Public Comment Open: Medicare Changes to SNF Therapy Payments

 From AOTA  The American Occupational Therapy Association

Medicare Proposing Changes to SNF Therapy Payments in Future: What Can You Do to Promote OT?

Occupational therapy practitioners are urged to understand and respond to a public comment notice on the payment program for skilled nursing facilities (SNFs). The Centers for Medicare & Medicaid Services (CMS) issued an advance notice of proposed rulemaking (advance notice) to modify the SNF Part A Prospective Payment System (PPS) payment methodology. The comment period is open until June 26. Note that CMS is asking for feedback before writing an actual proposed rule that would be put forward next year and possibly go into effect in federal fiscal year 2019.

The key issue for occupational therapy is how patient classification for payment will relate to actual therapy need and provision. The SNF PPS has been under scrutiny for many years. A key concern is that the current PPS tilts payments toward providing therapy—and possibly providing unnecessary therapy.

AOTA is urging members to comment on the advance notice. Changes to the SNF PPS could greatly affect occupational therapy practitioners and their clients. AOTA Regulatory Affairs staff will be submitting comments to CMS voicing key concerns about the advance notice related to patient access to occupational therapy services. Below, AOTA provides a template letter with suggestions for comment areas and directions for members to submit comments directly to CMS.


The SNF payment system has been under scrutiny by Congress, the CMS, and others, including the Medicare Payment Advisory Commission (MedPAC), which reports to Congress, for many years. Changes have been made periodically since the PPS came into use in 1999, but recent efforts to control Medicare spending have pushed reform of payment for SNFs and other post–acute care settings to the forefront. A few years ago, CMS contracted with Acumen, LLC to develop alternative payment models for the existing SNF PPS. Dr. Natalie Leland, PhD, OTR/L, BCG, FAOTA, and Associate Professor of Occupational Therapy at the University of Southern California, represented AOTA on the Technical Expert Panels (TEPs) held by Acumen in 2015 and 2016. In the May 4, 2017, publication of the advance notice, CMS solicits comments on a new Resident Classification System, Version I (RCS-I) that would replace the current Resource Utilization Groups, Version 4 (RUG-IV) for SNF PPS.

Details of Acumen’s work, TEP summaries, technical reports, and recommendations can be found on the CMS SNF PPS project page.

What is RCS-I?

As practitioners are aware, the current RUGs categories emphasize the counting of therapy minutes to determine the payment amount. The proposed RCS-I would change the system to emphasize patient characteristics, not services received. RCS-1 removes therapy minutes as a determinant of payment and creates a payment model based on resident clinical characteristics. In other words, the current system allows providers to receive payment for the therapy they decide to provide. A system based on clinical characteristics would determine the payment not on the amount of services provided, but rather define how many services a resident would receive based on identification of patient characteristics. Payment would flow from how the patient presents rather than from how much service is provided.

RCS-I would consist of 5 components, each with its own payment determinants, including a basic payment, or non-case-mix component, which covers SNF resources that do not vary according to resident characteristics, and 4 case-mix adjusted payment components. The payment would be determined by how a patient’s characteristics match up to groups of patients with similar characteristics; an estimate will be made in the system of how much should be paid for patients who have similar characteristics. The four components as proposed are:

  • Physical therapy/occupational therapy (PT/OT)
  • Speech-language pathology (SLP)
  • Nursing (covers nursing services and social services)
  • Non-therapy ancillary services

Section III.B.b. Physical and Occupational Therapy Case-Mix Classification beginning on page 20989 of the advance notice sets forth how occupational therapy services would be allotted for under RCS-I. The combining of PT and OT is of concern to AOTA. However, current MDS data collection shows little difference between the PT patient characteristics and OT patient characteristics. Researchers have focused on this lack of difference to support combining OT and PT need for payment purposes.

As noted above, the PT/OT component is only one determining factor, but it is significant.

To determine how the client’s characteristics relate to payment, residents would be categorized for PT/OT payment based on three resident characteristics within the MDS admission assessment:

  1. Clinical reason for resident’s SNF stay—uses item I8000 on the MDS 3.0;
  2. Resident’s functional status—based on self-performance of transfers, eating, and toileting; and
  3. Cognitive status—capitalizes on the Cognitive Function Scale (CFS), which is based on responses from the Brief Interview for Mental Status (BIMS) and Cognitive Performance Scale (CPS).

The clinical reason for the SNF stay in relation to OT and PT needs is used to categorize the patient into 1 of 5 clinical categories that Acumen identified as being generally predictive of PT/OT costs in SNFs:

  • Major Joint Replacement or Spinal Surgery
  • Other Orthopedic: orthopedic surgery (except major joint) and non-surgical orthopedic/musculoskeletal
  • Non-Orthopedic Surgery
  • Acute Neurologic
  • Medical Management: acute infections, cancer, pulmonary, cardiovascular and coagulations, medical management

AOTA is concerned that these categories are much too broad to be able to determine appropriate therapy needs. Co-morbidities are not fully included as factors influencing OT/PT need. AOTA is working to identify patients who might fall through the cracks and not get access to occupational therapy services. AOTA is also concerned about the timing and role of the occupational therapy evaluation in determining patient therapy needs.

The next step to identifying payment levels is determining patients’ functional and cognitive status characteristics. This information gathered as part of the data set on each patient would be used to finalize how much the SNF will be paid for the OT/PT services component. While the OT/PT status is only one component of the full payment level determined, this approach could dramatically affect the amount of therapy services provided to residents. Additionally, CMS would remove the existing 14-, 30-, 60-, and 90-day PPS assessments and only require the initial and discharge assessments, with significant change assessments if applicable. Further, CMS has failed to clearly define when a significant change assessment is warranted and its impact on therapy classification for payment purposes. This could be a noteworthy change in the number of assessments used to determine payment and may not capture changes in patient status.

Other concerns relate to how the proposed RCS-I will affect provision of and access to occupational therapy. AOTA is concerned with the limitations of the PT/OT clinical categories named above; the correct assessment of ADL components in determining the functional level; and failure to ensure that mild cognitive impairment is appropriately included in the cognitive determination. The effect of all of these limitations in the proposed system may seriously restrict which patients receive therapy and whether they receive the appropriate amount of therapy. Improving the PPS system could have beneficial effects on patients and on practitioners (e.g., fewer productivity pressures) but AOTA does not believe this proposed system has enough safeguards in place for implementation. In particular, RCS-I does not include protections that ensure the OT/PT allotment is used solely to provide therapy services, nor does it ensure that patients receive medically necessary services of the proper type. Rationing may occur, and domination of one discipline in a facility may affect how the OT/PT allotment is apportioned. AOTA is concerned that patient needs will not drive the system after a payment amount or category has been determined.

Call to Action—What Can You Do?

Comments are due online by 11:59 pm eastern standard time on June 26, 2017. You can submit comments to CMS, too! There is power in numbers and you can voice your concerns directly to CMS if you believe these changes negatively impact your patients and your ability to provide medically necessary services in a SNF setting. AOTA has developed a template letter to assist practitioners in submitting comments online to CMS by June 26. We encourage you to customize the letter with your own concerns. Specific examples of the types of patients who fall outside of the 5 clinical categories that may fall through the cracks in RCS-I would be particularly powerful. We encourage you to draft your letter in Word prior to going to the submission website.

Once your comment letter is ready for submission, you may submit electronic comments on this regulation to

  • Within the search bar, enter the Regulation Identifier Number associated with this regulation, 0938–AT17
  • Then click on the ‘‘Comment Now’’ box
  • Enter your comments into the comment box by copying and pasting from the document you have drafted in Word or personalized from the AOTA template.

View a web version

Posted in Featured, Government Affairs.