August 29, 2019 | Net Health

5 min read

Key Changes in the 2020 Final Rule for SNFs

The FY 2020 final rule for SNFs, which CMS released on July 30th, contains several provisions that will impact SNF therapy providers when PDPM goes into effect on October 1st. The changes provide key support to SNFs and their therapy provider partners in the transition to value-based care, and continue to promote greater alignment of SNF care with other post-acute care (PAC) settings.

Here are highlights and takeaways on three key areas outlined in the final rule:

Group Therapy Redefined

The 2020 final rule includes an updated definition of group therapy as “a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities.” The revised definition removes the strict requirement for a minimum of four patients in favor of a broader definition that is also used in the inpatient rehabilitation facility (IRF).

By expanding the definition, CMS has removed a significant roadblock to the adoption of group therapy under PDPM—particularly for SNFs in rural areas where it is especially difficult to find four clinically appropriate participants for group therapy with similar therapeutic needs.

This is great news for therapy providers—many of whom already see PDPM as a chance to enhance clinical decision-making around treatment modes based on what the patient actually needs, rather than focusing on therapy minutes.

In a recent PDPM webinar that brought together a panel of experts from key therapy associations (AOTA, APTA and ASHA), we asked attendees in an online poll, “Do you feel PDPM is an opportunity to consider new practices for treatment modes, especially group therapy?”

-The vast majority (72%) of the more then 330 respondents said it was an opportunity.

-Only 14% said it wasn’t an opportunity, while 14% were unsure.

Alice Bell, senior payment specialist for the Payment and Practice Management Department for APTA, commented that under PDPM, “the decision-making gets placed back in the hands of the therapist, and the therapist can really determine whether or not a group mode of delivery is the right thing for that patient, and also, when in the course of care is it most appropriate.”

The broader group therapy definition truly frees therapists to make decisions about group therapy without unnecessary constraints. However, it will also be important to keep in mind the old adage, “with freedom comes responsibility.”

While CMS is expecting therapists to experiment with new care models, the agency will also be closely monitoring therapy provisioning to ensure providers aren’t playing to incentives. Therapists will need to back their clinical decisions with specific documentation that justifies their plan of care for each patient and prescribed treatment modes.

ICD-10 Coding Changes Simplified

The 2020 final rule establishes a new sub-regulatory process for making routine changes to the ICD-10 codes used to classify patients under PDPM. The new streamlined process will consist of posting updated code mappings and lists to the CMS PDPM website, which will enable faster implementation of non-substantive coding changes. Substantive revisions to ICD-10 codes will still need to be proposed and finalized through notice and comment rule making.

To clarify, non-substantive changes are those made to maintain consistency with the current ICD-10 medical code data set, and will be posted to the CMS website following the routine annual update to the code list in June. The example CMS provided was splitting an ICD-10 code for a comorbid condition into one or more codes that provide additional detail.

On the other hand, a substantive change constitutes a change in policy, including changes that impact the PDPM clinical categories and lists. An example would be the deletion of a code from the list of comorbidities in the SNF Grouper software, which CMS would propose through notice and comment rule making.

Why is the new sub-regulatory process significant?

ICD-10 codes are typically updated in June and become effective on October 1st. The gives providers and software vendors just three months to update their systems with the new mappings and lists. Given that ICD-10 codes take on increased importance under PDPM, it’s crucial that stakeholders are able to update their systems and processes in a timely manner.

As part of the new process, CMS has committed to communicating any changes through the following ways:

-Ensuring updates to the ICD–10 mappings and lists are posted to the CMS website in a timely manner and are easy to locate, and are dated and accompanied by summaries of the changes and the specified effective dates.

-Alerting providers and stakeholders to any update to the ICD–10 mappings and lists through the Medicare Learning Network (MLN) newsletter.

These communications will enable both providers and software vendors to efficiently update and implement non-substantive changes. In the past, this hasn’t always been the case, and providers who didn’t have the strong support and resources to track regulatory updates could easily miss those changes.

New Patient Assessment Data Elements

The final update we want to highlight is around Standardized Patient Assessment Data Elements (SPADEs). SPADEs were established as part of the 2014 IMPACT Act to require PAC providers across four settings—HHAs, IRFs, LTCHs and SNFs—to report on specified patient data across a number of domains.

The ultimate goal is to standardize how PAC providers are reporting so it aligns with how patients are assessed across the four settings to improve care coordination and patient outcomes. Reporting on Section GG data as a quality measure on the MDS to assess a patient’s self-care and mobility status was a first step in this direction for SNFs.

Now CMS is taking the next step with SPADEs to standardize the collection of other patient data from a SNF on the MDS, including cognitive function, mental status, impairments and social determinants of health.

Although there will be no immediate change for SNF therapy providers on October 1st, 2019, it is important to learn about and closely monitor future SPADEs, as how the patient is assessed using SPADEs impacts associated documentation and reporting requirements, and provider payment.

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