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HTS is feeling optimistic as we read the latest reimbursement model change proposed by CMS and released late afternoon on Friday, April 27th. If you haven’t had the chance to dive into RSC-1, this was gearing up to be the biggest reimbursement overhaul since PPS.

The RSC-1 has now been modified and renamed to the Patient-Driven Payment Model (PDPM). The new model is designed to improve the incentives to treat the needs of the whole patient, instead of focusing on the volume of services the patient receives. CMS noted that RCS-1 received considerable feedback expressing concerns with the complexity of RCS-1. As a result, CMS has made significant changes that we are feeling pretty good about. If passed, this would take place starting October 1, 2019 — which means we don’t have much time before it becomes reality.

 

Here are 7 things we know up front about the PDPM changes to note:

  1. PDPM will be Much Less Complex than RSC-1
    Under the RSC-1, there were actually over 130,000 different possible classifications. The PDPM reduces this by nearly 80%. RUGs will certainly be going away, but this may make the reimbursement calculations much less of headache for all parties involved.
  2. Therapy is Detailed in the Discharge PPS Assessment
    A proposed modified section O requires PT, OT and ST details on all PPS discharge assessments for all Medicare A discharges (including those who DC from the facility). Therapy details include: start and end dates, total individual minutes provided, total concurrent minutes provided, total group minutes provided, and total days provided. This may be CMS’s way of safeguarding against underproviding and ensuring that patients receive what they need versus greatly reducing or eliminating necessary therapy services.
  3. PT & OT are Separate Payment Categories
    Under the RSC-1 model, PT and OT were a combined payment and ST was considered separate. Noting the obvious concerns, we are happy that each discipline will receive their own payment classification. Additionally, the new model eliminates the cognitive impairment factor from the PT and OT classification.
  4. Group & Concurrent Allow for a Total of 25%
     Under RSC-1, it was proposed to allow 25% group therapy and 25% concurrent therapy. Under the PDPM, there is a 25% group and concurrent therapy combined allotment.
  5. Section GG is Even MORE Important
     Replacing section G with GG for the functional component is required for PT & OT payment classifications, as well as,nursing case-mix classification. 6 areas are scored and totaled for the functional measure: eating, oral hygiene, toileting, sit-to-lying, lying-to-sitting on bed, sit-to-stand, chair/bed-to-chair, toilet transfer, walk 50 feet with 2 turns, and walk 150 feet. HTS implemented mandatory use of the CARE Tool for all therapists in 2014 to ensure that our outcomes and benchmarks are congruent with CMS.
  6. Reduced Burden of Multiple Assessments
     The reduction in required assessments as proposed with RCS-1 remains in the PDPM. Only 2 PPS assessments are required: 5-day assessment and D/C Assessment. PDPM adds an optional “Interim Payment Assessment” (IPA) which would allow for a resident to be re-classified if criteria are met.
  7. Reduction in Reimbursement with Length of Stay
    PDPM calls for reduction in reimbursement correlating with length of stay for PT, OT, and Non-Therapy Ancillary (NTA) classifications. For PT and OT, days 1-20 would be reimbursed at the full rate. On day 21, a decreasing adjustment factor of 2% is applied every 7 days throughout the remainder of the stay. NTA days 1-3 are reimbursed at an increased adjustment factor of 3. Day 4 through the remainder of the stay, the reimbursement is adjusted to a factor of 1. These adjustments are based on Medicare’s research indicating PT, OT, and NTA costs decrease the longer the resident stays.
Read More About the PDPM:

We Are Optimistic and Committed

We continue to be optimistic considering the enormous changes we are facing with this new payment model. CMS has an open forum and NASL and other groups are already collaborating on the details. CMS posted provider-specific impact data reflecting FY 2017 payment under RUG-IV compared with what the payment would have been under PDPM. After a full review, the total payment was indeed budget neutral.

You may view your SNF’s impact by following the link above (“CMS provided tools”). As we know more information, we will gladly pass it along. We are committed to being good partners in rehabilitation by informing our clients and colleagues with the most up to date information on rehabilitation and post-acute care.


Cassie Murray, OTR, QCP, IASSC CYB
Executive Director of Clinical Services
Healthcare Therapy Services, Inc.
cmurray@htstherapy.com | 800.486.4449 ext 210

HTS is a leading contract therapy and wellness provider in the Midwest. As the trusted authority in post-acute rehabilitation, our clients look to us to not only maintain exceptional clinical collaboration and outcomes, but also to be a trusted partner in helping their organizations perform better. Since 1988, HTS has been an independently owned, trusted, ethical provider of therapy services for senior living communities, home health agencies and hospitals.

Therapist owned and managed, our mission is to provide the very best people and programs to move our clients and employees forward so that together we can provide a “hope and a future” Jeremiah 29:11 to those we serve. We have grown from a single provider (who has been a longstanding client since 1988) to a company employing over 1,800 therapists in the Midwest and Southern states.

The Q4FY15 release of the Skilled Nursing Facility (SNF) Program for Evaluating Payment Patterns Electronic Report (PEPPER) with statistics through September 2015 is now available for download through the PEPPER Resources Portal. To obtain your SNF’s PEPPER, the Chief Executive Officer, President, Administrator or Compliance Officer of your organization should:

  1. Review the Secure PEPPER Access Guide.
  2. Review the instructions and obtain the information required to authenticate access. Note: A new validation code will be required. A patient control number or medical record number from a claim for a traditional Medicare FFS beneficiary with a “from” or “through” date in September 1-30, 2015 will be required.
  3. Visit the PEPPER Resources Portal.
  4. Complete all the fields.
  5. Download your PEPPER.

The SNF PEPPER will be available to download for approximately two years.

Revised in this release: The “Therapy RUGs” target area has been discontinued.

 


About SNF PEPPER

PEPPER is an educational tool that summarizes provider-specific data statistics for Medicare services that may be at risk for improper payments. Providers can use the data to support internal auditing and monitoring activities. PEPPER is distributed by TMF® Health Quality Institute under contract with the Centers for Medicare & Medicaid Services.