PDPM Part Three: Debunking Myths and Therapy’s Role in PDPM

This full version of this article addresses 4 components of PDPM: 1– A brief overview of the PDPM payment model; 2– New challenges impacting nursing, 3– Therapy: Debunking myths and therapy’s role in PDPM; and finally 4– What we can do now to begin preparing for change. This article focuses on Part 3: Debunking myths and therapy’s role in PDPM.


Therapy under the PDPM model will likely see a drastic change. While the treatment techniques provided to patients will remain mostly unchanged, how therapy is delivered will.  Remember PPS rewarded or incentivized Providers for delivering more therapy services.  One of the primary drivers for change to the PDPM model surrounds CMS’s worry of possible fraud, waste and abuse.  CMS believed that increased financial rewards from higher therapy RUG levels at times took precedence over patient need.  To combat this, PDPM is outcomes driven, removes much of the incentive to provide more therapy and instead relies on patient condition and functional scores as the primary drivers of reimbursement.

Does that mean that you will no longer need therapy in your facility? The answer is NO!  CMS has explicitly stated that under PDPM the expectation is that the patient will not see significant changes in the delivery of services.  The expectation that patient outcomes will either remain at the same level or even improve is central to CMS’s decision to switch from PPS.  What this means is that if a patient is receiving therapy at a Rehab Very High Level or 500 minimum minutes per week, then the expectation is that under PDPM,  a level of therapy care will need to be delivered that will yield the same or better outcomes than under the PPS RV category.  Section O of the MDS will also receive modifications and will be the instrument CMS uses to insure that the delivery of therapy care does not suffer under PDPM.  The new Section O on the Discharge MDS will track therapy start date, therapy end date, minutes of therapy provided (Individual + Group + Concurrent) by discipline and how many total days by discipline the patient receive each therapy service.  CMS has made it clear in the final rule that they will monitor the provision of therapy and expects that there will not be a significant decline in minutes provided.

CMS has stated that if they see a significant decline in provided therapy minutes, they could use this as justification to reduce payments in future years. It is not recommended to have a radical shift in therapy delivery.

One of the areas that CMS has included in the PDPM model is that will impact the delivery of therapy is to make concurrent and group therapy less restrictive than it currently is under PPS. Both group and concurrent therapy are allowed under PPS however, benefits for clinician’s to use these treatment categories is either nil or actually increases their risk of denial.  With PDPM, group and concurrent therapies will see a comeback to a maximum of 25% of the patient’s overall treatment minutes.  This will need to be monitored carefully by your rehab team; going over the 25% threshold will result in payment denials.  RUG levels will go away and will be replaced with 3 case mix silos.  One for OT, one for PT and another for ST.

As opposed to the 41 specific rehab RUG’s under PPS, there will now be hundreds of possible case mix combinations. Like nursing, coding accuracy will be a critical component to maximizing reimbursement and balancing the level of care that each patient needs.


This concludes Part 3 of the PDPM article. Stay tuned for Part 4.

Have questions about PDPM? We are here to help! Email our EVP of SNF Operations with your questions as it relates to PDPM changes for 2019.

For a hard copy of this article, view here PDPM Content 2018 Part 3- Therapy

Missed Part 1 and Part 2: read them here.


Article Written by:

Lance Hill, OTR/L, RAC-CT®

Executive Vice President of SNF Operations

Dir. of Regulatory and Clinical Compliance



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