
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:
-
-
- 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:
- “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)
- Diagnosis, Primary reason for SNF admission, 4 total:
-
- 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