Harmony Healthcare Blog

ICYMI: Patient Driven Payment Model: Q & A (Part 1 of 3)

Posted by The Harmony Team on Thu, Apr 25, 2019


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency


Whats Next written on wipe boardIs your Skilled Nursing Facility ready for the October 1, 2019 implementation of Patient Driven Payment Model (PDPM) as CMS proposed in the SNF PPS Final Rule FY 2019?  We encourage you to use this 3 Part Blog Series to gain an understanding of the Patient Driven Payment Model Reimbursement System.  Questions were submitted to HHI during our recent webinar:  Patient Driven Payment Model: 5 Things to Do Now!

  1. Is there an actual table of rates that we can access?

    Yes, per the Federal Register / Vol. 83, No. 153 Final Rule 
  2. Is the 25% group and concurrent therapy cap based on total therapy or are PT and OT evaluated separately? 

    To capture therapy delivery information over the course of a patient’s entire Part A stay, as it relates to the concurrent and group therapy limit under PDPM, CMS added Items 0425A1 – O0425C5 which will be added to Section O of the MDS.

    Using a lookback period of the entire PPS stay, providers will report, by each discipline and mode of therapy, the amount of therapy (in minutes) received by the patient.

    Providers should follow the steps outlined below for calculating compliance with the concurrent/group therapy limit:
  • Step 1: Total Therapy Minutes, by discipline (O0425X1 + O0425X2 + O0425X3)
  • Step 2: Total Concurrent and Group Therapy Minutes, by discipline (O0425X2+O0425X3)
  • Step 3: C/G Ratio (Step 2 result/Step 1 result)
  • Step 4: If Step 3 result is greater than 0.25, then the provider is non-compliant.

    There will be no penalty for exceeding the 25% combined concurrent and group therapy limit. However, providers will receive a warning edit on their assessment validation report that will inform them that they have exceeded the 25% limit.

    The warning edit will read as follows: “The total number of group and/or concurrent minutes for one or more therapy disciplines exceeds the 25 percent limit on concurrent and group therapy. Consistent violation of this limit may result in your facility being flagged for additional medical review.”

    CMS will also monitor therapy provision under PDPM to identify facilities that exceed the limit, in order to determine if additional administrative or policy action would be necessary. 
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  1. Will there still be a 3-day hospital admission required for coverage?

    Yes, under Traditional FFS Medicare, eligibility, entitlement, benefit periods and skilled coverage criteria do not change under PDPM. 
  1. NAC struggle with Section G. How do suggest they will do with GG?

    Review your process now.  Many facilities have Rehabilitation Services code Section GG on the MDS, and it is often based on only the evaluation.  The evaluation may occur on day one.  The assessment is based on the usual performance over first 3 days of the stay.  Many facilities cut the assessment time for the assessment.

    The Interdisciplinary Team should review their observations, documentation, speak with resident/family and direct caregivers.  Section GG is scored based on the patient’s usual performance, therefore the Interdisciplinary approach is critical. 
  1. With PDPM, what will be the best way for a facility team to measure therapy involvement/utilization to ensure appropriate levels of utilization are occurring and supported for our residents?

    CMS expects that there is no significant change in the way care is provided to the SNF patient.  This will be monitored and assessed via the discharge MDS that reports all therapy days and minutes since the start of the stay to the end of skilled stay.

    Measure progress towards goals, functional outcomes, patient and family satisfaction to validate that clinically appropriate reasonable and necessary care is provided. 
  1. How will ST frequency impact payment/scores?

    You do not need to deliver ST for the SLP Component. In fact, all patients have a PT, OT, SLP, NTA, Nursing and non-Case Mix component/rate. The 5-Day MDS does not code therapy involvement the way you code now.

    The SLP component is based on Speech-Language Pathology-Related Comorbidities, Acute Neurologic Clinical Category, Swallowing Disorder using items K0100A through K0100D, and Mechanically Altered Diet (while a resident) and Cognitive Impairment. 
  1. Will there be 2 sections/columns in GG to distinguish between nursing and therapy functional scores?

    No, Section GG will be completed as it is now.  There will be 6 GG Items for calculating the PT/OT Functional Score and 4 GG Items used for the Nursing Functional Score. Some Self-Care and Mobility tasks are averaged.  Under Section GG, increasing score means increasing independence.  Max Scores:  PT/OT:  6 items x max 4 points = maximum of 24 for the PT/OT Functional Score.  Nursing:  4 items x max 4 points = maximum of 16 for a Functional Score.

    PT/OT Functional Score: 
  1. Self-care: Eating
  2. Self-care: Oral Hygiene
  3. Self-care: Toileting Hygiene
  4. Average of following 2 items:

Mobility: Sit to lying
Mobility: Lying to sitting on side of bed

  1. Average of following 3 items:

Mobility: Sit to stand
Mobility: Chair/bed-to-chair transfer
Mobility: Toilet transfer

  1. Average of following 2 items:

Mobility: Walk 50 feet with 2 turns
Mobility: Walk 150 feet 

Nursing Function Score: 

  1. Self-care: Eating
  2. Self-care: Toileting Hygiene
  3. Average of following 2 items:

Mobility: Sit to lying
Mobility: Lying to sitting on side of bed

  1. Average of following 3 items:

Mobility: Sit to stand
Mobility: Chair/bed-to-chair transfer
Mobility: Toilet transfer

Harmony Healthcare International (HHI) is available to provide assistance You can contact us by clicking here. Looking to train your staff?  Join us in person at one of our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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Tags: Patient-Driven Payment Model

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