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

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