Patient - Driven Payment Model-PDPM


                               Major Payment Changes Just Around The Corner !!!

In Short
  • Five different case mix components to reflect varied needs/characteristics of resident care.
  • Combined together with non-case mix component to form the full PPS Diem rate.
  • Separates therapy into three components: PT, OT, SLP
  • Therapy minutes are not used to determine classification into a group.
  • Nursing is a separate component for classification.
  • NTA is a separate component.
  • Payment based on the CMI for each component, multiplied by the federal base rate and adjusted to the variable per Diem schedule.

Under PDPM, Medicare is changing the definition of "Group" in group therapy. Per the proposed rule taking effect October 1st 2019, a group is now defined as a"qualified therapist or therapist assistant treating TWO to SIX patients at the same time who are performing the same or similar activities"

- This new definition of Group will require therapists to pay close attention to coding. Because the minimum limit is not 2 residents, therapists will need to be able to clearly identify if 2 residents treated at the same time is "Group" or "Concurrent" and code accordingly. Concurrent and group treatments should both be "pre-planned" events, so the intent of the treatment should be clear from the start. However, coding a treatment for 2 Part A residents as "group" will be something new for all therapists and will require a new mindset.

This proposal does not change the 25% limit on combined group and concurrent therapy for each discipline

Coming in 2020

Reduction of Payment for Part B Services Provided by Assistants (PTA, COTA, OTA)

  • All therapy services on or after 1/1/20 provided in whole or in part by an Assistant will need to be billed using the new payment modifiers
    • New PTA Payment Modifier: CQ
    • New OTA Payment Modifier: CO
  • All therapy services on or after 1/1/2022 provided in whole or in part by an Assistant will have a payment reduction of 15%  applied

What does provided in whole or in part mean?

CMS is defining in whole or in part  as provision of  more than 10% of a therapy service by an assistant.  The Final Rule states that specifics to this point will be addressed in the 2020 Proposed and Final Rules. {This is an improvement from the Proposed Rule which defined in whole or in part as �€�œany minute! By using the payment modifiers in 2020, CMS will have 2 years of data collection to assess potential revisions to the requirements.