Maximizing PT Reimbursement

Under PDPM, PT reimbursement is built on two things: Functional Score and Clinical Category.

First, your 𝗳𝘂𝗻𝗰𝘁𝗶𝗼𝗻𝗮𝗹 𝘀𝗰𝗼𝗿𝗲 can drive a huge influence on your CMI. At scores 0-5, your patients are most dependent, and at 24, they're most independent. Yet it's not always that "most-dependent" patient that drives the highest CMI!

Next, your patients' 𝗰𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝗰𝗮𝘁𝗲𝗴𝗼𝗿𝘆 drives CMI changes as well. Major Joint Replacement/Spinal Surgery typically drives the highest reimbursement, but Orthopedic, Medical Management, and Non-Orthopedic Surgery typically follow just behind.

However, the two factors together can lead to interesting interleaving -- the CMI ranking of these clinical categories are not strictly in order of category, but based on functional score as well.

Take a look at the table below to see that in more detail:

Other Orthopedic with a Section GG score of 10-23, has a PT CMI of 1.67, greater than Major Joint Replacement with a low Section GG of 0-5. Categories and Functional Scores mix together to create a CMI hierarchy.

That means one wrong ICD-10 code or a few points off in your functional score can swing reimbursement dramatically.

With Hopforce, you don’t need to memorize the tables. Just plug in your data and:

• Instantly calculate PT/OT CMGs

• Experiment with functional score changes

• Spot when a resident falls into or out of the mid-range “sweet spot”