Early PDPM Reactions: Therapy Companies’ Reimbursement Optimism, Continued Coding Challenges

With intense attention on therapy cuts and reimbursement changes during the transition to the Patient Driven Payment Model (PDPM) on October 1, operators and lead clinicians have focused on continuing education and training to remain financially sustainable amid this historic shift.

SNN spoke to four therapy companies to see how operators and clinicians are faring more than a month after PDPM’s inception.

So far, there’s good news for speech therapy — with added reimbursement categories such as swallowing disorders and other speech-related issues.

Difficulties remain, however, with streamlining certain coding categories such as “GG” — defined as functional and cognitive scoring, a detailed documentation requirement that’s newly relevant to reimbursement.

Other trouble spots involve the ongoing retraining of therapists to more easily move from a focus on therapy volume to individual patient goals, and ensuring clinicians are flexible enough to promptly change clinical plans to fit a patient’s altering needs — and to update those changes in new system modalities.

Susan Krall, vice president of strategic partnerships at the Dallas-based Quality Rehab Management (QRM) said her company experienced a 25% growth in clients coming down the pipeline since the new payment model’s inception.

QRM helps its health care clients transition to in-house services, and provides programming consultations to facilities that already have therapists on their payroll.

“People in-house and on their own realize they need help in navigating this new payer source and ensuring they don’t have trouble staffing. They want someone to help manage their labor and assist in driving clinical outcomes,” Krall said.

QRM’s education and training under PDPM includes nursing, administrators, Minimum Data Set (MDS) coordinators, clinicians who make individual care plans, social services staff, and medical and therapy directors. Their team offers a medical review to help clients find opportunities to use reports from a variety of software vendors, in addition to electronic health records for claims with multiple reports.

“We sit down together to see how we’re progressing to find ways to ensure we’re identifying patient needs, addressing them, and watching our outcomes,” Krall said.

Section GG impacts reimbursement for physical and occupational therapy as well as nursing, focusing on patient’s functional capabilities and deficits in the first three days through collaborative discussion and goal-setting.

“For GG, you need to ensure accuracy in accordance with CMS because you will be audited, as it’s part of reimbursement,” Krall said. “The mission is for CNAs and bedside caregivers to know what the goals of the patients are now more than previously. Right away this goal shifted even though GG has been around since October of 2016.”

Finding a patient’s usual performance in the first three days can be challenging because admissions often come in the evening, after key players are gone. It’s crucial to put systems in place where someone tracks GG from the first night up to the third night through midnight, Krall said.

“Now GG is often tracked when patients come in on a Friday, Saturday, and Sunday night, which were not days traditionally tracked with as much detail as we need now,” Krall said.

Potential confusion may also surround the clinical requirement to determine what the patient’s “usual” ability is — an essential component for the medical record.

Krall pointed to CMS’s coding definition: “The usual amount of help provided to complete the functional tasks included in GG. Specific tasks must be decided and agreed upon.”

The details of “usual” may include not only therapy in an hour, but bed mobility and eating — and every time someone transfers from one location to the next, the usual could change.

As each patient may have a different “usual,” specific questions that need answering include:

• Was this a level of usual before the benefit of intervention?
• Who observed the patient eat one meal versus another?

Documentation must be combined for initial Medicare assessments, Krall added.

Despite some coding issues in need of more ironing out, new reimbursement drivers for speech therapy have speech teams excited to play a bigger role at facilities. Coding categories involve comorbidity, cognition assessment, and swallowing.

“These are items that historically were not as prioritized and didn’t propel reimbursement in the past,” Krall said.

Pointing to the advantages of PDPM, Krall believes having more clinical eyes observing medical issues that could potentially lead to rehospitalization and decline is a win for nursing homes and rehab facilities – and applauded the inclusion of speech therapy for additional reimbursements.

“It’s great to have speech therapists included with the rest of the team, and an opportunity to see all of the available clinical assessments,” Krall said.

The shift to PDPM brought initial news of layoffs as volume no longer drove hours, with Genesis HealthCare (NYSE: GEN) reducing its therapist headcount by almost 6%.

But the therapy companies reached by SNN didn’t have a unilateral answer on staff reduction.

In terms of therapy layoffs, Krall suggested that there will be “natural shifts in delivery – both up and down – if every decision of intervention is based on a patient’s needs. And using the efficiencies of group and concurrent therapy on a patient-by-patient basis is essential for succeeding in this new climate, while working with an “interdisciplinary team who agrees that the intervention being delivered is medically necessary,” she said.

“Our clients are not saying, ‘I need a reduction in therapists.’ Instead they are asking, ‘Do we have the right amount of staff? Do we have too much? The good answer is to use efficiencies, manage labor costs, and make sure patients have what they need,” Krall said.

Adjusting to less structured days

Tammy Begler, vice president of SYNERTX Rehabilitation in Flagstaff, Ariz., said the transition to PDPM was smooth without many significant changes — in part because staffing levels were not reduced. And although the rehab company experienced some reductions based on decreased caseloads last summer, therapy jobs weren’t lost under PDPM, Begler said.

Challenges at SYNERTX pertained more to coding, according to Begler.

“Back office items have been a challenge, such as creating new invoices, etc., but it’s too early to tell. It’s a new day, and all is well out there in the therapy world; all of SYNERTX training and hard work has paid off at the facility level,” she said. “Now we are refining the processes at the facility level for all aspects of teamwork that lead to accurate PDPM coding. Overall, upfront training is now making more sense as the information is implemented into practice.”

Begler estimates that since PDPM is required to be budget neutral by CMS, SYNERTX will deliver the right level of care for the same outcomes, with the same margins for the company. However, she noted a slight increase in speech therapy, but “that does not always mean increased income for SYNERTX based on the contract agreement.”

As Krall mentioned, PDPM has challenged therapists to move their focus from scheduled minutes to the clinical needs of a patient on a particular day.

“The therapy minutes delivered are not significantly different under PDPM. So although therapists do have a schedule, the emphasis now is to do what is right for the patient that day. There’s a lot more freedom for the therapists, so they still get nervous,” Begler said.

In essence, therapists are ultimately dropping what Begler referred to as “old habits” — such as providing high-level therapy to residents every seven days in a highly structured format.

“Now we can have an open mind to address what the patient needs that day,” Begler said. “There is more room to show how the patient presents clinically each day, which is refreshing.”

Begler’s therapy team meets weekly to develop a plan for the patient. They enter the plan into the system to estimate how many minutes they believe the resident might need each day — with varying amounts of time allocated depending on the specific patient. The actual amount of minutes is measured when they see patients in the field, which is the second step in the process.

For example, if there’s an exhausted resident returning from dialysis without the strength to do as much therapy that day, the therapist can adjust the minutes. Or conversely, if a patient’s daughter walks in, “the therapist may want to do transfer training with the family member” in order to teach the family to work with the patient.

“It’s okay to adjust the plan,” she said.

SYNERTX scores the patients for GG on evaluations and discharges, and Begler discussed the coding complications for deciding on a patient’s usual status.

“It’s tricky because there are guidelines to capture the usual level of ability, but you also need to keep the patient safe,” Begler said. “Scoring isn’t easy because you have to decide: Will it be safe for them to do this independently or should I get in there?”

Additionally, scoring a patient incorrectly can impact reimbursement negatively under PDPM as well as the outcomes for the facility overall, Begler added.

Begler offered another example of how GG coding continues to need extra attention, describing a hypothetical situation in which clinicians must score a resident’s ability to sit up from laying down. When coming straight from the hospital, exploring the “usual” could be dangerous for a patient.

“Why would you let them do it independently if you don’t know if they’re cognitively intact in the first three days? They could be ill or disoriented and unsafe. You tend to help them. Trying to capture usual in three days is necessary for GG, which is capturing a baseline because that will be the outcome scoring. It’s hard to score in nursing and therapy.”

But because a patient’s overall GG score is part of calculating and determining factors that “can impact some reimbursements and it’s clinically important,” Begler said, it’s a “good challenge to get accurate.”

Speech in focus

Matthew McGarvey, vice president of operations at Language Fundamentals, says the company is thriving with the new speech language pathology component added to PDPM.

“For years, speech has dragged behind physical and occupational therapy, but with PDPM we’re now on a level playing field because speech has a new importance, and it’s exciting to be part of,” McGarvey said.

Language Fundamentals hires speech language pathologists who want to work in the medical setting dealing with cognitive communicative disorders, speech language deficits, dysphagia — a swallowing disorder — and speech pathology.

Prior to PDPM, speech therapists documented swallowing assessments on the standard five-day MDS. But now the assessment is done earlier — and for a “clinician to assess a patient before five days is a great way to ensure that any swallowing disorders are captured to help give the patient the most appropriate and least restrictive diet, which greatly reduces the potential risk of aspiration, which should ideally help to reduce hospital readmissions,” McGarvey said.

This shift could create a significant link between speech services and reducing hospitalizations: aspiration pneumonia is one of the top reasons for hospital readmissions, McGarvey explained.

Unlike in other disciplines, the workload has actually increased for Language Fundamentals as speech has become more actively involved with each new admission –– even in cases they may not have seen in the past.

“We have a bigger workload under PDPM. And it’s great that speech therapists always shine in treating the long-term care population, and PDPM doesn’t change that. There’s still a lot of patients to treat, such as those who suffer from dysphagia, or those with cognitive communicative deficits,” McGarvey said, adding that it’s “too early to tell about exact increases in billable hours.”

David Tate, chief strategy officer of the Dallas-based Reliant Rehab, believes that his company is prepared for PDPM because leadership provided the therapy team “with a great map for organizing clinical pathways”  — and some clinical teams were glad to move away from the old Resource Utilization Group (RUG) system.

“Some felt RUGs was somewhat arbitrary in levels of care provided based on volume without defining patient conditions,” Tate said.

Because the new system is not intended to be prescriptive, every patient won’t fall into the same case mix group to receive exactly the same care, he noted — with Reliant’s internally developed pathways helping to guide care.

“Some patients will benefit from more or less therapy, but these are guideposts for our therapists to follow, which are intended to create uniformity based on a patient’s clinical condition,” Tate said.

The training programs under this model continues to teach therapists how evaluations are important to skilled nursing providers, and to identify the conditions and codes out of the MDS, Tate said.

Reliant staffs 9,000 therapists, and the company did make some staffing adjustments related to moving from individual to concurrent therapy under PDPM, but Tate says those shifts were minimal.

“We had some, and we chose not to share the specifics. We make staffing adjustments all the time by looking at our skilled and long-term census and determining how to right-size staffing with the census,” Tate said.

Editor’s Note: An earlier version of this story misattributed certain quotes about Section GG coding confusion to David Tate. In addition, the earlier version stated that Reliant employs 18 therapists; that number is actually 9,000. SNN regrets the errors.