On July 31, 2018, CMS released the SNF-PPS Final Rule which will establish the new Patient Driven Payment Model (PDPM) for Medicare Part A reimbursement effective October 1 2019. This new reimbursement system will base payment on the resident’s medical diagnostic conditions and care needs as compared to the current PPS RUGs system which is primarily based on volume of therapy minutes. At this time, the PDPM will only apply for “fee for service” traditional Medicare Part A not Medicare Advantage (yet).

Per the Centers for Medicare and Medicaid Services (CMS), the PDPM is designed to improve payment accuracy and incentives to treat the needs of the whole patient, instead of focusing on the volume of services provided. This model sets up expectations for enhanced interdisciplinary collaboration and case management.

How will this affect my role as a member of the rehabilitation team?

  • ICD-10 coding for medical conditions will be a key component
  • Therapy evaluations will no longer be viewed as “unbillable”
  • Comprehensive functional assessments including cognitive abilities will be a critical role for therapy
  • Section GG will be used to determine functional outcomes; collaboration with nursing and therapy to determine the most accurate code will be vital
  • Opportunity to use concurrent and group as clinically appropriate (limits set at a combined 25% of therapy minutes per discipline)
  • Interdisciplinary team collaboration to to prevent potentially avoidable hospital re-admissions
  • Continued focus on the CMS Five Star Rating System and the quality measures used to determine scores.

Functional Pathways will continue to be a leader in preparing for this significant change in the long-term care industry.  Stay tuned for upcoming events to prepare for a successful transition to the PDPM.

Beth Reigart, Clinical Operations Specialist