Three Months into PDPM, Teasing Out Therapy Opportunities — and Fixing Common Mistakes

Three months into the Patient-Driven Payment Model (PDPM), operators are still strategizing how to best streamline coding and reimbursements.

Some are beginning to glean positive results with increased margins, whether it’s through an increase in more efficient group and concurrent modalities or a reduction in therapy headcounts — or both. But operators still have areas to improve, particularly around common coding mistakes and ensuring quality outcomes.

Joel Wright, vice president of operations at Therapy Management Corporation (TMC), touted the future of therapy services in nursing homes as more efficient — while taking less time to garner better outcomes — during a Tuesday webinar on the first 90 days of PDPM.


Before PDPM, payment was volume-based, leading some providers to focus more on the number of minutes than the specific service.

“Now the cream has the opportunity to rise to the top,” Wright said.

Three months after PDPM, therapy is exceedingly driven by the welfare of patients and customer satisfaction — and will result in an improvement in quality over time, he said.


Although therapy minutes have not dropped as precipitously as some predicted, Wright said, he noted that volume decreased at a fast pace immediately after PDPM, but has recently “bounced back up.” That number will eventually come back down again as operators prove they can achieve solid outcomes in less time, he predicted.

Wright said there’s more variation in the amount of minutes provided as operators tailor plans more closely to resident needs, while also increasing group and concurrent therapy services — which is “a good thing for therapy to become less expensive as time goes on.”

“Therapy outcomes are reported at flat to rising,” he said, with improved care achieved at a lower cost — “although I don’t think it’s going to create a lot of jobs; that’s for sure,” he said.

The day after the rollout of PDPM, for example, operator giant Genesis HealthCare (NYSE: GEN) let go of almost 585 rehab employees, with anecdotal reports of layoffs and hour reductions coming in over the course of October and beyond.

Key questions remain

As providers transition into 2020, Wright suggested that nursing home administrators ask a host of questions about their operations to make sure they remain optimized for PDPM.

For instance, operators should monitor quality outcomes closely, as CMS may not necessarily crack down on providers who demonstrate significant shifts in therapy minutes as long as outcomes improve. In addition, providers with third-party therapy partners should review their contracts, comparing their daily rates against similar buildings in the same area.

Some providers may have shifted quickly to group and concurrent services as a cost-saving measure; in fact, 75% respondents to a recent SNN poll said they had increased the use of group and concurrent therapy, with most reporting that these modalities accounted for up to 20% of the total.

If a given building’s group and concurrent proportion approaches the 25% limit, Wright said leaders should work on emphasizing individual sessions and using the other modalities when it’s more efficient.

For specific coding and documentation instructions, Brenda Parkhurst, director of coding integrity, pointed to financial opportunities in several categories which aren’t being consistently coded, including: depression/mood assessment, stroke-related codes including swallowing, nursing and non-therapy ancillaries (NTAs), and additional supplemental categories such as IV fluids, using nebulizers, and other respiratory issues.

And it’s not just the therapy departments that can benefit from PDPM strategies: It’s a good idea to include nurses and CNAs for some basic therapeutic activities, such as helping a patient get out of bed in the morning, according to Wright.

“The more time a patient can spend out of bed, the better their welfare will be,” he said, adding that the assistance “doesn’t have to just come from therapists; the whole interdisciplinary team can assist.”

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