The Medicare Patient-Driven Payment Model (PDPM)

Changes to the Skilled Nursing Facility Payment System

Join ASHA, APTA, AOTA, and CMS for a free webinar "Therapy Services After Payment Changes in SNFs: How to Show Your Value Within PDPM" to help you prepare for the transition.

Wednesday, September 4, 2019 at 2:00 p.m. (EDT)

The Medicare Patient-Driven Payment Model (PDPM) is a major overhaul to the current skilled nursing facility (SNF) prospective payment system (PPS). It is designed to address concerns that a payment system based on the volume of services provided creates inappropriate financial incentives. This revised payment methodology is driven by the patient’s clinical characteristics rather than the number of therapy minutes provided. Other significant elements of the PDPM include the use of Section O of the  Minimum Data Set (MDS) to track the delivery of therapy services and a limitation on the use of group and concurrent therapy [PDF] combined at 25% of all therapy provided to the patient, per discipline. PDPM will be implemented on October 1, 2019.

ASHA actively engaged in the development of the PDPM through formal written comments, meetings with CMS staff, and speech-language pathology member representation on technical expert panels to ensure a move to such a payment model represents appropriate clinical practice.

See: CMS Finalizes Dramatic Overhaul of SNF PPS Effective October 1, 2019

Speech-Language Pathology Case-Mix Factors

Under the PDPM, payment for patients with speech-language pathology needs will be determined by the presence of the following five case-mix factors:

  1. the patient’s primary diagnosis,
  2. the presence of one or more of twelve comorbidities (aphasia; CVA, TIA, or stroke; hemiplegia or hemiparesis; TBI; tracheostomy care while a resident; ventilator or respirator while a resident; laryngeal cancer; apraxia; dysphagia; ALS; oral cancers; speech and language deficits)
  3. a mechanically altered diet,
  4. a swallowing disorder, and/or
  5. a cognitive impairment.

For example, a SNF resident who meets the criteria for all five factors would get a higher speech-language pathology payment than a resident with only one or two of these case-mix factors. 

See: CMS Fact Sheet on PDPM Patient Classification [PDF]

Speech-Language Pathology Diagnosis Codes

The list of diagnosis codes (International Classification of Diseases or ICD) that trigger a speech-language pathology payment and the speech-language pathology comorbidity payment (when an applicable comorbidity is present) is available on the CMS website (see “PDPM ICD-10 Mappings”). The current list of ICD-10 codes relevant to speech-language pathology services is limited because the historical claims data CMS used to develop PDPM did not include enough information associated with cognitive, communication, and swallowing disorders. However, the list will be modified over time, as CMS refines the payment system. Moving forward, it is important for SLPs and SNFs to accurately and comprehensively include the specific treating diagnosis codes (in addition to the medical diagnoses) that describe cognitive, communication, and swallowing disorders on claims. This will help ASHA to advocate for future changes to PDPM.

Payment for Speech-Language Pathology Services is Unique

It is also important to note that payment for speech-language pathology services is different from payment for occupational and physical therapy (OT and PT). For example, ASHA successfully advocated for the inclusion of comorbidities in the speech-language pathology portion of the SNF payment. PT and OT are not reimbursed for comorbidities. Another key distinction is that PT and OT payments decrease as the episode goes on (known as a variable per diem payment) while speech-language pathology payment is consistent across the episode. 

Practical Tips for Succeeding Under PDPM

Although PDPM is meant to alleviate pressures to provide as much therapy as possible, it does not address industry-developed pressures such as productivity requirements. It also creates potential new challenges for SLPs. For example, the additional payment for patients on mechanically altered diets may create unintended payment incentives to place patients on mechanically altered diets unnecessarily or keep patients on them longer than clinically warranted.

ASHA’s free webinars on PDPM and other resources developed to help you know the facts and know your value should help dispel the myths surrounding PDPM and empower you to take charge of describing the value SLPs bring to patient care in SNFs.

Remember, it is critical for services to be driven by patient need, not administrative or payer mandates. ASHA, the American Occupational Therapy Association, and the American Physical Therapy Association have developed a consensus statement [PDF] on the importance of clinical judgment in care decisions. Additionally, if you feel you are being asked to do things that violate ASHA’s ethical standards, payer requirements, or are contrary to patient needs, there is a mechanism available to report these concerns [PDF].

Free ASHA Webinars

Upcoming Changes in Medicare Payments for Skilled Nursing Facilities

This two-part series about PDPM dispels the myths surrounding the transition, discusses your role in patient care, and demonstrates the value of speech-language pathology in skilled nursing facilities.

ASHA Resources

ASHA Corporate Partners