CMS Proposes Significant Revisions to the SNF PPS Beginning October 2019

May 16, 2018

The Centers for Medicare & Medicaid Services (CMS) released a proposed rule [PDF], which would implement a revised prospective payment system (PPS) for skilled nursing facilities (SNFs) effective October 1, 2019, for fiscal year 2020. Therapy would no longer be used as the primary determinant of SNF Part A payment. A revised payment methodology called the Patient-Driven Payment Model (PDPM) will use patient clinical characteristics, such as diagnosis and comorbidities, to drive payment. This concept was previously known as the Resident Classification System (RCS) 1.

As outlined in the proposal, CMS research found that patients with certain clinical characteristics (e.g., the primary reason for the SNF stay) were more likely to require therapy and, therefore, should get a payment for the delivery of therapy services. Under the proposal, a SNF would receive payment for physical therapy, occupational therapy, and/or speech-language pathology services based on the patient's diagnosis and other characteristics. Previously, SNFs received a payment for general therapy based on the number of therapy minutes provided. CMS and its contractor found that in addition to the primary diagnosis (primarily acute neurologic conditions), the presence of a swallowing disorder and/or mechanically altered diet, a comorbidity related to speech-language disorders, and/or presence of a cognitive impairment warranted additional payments to SNFs to support residents requiring speech-language pathology services.

There would be a total of 12 speech-language pathology case mix groups based on the various combinations of the five patient characteristics described above. For example, if a patient has an acute neurologic condition, a comorbidity related to a speech-language disorder, a cognitive impairment, and both a swallowing disorder and mechanically altered diet, their payment for speech-language pathology services would be higher than a payment for a patient with "only" an acute neurologic condition and swallowing disorder. However, both of these patients would receive a payment for speech-language pathology services.  

Some additional highlights in the proposed rule for the PDPM include the following:

  • CMS will restrict the use of group and concurrent therapy to a maximum 25% of the episode for a patient combined.
  • CMS incorporated mechanically altered diets as a mechanism to increase payment for speech-language pathology services, which was requested by ASHA in previous comments.
  • CMS agreed with ASHA's recommendations to use Section O of the Minimum Data Set (MDS) to track when a patient does not receive therapy and to ensure compliance with proposed restrictions on the use of group and concurrent therapy.
  • CMS proposes to reduce the number and frequency of assessments requiring assessments only at admission and discharge, and an assessment entitled an "interim payment assessment."

ASHA has had representation on technical expert panels and submitted extensive comments to CMS as it has refined this proposal. ASHA is committed to ensuring that efforts to more appropriately align payment incentives does not come at the expense of Medicare beneficiaries who need access to speech-language pathology services. Comments can be submitted by any member of the public and are due June 26, 2018. ASHA will provide official comment on the proposed rule.  


For questions, please contact Sarah Warren, ASHA's director of health care policy, Medicare, at


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