Senior Living Health Care Connection: New PDPM case mix (part 1)

Therapy components outlined

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:

1. The ICD-10 code for the primary diagnosis, which may also be a surgical procedure done in the hospital
2. 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.”                      

PT and OT components use four “collapsed” clinical categories:

PDPM uses the functional scores for 10 section GG (functional abilities and goals) items:

Scoring goes from “set-up assistance, independent” for a score of 4 to “substantial/maximal assistance” for a score of 1. “Dependent,” “refused,” “not applicable” or “not attempted” all have a score of 0. Note that the higher scores in GG reflect increasing independence. While the case mix groups for PT and OT are the same, the case mix indicators are different so the payment is calculated differently.

SLP components contain the following patient characteristics:

• Acute neurologic clinical classification
• Certain SLP-related comorbidities

Speech comorbidities

• Presence of cognitive impairment, one of four PDPM cognitive performance levels, is assigned based on the brief interview for mental status or the staff assessment for PDPM cognitive levels
• Use of a mechanically altered diet
• Presence of swallowing disorder 

ICD-10 accuracy is vital for PDPM success. We will review NTA, the nursing groups as well as best practices in subsequent articles.

For additional information, contact Joan McCarthy, RSM health care consultant, at +1 312 634 3479.