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PDPM and PDGM - How it Affects Physical Therapists

Posted on: April 28, 2020

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With the Centers for Medicare and Medicaid Services (CMS) newly implementing the Patient Driven Payment Model (PDPM) and Patient Driven Grouping Model (PDGM), physical therapists need to understand the implications on their practice and how to demonstrate their value to patients in skilled nursing facilities (SNF) and home health agencies (HHAs). The new payment models are based on the patient's condition and their specific needs rather than the volume of therapy. The PDPM moves away from the fee for services to a structure that holds clinicians accountable for outcomes and costs.

The PDPM went effect October 1, 2019 and the PDGM January 1, 2020, however, all payers have until September 30, 2020 to implement the changes. Prior to these changes, patients were classified into therapy payment groups under Resource Utilization Groups (RUGs). This method uses the volume of therapy services a patient receives as the basis for payment. CMS implemented this change to prevent financial incentive to provide SNF patients care regardless of their individual status, goals, or needs. CMS said this has created a financial incentive for SNF providers to provide therapy to patients regardless of the patient’s unique characteristics, goals, or needs. CMS has said the decision to replace RUGs with PDPM is to “eliminate this incentive and improve the overall accuracy and appropriateness of SNF payments by classifying patients into payment groups based on specific, date-driven patient characteristics, while simultaneously reducing the administrative burden on SNF providers.”

With the elimination of RUGs and therapy utilization for payment, the American Physical Therapy Association (APTA) recommends that physical therapists understand and demonstrate the value of physical therapy for the patient and the facility or agency that services these patients. Ensure you are providing care that is supported by the evidence, choose appropriate testing and measurements that are specific to your patients individual needs.

Start by choosing appropriate ICD 10 codes.The APTA has developed PDF’s to help you identify appropriate ICD-10-CM codes that are commonly used in physical therapist practice. First, choose ICD 10 codes for the diagnosis, condition, problem, or other reason for the encounter or visit. The ICD 10 codes should capture the medical condition of the patient for which therapy services are needed, be sure to list additional codes that describe comorbidities and coexisting conditions. In other words chose codes that correspond to the treatment and condition of the patient.

Another means of proving your value is to demonstrate the crucial role of the practitioner's clinical judgment using evidence-based practice.

The APTA’s “Choosing Wisely” initiative provides the following recommendations:

No heat!

The literature supports active treatment plans. It has been shown that active treatment has a greater impact on pain, mobility, function and quality of life. While passive treatment can exacerbate fears and anxiety about being physically active while in pain. This can prolong recovery, increase costs, and increase the risk of exposure to invasive and costly interventions such as injections or surgery.

Prescribe an appropriate amount of resistance for strengthening.

Often older adults are given exercises that are not inadequate to increase gains in muscle strength. An increase in strength has been shown to:

  • Improve health
  • Improve quality of life and functional capacity
  • Reduce risk of falls

No bed rest after deep vein thrombosis (DVT).

Both ambulation and activity are recommended following DVT and initiation of anticoagulation medication unless there are overriding medical indications. Patients can be harmed by prolonged bed rest that is not medically necessary.

Do not use continuous passive motion (CPM) s/p total knee arthroplasty (TKA).

CMP has not been shown to be effective and can have negative implications due to prolonged bed rest. Early mobilization following uncomplicated TKA has been shown to be effective in rehabilitation protocols.

No Whirlpools!

Whirlpools to treat wounds predisposes the patient to risks of bacterial cross-contamination, damage to fragile tissue from high turbine forces and complications in extremity edema when arms and legs are treated in a dependent position in warm water.

Works Cited

ICD-10-Codes: http://www.apta.org/ICD10/IdentifyingCodes/

Chose wisely: http://www.choosingwisely.org/societies/american-physical-therapy-association/

Best Practice: http://integrity.apta.org/BestPractices/

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Allison Stringer, MS, PT, FAAOMPT, CHA
About Allison Stringer, MS, PT, FAAOMPT, CHA

Allison Stringer, Physical Therapist, is the Clinic Director for Professional Physical Therapy in Salem, MA. Allison received her Master’s Degree in Physical Therapy from Simmons College in 1993. In 2000, she achieved the status of a Fellow of the American Academy of Orthopedic Manual Physical Therapists after completed the Institute of Orthopedic Manual Physical Therapy. Allison continues to treat patients and specializes in manual Physical Therapy for patients with orthopedic injuries to the spine and extremities, sports medicine, and wide range of Women’s Health issues including incontinence.