Upcoming Patient Driven Payment Model (PDPM) for SNFs, CMS Medicare PDPM 101

Photo by Evgeni Tcherkasski on Unsplash

Effective 10/1/2019

Under PDPM

  • OT Services daily rate for each patient will be determined at admission by their “categorization” and entered into the MDS (minimum data set) based on:
      1. Diagnosis, Primary reason for SNF admission, 4 total:
        • Major joint replacement or spinal surgery OR
        • Non-orthopedic surgery & acute neurologic OR
        • Other Orthopedic OR
        • Medical management…which is then determined by #2:
      2. “Functional score” using Section GG (Continuity Assessment Record and Evaluation – CARE)
        • Scored from 1 (dependent) to 6 (independent)
        • 10 items of Section GG includes:
          • 3 self care: eating, oral hygiene, toileting hygiene
          • 7 mobility (e.g., sit to lying; toilet transfer; walk 30 feet with 2 turns)
        • Each set of scores (10 total) are converted with software to make up the functional score, based on their level assistance required (similar to FIM)
        • The functional score is summed from each aggregate activity, with higher independence correlating to higher functional score.
        • This will deteremine the “case mix” based on the sum and which range it belongs:
          • 0-5 (higher case mix due to lower function)
          • 6-9
          • 10-23
          • 24 (lower case mix due to higher function)
  • Daily rate of OT payment = (Base rate) x (Case mix)
  • Therefore, the daily rate will be determined by the data entered into the MDS upon evaluation, and not by the ongoing services provided.
  • Comorbidities will continue to be considered.
  • MDS will continue to collect data on OT’s role in cognition and swallow.
    • Therefore, document cognitive and swallow interventions.
  • No more than 25% of total therapy for a patient can be group or concurrent therapy to receive payment; ensures therapists will continue to choose primarily 1:1 therapy.

The Value of OT under PDPM

Value = (Quality + Service) / Cost

Therefore, SNFs will receive payment for improved outcomes, and conversely, penalized for poor outcomes:

  • Minimizing risk for falls
  • Minimizing pressure ulcers
  • Preventing readmission
  • Facilitating a safe transition and discharge into the community
Jeff is a licensed occupational therapist and lead content creator for OT Dude. He covers all things occupational therapy as well as other topics including healthcare, wellness, mental health, technology, science, sociology, and philosophy. Buy me a Coffee on Venmo.