Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
As a follow up to the webinar Friday March 16, 2018, here is a narrative of the discussion of the modes of therapy and the related MDS Guidelines form section of the RAI Manual:
1. Minutes of Therapy
2. Non-Skilled Services
4. Therapy Aides
5. Therapy Students
6. Individual Therapy
7. Concurrent Therapy
8. Group Therapy
9. Therapy Modalities
1. Minutes of Therapy
- Includes only therapies that were provided once the individual is living/being cared for at the long-term care facility. Do not include therapies that occurred while the person was an inpatient at a hospital or recuperative/rehabilitation center or other long-term care facility, or a recipient of home care or community-based services.
- If a resident from a hospital stay, an initial evaluation must be performed after entry to the facility, and only those therapies that occurred since admission/reentry to the facility and after the initial evaluation shall be counted.
- The therapist’s time spend of documentation or on initial evaluation is not included.
- The therapist’s time spend on subsequent reevaluations, conducted as part of the treatment process, should be
- Family education when the resident is present is counted and must be documented in the resident’s record.
- Only skilled therapy time (i.e., requires the skills, knowledge and judgement of a qualified therapist and all the requirements for skilled therapy are met) shall be recorded on the MDS.
In some instances, the time during which a resident received a treatment modality includes partly skilled and partly unskilled time; only time that is skilled may be recorded on the MDS. Therapist time during a portion of a treatment that is non-skilled; during a non-therapeutic rest period; or during a treatment that does not meet the therapy mode definitions may not be included.
- The time required to adjust equipment or otherwise prepare the treatment area for skilled rehabilitation service is the set-up time and is to be included in the count of minutes of therapy delivered to the resident.
- Set-up may be performed by the therapist, therapy assistant, or therapy aide.
- Respiratory Therapy: Only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident
- Treatment administration and monitoring, and
- Set-up and removal of treatment equipment.
- Time that a resident self-administers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes.
- Set-up time shall be recorded under the mode for which the resident receives initial treatment when he/she receives more than one mode of therapy per visit:
- Code as individual minutes when the resident receives only individual therapy or individual therapy followed by another mode(s);
- Code as concurrent minutes when the resident receives only concurrent therapy or concurrent therapy followed by another mode(s); and
- Code as group minutes when the resident receives only group therapy or group therapy followed by another mode(s).
- For Speech-Language Pathology Services (SLP) and Physical (PT) and Occupational Therapies (OT) include only skilled therapy services. Skilled therapy services must meet all of the following conditions (Refer to Medicare Benefit Policy Manual, Chapter 8 and 15, for detailed requirements and policies):
- For Part A, services must be ordered by a physician. For part B the plan of care must be certified by a physician following the therapy evaluations;
- The services must be directly and specifically related to an active written treatment plan that is approves by the physician after any needed consultation with the qualified therapist and is based on an initial evaluation performed by a qualified therapist prior to the start of therapy services in the facility;
- The services must be of a level of complexity and sophistication, or the condition of the resident must be of a nature that requires the judgement, knowledge, and skills of a therapist;
- The services must be provided with the expectation, based on the assessment of the resident’s restoration potential made by the physician, that:
- the condition of the patient will improve materially in a reasonable and generally predictable period of time; or,
- the services must be necessary for the establishment of a safe and effective maintenance program; or,
- the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program.
- The services must be considered under accepted standards of medical practice to be specific and effective treatment for the resident’s conditions; and,
- The services must be reasonable and necessary for the treatment of the resident’s condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable and they must be furnished by qualified personnel.
- Include services provide by a qualified occupational/physical therapy assistance who is employed by (or under contract with) the long-term care facility only if he or she is under the direction of a qualified occupational/physical therapist. Medicare does not recognize speech-language pathology assistants; therefore, services provided by these individuals are not to be coded on the MDS.
- For purposes of the MDS, when the payer for therapy services is not Medicare Part B, follow the definitions and coding for Medicare Part A.
- Record the actual minutes of therapy. Do not round therapy minutes (e.g., reporting) to the nearest 5th minutes. The conversion of units to minutes or minutes to units is not appropriate. Please not that therapy logs are not an MDS requirement but reflect a standard clinical practice expected of all therapy professionals. These therapy logs may be used to verify the provision of therapy services in accordance with the plan of care and to validate information reported on the MDS assessment.
- When therapy is provided, staff need to document the different modes of therapy and set up minutes that are being included on the MDS. It is important to keep records of time included for each. When submitting a Part B claim, minutes reported on the MDS may not match the time reported on a claim.
For example, therapy aide set-up time is recorded on the MDS when it precedes skilled therapy; however, the therapy aide set-up time is not included for billing purposes on a therapy Medicare Part B claim.
- For purposes of the MDS, providers should record services for respiratory, psychological, and recreational therapies (Item O0400D, E, and F) when the following criteria are met:
- The physician orders the therapy;
- The physician’s order includes a statement of frequency, duration, and score of treatment;
- The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by qualified personnel (see glossary in Appendix A for definitions of respiratory, psychological and recreational therapies);
- The services must be reasonable and necessary for treatment of the resident’s condition.
2. Non-Skilled Services
- Services provided at the request of the resident or family that are not medically necessary (sometimes referred to as family-funded services) shall not be counted in item O0400 Therapies, even when performed by a therapist or an assistant.
- As noted above, therapy services can include the actual performance of a maintenance program in those instances where the skills of a qualified therapist are needed to accomplish this safely and effectively. However, when the performance of a maintenance program does not require the skills of a therapist because it could be accomplished safely and effectively by the patient or with the assistance of non-therapists (including unskilled caregivers), such services are not considered therapy services in this context. Sometimes a nursing home may nevertheless elect to have licensed professionals perform repetitive exercises and other maintenance treatments or to supervise aides performing these maintenance services even when the involvement of a qualified therapist is not medically necessary. In these situations, the services shall not be coded as therapy in item O0400 Minutes, since the specific interventions would be considered restorative nursing care when performed by nurses or aides. Services provided by therapists, licenses or not, that are not specifically listen in this manual or on the MDS item stall not be coded as therapy in Item 0400. These services should be documented in the resident’s medical record.
- In situations where the ongoing performance of a safe and effective maintenance program does not require any skilled services, once the qualified therapist has designed the maintenance program and discharged the resident from a rehabilitation (i.e., skilled) therapy program, the services performed by the therapist and the assistant are not to be reported in item O0400A, B, or C Therapies. The services may be reported on the MDS assessment in item O0500 Restorative Nursing Care, provided the requirements for restorative nursing program are met.
- Services provided by therapy aides are not skilled services (see therapy aide section below).
- When a resident refuses to participate in therapy, it is important for care planning purposes to identify why the resident is refusing therapy. However, the time spent investigating the refusal or trying to persuade the resident to participate in treatment is not a skilled service and shall not be included in the therapy minutes.
Medicare Part A Co-Treatment
When two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments, both discipline may code the treatment session in full. All policies regarding mode, modalities and student supervision must be followed as well as all other federal, state, practice and facility policies. For example, if two therapists (from different disciplines) were conducting a group treatment session, the group must be comprised of four participants who were doing the same or similar activities in each discipline. The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient. Because co-treatment is appropriate for specific clinical circumstances and would not be suitable for all residents, its use should be limited.
Medicare Part B Co-Treatment
Therapists, or therapy assistants, working together as a “team” to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.
CPT codes are used for billing the services of one therapist or therapy assistant. The therapist cannot bill for his/her services and those of another therapist or a therapy assistant, when both provide the same or different services, at the same time, to the same patient(s). Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units. For example, a PT and an OT work together for 30 minutes with one patient on transfer activities. The PT and OT could each bill one unit of 97530. Alternatively, the 2 units of 97530 could be billed by either the PT or the OT, but not both.
Similarly, if two therapy assistants provide services to the same patient at the same time, only the service of one therapy assistant can be billed by the supervising therapist or the service units can be split between the two therapy assistants and billed by the supervising therapist(s).
4. Therapy Aides
Therapy Aides cannot provide skilled services. Only the time a therapy aide spends on set-up preceding skilled therapy may be coded on the MDS (e.g., set up the treatment area for wound therapy) and should be coded under the appropriate mode for the skilled therapy (individual, concurrent, or group) in O0400. The therapy aide must be under direct supervision of the therapist or assistant (i.e., the therapist/assistant must be in the facility and immediately available).
5. Therapy Students
Medicare Part A Therapy Students are not required to be in line-of-sight of the professional supervising therapist/assistant (Federal Register, August 8, 2011). Within individual facilities, supervising therapists/assistants must make the determination as to whether or not a student is ready to treat patients without line-of-sight supervision. Additionally, all state and professional practice guidelines for student supervision must be followed.
Time may be coded on the MDS when the therapist provides skilled services and direction to a student who is participating in the provision of therapy. All time that the student spends with patients should be documented.
Medicare Part B – The following criteria must be met in order for services provided by a student to be billed by the long-term care facility:
- The qualified professional is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgement, and is responsible for the assessment and treatment.
- The practitioner is not engaged in treating another patient or doing other tasks at the same time.
- The qualified professional is the person responsible for the services and, as such, signs all documentation (A student many, of course, also sign but it is not necessary because the Part B payment is for the clinician’s service, not for the student’s services.)
- Physical therapy assistants and occupational therapy assistants are not precluded from serving as clinical instructors for therapy assistant students while providing services within their scope of work and performed under the direction and supervision on qualified physical or occupational therapist.
Modes of Therapy
A resident may receive therapy via different modes during the same day or even treatment session. When developing the plan of care, the therapist and assistant must determine which mode(s) of therapy and the amount of time the resident receives for each mode and code the MDS appropriately. The therapist and assistant should document the reason a specific mode of therapy was chosen as well as anticipated goals for that mode of therapy. For any therapy that does not meet one of the therapy mode definitions below, those minutes may not be counted on the MDS. (Please also see the section on group therapy for limited exceptions related to group size.) The therapy mode definitions must always be followed and apply regardless of when the therapy is provided in relationship to all assessment windows (i.e., applies whether or not the resident is in a look back period for an MDS assessment).
6. Individual Therapy
The treatment of one resident at a time. The resident is receiving the therapist’s or the assistant’s full attention. Treatment of a resident individually at intermittent times during the day is individual treatment, and the minutes of individual treatment are added for the daily count.
For example, the speech-language pathologist treats the resident individually during breakfast for 8 minutes and again at lunch for 13 minutes. The total of individual time for this day would be 21 minutes.
When a therapy student is involved with the treatment of a resident, the minutes may be coded as individual therapy when only one resident is being treated by the therapy student and supervising therapist/assistant (Medicare A and Medicare B). The supervising therapist/assistant shall not be engaged in any other activity or treatment when the resident is receiving therapy under Medicare B. However, for those residents whose stay is covered under Medicare A, the supervising therapist/assistant shall not be treating or supervising other individuals and he/she is able to immediately intervene/assist the student as needed.
A speech therapy graduate student treats Mr. A for 30 minutes. Mr A’s therapy is covered under the Medicare Part A benefit. The supervising speech-language pathologist is not treating any patients at this time but is not in the room with the student of Mr. A. A.’s therapy may be coded as 30 minutes of individual therapy on the MDS.
7. Concurrent Therapy
Medicare Part A Concurrent Therapy
The treatment of 2 residents, who are not performing the same or similar activities, at the same time, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant.
- Note: The minutes being coded on the MDS are unadjusted minutes, meaning, the minutes are coded in the MDS as the full time spent in therapy; however, the software grouper will allocate the minutes appropriately.
- In the case of concurrent therapy, the minutes will be divided by 2.
When a therapy student is involved with the treatment, and one of the following occurs, the minutes may be coded as concurrent therapy:
- The therapy student is treating one resident and the supervising therapist/assistant is treating another resident, and both residents are in line of sight of the therapist/assistant or student providing their therapy; or
- The therapy student is treating 2 residents, regardless of payer source, both or whom are in line-of-sight of the therapy student, and the therapist is not treating any residents and not supervising other individuals; or
- The therapy student is not treating any residents and the supervising therapist/assistant is treating 2 residents at the same time, regardless of payer source, both of whom are in line-of-sight.
Medicare Part B Concurrent Therapy
The treatment of two or more residents who may or may not be performing the same or similar activity, regardless of payer source, at the same time is documented as group treatment
A physical therapist provides therapies that are not the same or similar, to Mrs. Q and Mrs. R at the same time, for 30 minutes. Q’s stay is covered under the Medicare SNF PPS Part A benefit. Mrs. R. is paying privately for therapy. Based on the information above, the therapist would code each individual’s MDS for this day of treatment as follows:
- Mrs. Q received concurrent therapy for 30 minutes (Part A)
- Mrs. R received concurrent therapy for 30 minutes (Private)
A physical therapist provides therapies that are not the same or similar to Mrs. S. and Mr. T. at the same time, for 30 minutes. S.’s stay is covered under the Medicare SNF PPS Part A benefit. Mr. T.’s therapy is covered under Medicare Part B. Based on the information above, the therapist would code each individual’s MDS for this day of treatment as follows:
- Mrs. S received concurrent therapy for 30 minutes. (Part A)
- Mr. T received group therapy (Medicare Part B definition) for 30 minutes. (Please refer to the Medicare Benefit Policy Manual, Chapter 15, and the Medicare Claims Processing Manual, Chapter 5, for coverage and billing requirements under the Medicare Part B benefit.)
An Occupational Therapist provides therapy to Mr. K. for 60 minutes. An occupational therapy graduate student who is supervised by the occupational therapist, is treating Mr. R. at the same time for the same 60 minutes but Mr. K. and Mr. R. are not doing the same or similar activities. Both Mr. K. and Mr. R.’s stays are covered under the Medicare Part A benefit. Based on the information above, the therapist would code each individual’s MDS for this day of treatment as follows:
- Mr. K received concurrent therapy for 60 minutes (Part A)
- Mr. R received concurrent therapy for 60 minutes (Part A)
8. Group Therapy
Medicare Part A Group Therapy
The treatment of 4 residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or assistant who is not supervising any other individuals.
- Note: The minutes being coded on the MDS are unadjusted minutes, meaning, the minutes are coded in the MDS as the full time spent in therapy; however, the software grouper will allocate the minutes appropriately. In the case of group therapy, the minutes will be divided by 4.
When a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes may be coded as group therapy:
- The therapy student is providing the group treatment and the supervising therapist/assistant is not treating any residents and is not supervising other individuals (students or residents); or
- The supervising therapist/assistant is providing the group treatment and the therapy student is not proving treatment to any resident. In this case, the student is simply assisting the supervising therapist.
Medicare Part B Group Therapy
The treatment of 2 or more individuals simultaneously, regardless of payer source, who may or may not be performing the same activity.
- When a therapy student is involved with a group therapy treatment, and one of the following occurs, the minutes may be coded as group therapy:
- The therapy student is providing group treatment and the supervising therapist/assistant is not engaged in any other activity or treatment; or
- The supervising therapist/assistant is providing group treatment and the therapy student is not providing treatment to any resident.
- A Physical Therapist provides similar therapies to Mr. W., Mr. X., Mrs. Y., and Mr. Z. at the same time, for 30 minutes. W. and Mr. X.’s stays are covered under the Medicare SNF PPS Part A benefit. Mrs. Y.’s therapy is covered under Medicare Part B, and Mr. Z has private insurance paying for therapy. Based on the information above, the therapist would code each individual’s MDS for this day of treatment as follows:
- Mr. W received group therapy for 30 minutes. (Part A)
- Mr. X received group therapy for 30 minutes. (Part A)
- Mr. Y received group therapy for 30 minutes. (Part B)
- Mr. Z. received group therapy for 30 minutes. (Private)
- Mrs. V, whose stay is covered by SNF PPS Part A benefit, begins therapy in an individual session. After 13 minutes the therapist begins working with Mr. S., whose therapy is covered by Medicare Part B, while Mrs. V. continues with her skilled intervention and is in line-of-sight of the treating therapist. The therapist provides treatment during the same time period to Mrs. V. and Mr. S. for 25 minutes who are not performing the same or similar activities, at which time Mrs. V.’s therapy session ends. The therapist continues to treat Mr. S. individually for 10 minutes. Based on the information above, the therapist would code each individual’s MDS for this day of treatment as follows:
- Mrs. V received individual therapy for 13 minutes and concurrent therapy for 24. (Part A)
- Mr. S received group therapy (Part B)
- Mr. A and Mr. B, whose stays are covered by Medicare Part A, begin working with a physical therapist on two different therapy interventions. After 30 minutes, Mr. A. and Mr. B. are joined by Mr. T. and Mr. E., whose stays are also covered by Medicare Part A., and the therapist begins working with all of them on the same therapy goals as part of a group session. After 15 minutes in this group session Mr. A. becomes ill and is forced to leave the group, while the therapist continues working with the remaining group members for an additional 15 minutes. Based on the information above, the therapist would code each individual’s MDS for this day of treatment as follows:
- Mr. A received concurrent therapy for 30 minutes and group therapy for 15 minutes. (Part A)
- Mr. B received concurrent therapy for 30 minutes and group therapy for 30 minutes. (Part A)
- Mr. T received group therapy for 30 minutes. (Part A)
- Mr. E received group therapy for 30 minutes. (Part A)
9. Therapy Modalities
- Only skilled therapy time (i.e., require the skills, knowledge and judgement of a qualified therapist and all the requirements for skilled therapy are met, see page O-17) shall be recorded on the MDS.
- In some instances, the time a resident receives certain modalities is partly skilled and partly unskilled time; only the time that is skilled may be recorded on the MDS. For example, a resident is receiving TENS (transcutaneous electrical nerve stimulation) for pain management. The portion of the treatment that is skilled, such as proper electrode placement, establishing proper pulse frequency and duration, and determining appropriate stimulation mode, shall be recorded on the MDS.
- In other instances, some modalities only meet the requirements of skilled therapy in certain situations. For example, the application of a hot pack is often not a skilled intervention. However, when the resident’s condition is complicated and the skills, knowledge, and judgement of the therapist are required for treatment, then those minutes associated with skilled therapy time may be recorded on the MDS.
- The use and rationale for all therapy modalities, whether skilled or unskilled should always be documented as part of the resident’s plan of care.
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