stacy Baker, OTR/L, CHC, RAC-CT


Please contact us to register. Not a partner? Contact us to learn how we’re providing even more value to our partners.

The transition to PDPM will be on October 1, 2019 resulting in a “hard stop” of RUG-IV on September 30, 2019. Strategies for a successful transition include:

  • Development of a plan for data collection for IPA look-back periods which may creep back into September dates of service.
  • Completion of a triple check process to assure COTs are accurate and completed (missed COT will be provider liable).
  • Assuring no principal diagnoses map to “return to provider”.
  • Collection of section GG interim performance data.
  • Completion of resident interviews on or before the transitional IPA ARD.
  • Optimization of processes to code diagnoses for Nursing, NTA, and SLP components accurately.

A transitional IPA will be required for each Medicare A resident present in the facility on October 1, 2019. Transitional IPAs are not to be confused with an IPA. See below for key differences:

Click here for the Variable Per Diem Adjustment Factor Fact Sheet.


Transition to PDPM Example

Admission Date: 9/22/19  |  5 Day ARD: 9/29/19  |  Transitional IPA ARD: 10/4/19

Source: McGill J., (Producer). (2019). Strategies for PDPM transition and IPAs [Video Webinar].
Retrieved from www.aanac.org

  • RUG-IV will be used for payment for admission of 9/22 through 9/30.
  • Payment for the transitional IPA begins 10/1 and continues through the end of the Medicare stay unless another IPA is done.
  • The Transitional IPA ARD window is October 1-7. The provider may select any of these 7 days.
  • For this example, the transitional IPA will be 10/4.
  • The variable per diem begins 10/1.
  • The NTA is adjusted by 3.0 for Oct 1-3.
  • PT/OT component will not decrease by 2% until Oct 21.

Successful transition to PDPM will undoubtedly involve optimization of efficiency in providing care and improving patient outcomes. It’s never too late to reassess and tweak your facility’s operational strategies to get ready for the transition. Don’t know where to start or stuck on a process change solution? Contact your HTS Regional Director or the HTS Director of Clinical Outcomes today!


1. Start Date: October 1, 2019

2. Applies only to traditional Medicare Part A Skilled Nursing Patients

3. PDPM is a site-neutral reimbursement structure for post-acute care.

4. May impact SNF episodic spending

5. May create opportunities for SNF to increase their clinical scope to accept higher acuity patients

6. Increase of information needed from the hospitals transfer documentation to justify all active conditions:

  • History
  • Physical
  • Medication List
  • Labs
  • Therapy progress notes
  • Chest X-ray
  • Immunizations

Additional requested information under PDPM

  • ICD.10 codes with specificity
  • All active diagnoses
  • Post-Operative Reports
  • Any physician consults

7. PDPM should NOT affect the timeliness in which patients are accepted by Skilled Nursing Facilities

8. PDPM should not drastically reduce the amount of therapies provided or weekend availability

9. This is the largest change to SNF reimbursement in 20 years

10. There is opportunity to improve processes and care collaboration between hospitals and SNFs for optimal success under PDPM

Article by Skilled Nursing News

The federal government on Tuesday finalized a predicted funding increase for nursing homes, while also formalizing changes to several key quality programs — with an eye toward clarifying some parts of the new Medicare payment model for skilled nursing facilities.

Under the terms of the 2020 final rule for Medicare skilled nursing facilities, the Centers for Medicare & Medicaid Services (CMS) will increase payments to nursing homes by $851 million in the coming fiscal year, which begins October 1 of this year.

That figure represents a slight drop-off from the increase of $887 million projected in the proposed version of the rule, which CMS released back in April; the $851 million comes from a 2.8% increase to the Medicare market basket rate in the final rule, as opposed to a 3% rise in the proposal.

The Tuesday announcement also includes several clarifications related to the Patient-Driven Payment Model, also set to take effect October 1. CMS formally changed the definition of “group therapy” to any modality with two to six residents performing the same or similar activities. That change brings group therapy in SNFs more in line with other care settings, such as inpatient rehabilitation facilities, which use the same definition; CMS currently defines group therapy as activities with exactly four residents.

“As PDPM implementation takes place, CMS believes aligning the group therapy definition serves to improve the agency’s consistency in payment policies across PAC settings,” the agency wrote in a fact sheet about the changes.

Click here to continue reading this article.

Article by:  Sheena Mattingly, HTS Clinical Specialist

Speech Therapy’s role is going to become exceedingly important under PDPM. This is due to the change in reimbursement which will be focused on patient characteristics rather than therapy minutes. Here are the top 5 things you need to know:

  1. Medical complexity and clinical outcomes are the basis for the new patient-driven payment model (PDPM). SLPs will play an important role in determining SNF payment which will require system optimization for timeliness in order to code the most accurate information.
  2. PDPM does not change coverage criteria for skilled care. SNF care is still only covered if all four of the following are met:
    • SNF or skilled rehab services are required to be performed by or under the supervision of professional or technical personnel and is ordered by a physician for the condition which the patient received inpatient hospital services.
    • Skilled services are required daily.
    • Daily skilled services can only be provided on an inpatient basis in a SNF.
    • Services delivered are consistent with the nature of the severity of the illness or injury, medical needs, and accepted standards of medical practice, and are reasonable in duration and quantity.
  3. Understanding the components related to the payment model will help with adjustment to the new system. The need for ST is related to the presence of a swallowing disorder, a mechanically altered diet, a ST comorbidity related, and/or cognitive impairment. Combinations of these characteristics produce 12 ST case-mix groups. Our data analytics have observed a trend in need for optimization especially in section K of the MDS. For this reason, we have created tools and resources to help your SLP, dietician, and nursing staff code section K. Please contact us today for more information!
  4. Sections B, C, K, and I are crucial for accurate coding for the ST reimbursement component. Check out our 5 Day Assessment Tool to optimize IDT communication to improve your coding.
  5. CMS will monitor provider practice during PDPM implementation to audit changes in volume and intensity of therapy services, compliance with group and concurrent therapy limit, and coding practices.