PPS Questions
I see a lot of questions asked about PPS. What is it? How does it figure into the OT world?
Many new grads, or OTs who have not worked in Long Term Care (LTC), may have never heard of PPS. However, in LTC it is the second most important thing to know besides the therapy techniques we employ.
PPS or Prospective Payment System, is the way Medicare (CMS) pays for the therapy we provide. Essentially, LTC residents are categorized into two groups, Part A Medicare, and Part B Medicare. The Part A Medicare group are the ones who will be classified into a RUG group (Resource Utilization Groups). The Part B Medicare group is billed differently, and I'll discuss this in a bit.
For the Part A group, minutes of therapy delivered is the key to reimbursement. Every Part A patient will be categorized into a RUG group, and each group level specifies the amount of therapy minutes needed weekly in order to be paid at that level. Weekly therapy minutes in every RUG group are always totaled from Sunday to Saturday. For a more in-depth explanation of the different RUG categories, visit this page.
The basic breakdown of RUG group minutes is like this:
Rehab Low - 45 minutes
Rehab Medium - 150 minutes
Rehab High - 325 minutes
Rehab Very High - 500 minutes
Rehab Ultra High - 725 minutes
In addition, some of these categories require additional requirements such as a certain number of days therapy is delivered per week, two disciplines must be involved, or Restorative Therapy in conjunction with traditional Therapy. There are other factors that may be included in a patient's rate too, but these will be calculated by the facilities MDS Coordinator.
The Part B patients are billed per CPT code, which normally are in 15 minute increments. For example, if you spend 30 minutes working on a dressing task with a patient, you would bill two units of self care under CPT code 97535. The CPT (Current Procedural Terminology) codes are a lengthy list of medical procedures that have been categorized and numbered. These include any and every procedure done by a doctor, nurse, therapist, etc. There are only a handful of codes commonly used in therapy, though.
So, that is PPS and Rug groups explained in a nutshell. If you click on the links included here you can read more detailed versions. For OT, we need to know how to use and bill correctly under these systems in order to maximize the reimbursement for our companies. But don't let all these numbers boggle your mind too much, as many contract companies have cheat sheets developed to summarize the minutes, groups and CPT codes commonly used. (Phew!)
Until next time, hope all your thoughts are good,
Tim