The Medicare Patient-Driven Payment Model (PDPM) in Skilled Nursing Facilities

The transition to PDPM makes the use of clinical judgment and reporting potentially inappropriate administrative mandates and behavior more important than ever. When faced with an administrative mandate, ASHA and our occupational and physical therapy colleagues stand united in our firm commitment to ensuring clinical judgment drives patient care decisions. Reporting options exist to ensure that you can bring inappropriate mandates and requirements to the attention of decision-makers and oversight agencies. Please use these consensus documents as resources to support your advocacy on behalf of your patients and in demonstrating the value of your clinical judgment in driving patient care.

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

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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

Diagnosis codes (International Classification of Diseases or ICD-10) have two distinct roles under PDPM. They are used to identify the primary diagnosis and secondary or treating diagnosis(es).

Primary Diagnosis: SNFs assign an ICD-10 code to report the patient’s primary diagnosis, which is the reason for the SNF stay. The primary diagnosis is coded within Section I0200B and maps to a clinical category. Speech-language pathology related primary diagnoses that map to the acute neurologic clinical category will factor into the speech-language pathology payment. Currently, the primary diagnoses that map to the acute neurologic clinical category and trigger a speech-language pathology payment are limited to speech, language, and swallowing disorders due to cerebrovascular accident (CVA) and aphasia.

Secondary or Treating Diagnosis(es): Clinicians will use ICD-10 codes to capture additional diagnoses and comorbiditiesassociated with the patient. These codes can factor into the classification of patients into a speech-language pathology comorbidity payment. Currently, the diagnoses that trigger a speech-language pathology comorbidity payment within Section I800 of the MDS are limited to amyotrophic lateral sclerosis (ALS), oral and laryngeal cancers, and speech, language, and swallowing disorders due to CVA.

SLPs can find the ICD-10 codes that map to clinical categories or trigger comorbidity payments on the CMS website (select "PDPM ICD-10 Mappings"). The ICD-10 codes for primary diagnosis or comorbidities that trigger a speech-language pathology payment are 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 lists will be modified over time, as CMS refines the payment system.

It is important for SLPs and SNFs to accurately and comprehensively report the ICD-10 codes for specific secondary medical or treating diagnoses—in addition to the primary diagnosis for the SNF stay—that support and describe cognitive, communication, and swallowing disorders, even if those codes are not on the PDPM lists. Coding to the highest level of clinical specificity justifies medical necessity and supports the skilled areas SLPs are treating. Secondary medical and/or treating diagnoses can and should be used even when they are noted as "return to provider" codes within the PDPM clinical category mapping. The "return to provider" note only applies to the primary diagnosis area. It is not appropriate for the MDS or SNFs to require SLPs to change their secondary medical and/or treating diagnosis to a different diagnosis that will trigger a speech-language pathology and/or comorbidity payment.

Coding to the highest level of accuracy for diagnoses related to cognitive, communication, and swallowing disorders will help ASHA advocate for future changes to PDPM, including the addition of more ICD-10 codes that trigger a speech-language pathology and/or comorbidity payment.

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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, including in the area of quality improvement.

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].

ASHA Resources

Free ASHA Webinars and Podcast

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. 

Questions? Contact ASHA's health care policy team at reimbursement@asha.org.

ASHA Website Resources

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