Harmony Healthcare Blog

Patient Driven Payment Model: Questions and Answers (Part 2 of 3)

Posted by Sally Fecto on Tue, Mar 05, 2019


Edited by Kris Mastrangelo

C.A.R.E.

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


What Are The Rules? written on a chalkboardIs 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!

Question and Answer with Sally Fecto, Sr. VP Field Operations Harmony Healthcare International (HHI)

  1. Who is responsible for doing the cognitive assessment? I see there is a component under SLP, what if SLP is NOT involved in the patient care?The cognitive assessment may be done by a qualified clinician.  A qualified clinician is defined as a healthcare professional practicing within their scope of practice and consistent with Federal, State, and local law and regulations.

    The cognitive assessment and scoring are based on MDS coding of the BIMS or the CPS.  Either a BIMS score or CPS score is necessary to classify the patient under the SLP component. The BIMS is completed by interview.  The Cognitive Performance Scale (CPS) is based on the responses to the Staff Assessment.

    Any degree of cognitive impairment contributes to the SLP Component.
    • BIMS: < 12
    • CPS Score: >

  2. If rehab is not providing services who will complete rehab section GG. Sill Nursing? 

    Yes, nursing will complete the rehab portion of section GG if therapy has not observed, assessed or treated the patient (as they will not know the usual functional status).  Nursing will observe, review documentation, interview patient, family and direct caregivers. 

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  1. Can you group all other payor sources along with your Medicare A residents?

    Reimbursement for group therapy varies based on practice setting and whether the services are covered under Part A (inpatient) or Part B (outpatient). Group therapy policies are further defined in local coverage determinations (LCDs) issued by Medicare Administrative Contractors (MACs).


    Group therapy is defined for Part A as the treatment of 4 residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals.

    For Medicare Part B, treatment of two patients (or more), regardless of payer source, at the same time is documented as group treatment. For all other payers, follow Medicare Part A instructions. 
  1. Can OT address cognition or is it now going to be speech driven?

    There is no change in clinical practice.  The Cognitive impact is in the identification of the patient conditions to derive the SLP component.  The cognitively impaired patient may not be receiving SLP services and the cognitive impairment contributes to the CMG for SLP. 
  1. I have heard that one organization has interpreted the PDPM information to mean that a SNF will receive the therapy components for rate whether or not therapy is involved. I realize there is not a minute threshold but does therapy at least have to be involved to receive therapy component part of the rate?

    No, therapy doe s not need to be involved to receive the therapy component of the Part A rate. All Medicare A patients will classify into one of the 5 Case Mix Groups (CMGs) regardless of whether therapy is involved or not.
    • PT
    • OT
    • SLP
    • NTA
    • Nursing 
  1. Just to clarify, the presence or absence of a therapy SOC date in Section O of the 5-day assessment has no impact on the reimbursement categories for OT, PT, and ST, right?

    Yes, Section O0425 will be added to the MDS Item Set and is specific to Part A Therapies
    This section will be completed only if A0310H = 1, a SNF Part A PPS Discharge Assessment.  Therefore, therapy is not recorded on the MDS until the SNF Part A PPS Discharge Assessment.

    The patient need not be receiving any or all 3 disciplines to qualify for the PT, OT and SLP Case Mix Groups (CMGs).  Classification is based on primary medical reason for SNF care, functional score, Cognitive, Dysphagia, mechanically altered diet and other Comorbidities. 
  1. What dx will we put on the UB for billing? Of course, the primary but then what? The NTA? Then Therapy dx?

    Continue to report relevant ICD-10 codes that support the skilled stay.  There is one diagnosis that must be on the UB04 for reimbursement.  HIV/AIDS code of B20 must be on the UB to trigger reimbursement. Rather than a 128 percent adjustment for the entire PPS per diem rate, the adjustment under PDPM is an increase of 18 percent in the nursing component of the per diem rate and a reclassification under the NTA component to a higher rate category.


    Under the PDPM, the HIPPS code is structured differently. There are five Case Mix adjusted rate components under the revised model: 
    • The first position represents the Physical and Occupational Therapy Case Mix group.
    • The second position represents the Speech-Language Pathology Case Mix group.
    • The third character represents the nursing Case Mix group.
    • The fourth character represents the Non-Therapy Ancillary Case Mix group.
    • The fifth character represents the AI code.

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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