Starting on Oct. 1, 2019, the Centers for Medicare and Medicaid Services (CMS) is replacing the current resource utilization group, version IV grouping methodology, with the patient-driven payment model (PDPM). In PDPM there are five case-mix adjusted components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nontherapy ancillary (NTA) and nursing. Each resident is classified into one group of each of the case-mix adjusted components. So, each resident will be classified into a group within each of the five components: PT, OT, SLP, NTA and nursing. Each separate component has its own case-mix adjusted index and a corresponding per diem rate. There are 16 PT groups, 16 OT groups, 12 SLP groups, six NTA groups and 25 nursing groups. We will review the primary components in the PDPM in four articles.
The first of these articles deals with the therapy components: PT, OT and SLP. PT and OT are driven by two different criteria:
- The ICD-10 code for the primary diagnosis, which may also be a surgical procedure done in the hospital
- The PT/OT function score
The patients are classified into a clinical category based on the primary diagnosis ICD-10 code in item 10020B on the minimum data set (MDS) and surgical procedures coded in 30 new items J2100–J500. Mapping the ICD-10 code to the PDPM clinical categories can be found on the CMS website. Go to the bottom of the page on the CMS website under PDPM resources and look at the “ICD-10 Clinical Category Crosswalk.”