When You’re A Therapist – Every Minute Counts..Right?

Well, sort of…It depends on your definition of “counts,” and for therapists, that definition pertains to billing. Of course every minute spent with a patient matters, but every minute does not necessarily “count,” at least not from a billing perspective.

Let’s take a look…

These days, the work day of a long term care therapist is broken down into minutes. Yes, minutes. Not hours, not patients, not treatment sessions, not visits, but minutes. I don’t know any other profession that does this. Most typical professionals say “I work an 8 hour day,” or “I work a 5 hour day.” However, you just may hear a long term care therapist say “I work a 480 minute day,” or “I work a 300 minute day.” Well, that’s just silly, isn’t it? But unfortunately, that has been our reality lately, particularly with productivity requirements and tracking our minutes. Our work day is broken down into minutes…and the intention of every minute is for billable direct patient care time. Therapists are given assignments in minutes {Mr. Smith needs a 65 minute treatment, Ms. Walker needs a 75 minute treatment} and therapists calculate their productivity using minutes {I was 87% productive today because I billed 360 minutes out of my 420 minute day}. I could get going on a productivity tangent here, but that was an earlier blog. (Click here to read it.) I suggest reading that when you have a chance, particularly the part about billable vs total productivity. If you are a long term care therapist that currently does not have to “worry” about productivity, just wait.

So, back to minutes… Therapists want to be productive and as such, want every minute of their day to “count.” However, due to the multiple insurance types, rules and regulations, some therapists struggle with what can and can’t be billed for. Therefore, I am frequently asked the question…  “Can I bill for that?” “Does that count?” “How many minutes can I bill for that?”

The answer? According to Medicare, it all comes down to SKILL

So What Is Skill?

According to Webster, skill is defined as:

  • the ability to do something that comes from training, experience, or practicemwol2010_mw_logo_header (1)
  • the ability to use one’s knowledge effectively and readily in execution or performance
  • a learned power of doing something competently
  • to make a difference

Medicare also defines skill. Extensive definitions can be found in the Medicare Benefit Policy Manual, Chapter 8, Section 30.2.1.  This is the Section that governs services in a Skilled Nursing Facility under Part A and had its’ last major update in January 2014 – with the main purpose of making sure we understand what is considered  “skilled.”

Therapy services for PT, OT and Speech must meet all of the following conditions to meet the definition of Skill:

  1. For Part A, therapy services must be ordered by a physician before therapy starts. The evaluation does not require a physician signature, though it is prudent to have it signed to show physician involvement and approval. The physician orders for therapy should include a specified frequency and duration. Medicare Part A does not require a Plan of Care document, as Part B does.
  2. For Part B, there must be a specific therapy plan of care and it must be signed/certified by a physician within 30 days of creation and can only stand for 90 days before requiring a new Plan of Care document.
  3. Services must be directly and specifically related to an active written treatment plan that is approved 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
  4. Services must be of a level of complexity and sophistication, or the condition of the resident must be of a nature that requires the judgment, knowledge and skills of a therapist
  5. 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 programor, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program;
  6. Services must be considered under accepted standards of medical practice to be specific and effective treatment for the resident’s condition
  7. 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 {The amount of therapy determines the RUG score for Part A. This amount must be reasonable and necessary for the treatment of the resident’s condition. If your resident is receiving Ultra High therapy amounts, your documentation must support the need for this based on the resident’s condition. Is the expected amount mentioned in the initial evaluation? Frequency and duration are typically documented, but amount is just as important. 5x per week for 4 weeks can result in a Rehab Medium or a Rehab Ultra. It is the amount of therapy daily that will determine the RUG and requires documentation.}
  8.  Services must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result. {Please note that your State Practice Act may be more strict than Medicare and if so, you must adhere to your State Practice Act standards.}

Categories of Skilled Care

The Medicare Benefit Policy Manual, Chapter 8, Section 30.2.3 outlines the 4 categories of skilled care. As therapists, the services we provide, in addition to meeting the criteria listed above, should fit into at least one of the following categories:

  1. Management and Evaluation of a Patient Care Plan. “The development, management, and evaluation of a patient care plan to meet the patient’s medical needs, promote recovery, and ensure medical safety.”
    • Does your evaluation or course of treatment provide recommendations to nursing for the resident plan of care? Are you making recommendations on how the resident should be transferred? Diet consistency? Swallowing strategies? ADL participation? These recommendations are derived from the therapists’ use of skill.
  2. Observation and Assessment of Patient’s Condition. “Observation and assessment are skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized.”
    • Most of our long term care residents receiving therapy services may fit into this category. “Likelihood of change” does not just include improvement. Residents experiencing a decline in status, even an expected decline {hint-Hospice} may benefit from skilled therapy services. Residents are often discharged from therapy with “lack of progress” or “declining status” as the reason. It is in these cases that the skills of the therapist may be best utilized, to support the resident during the period of instability through observation and assessment, and provide modification to the plan of care as the resident’s status changes. {And yes, the Federal Regulations specifically mention residents at “end of life” and residents with dementia should not be overlooked for skilled therapy services if the skill of a therapist is needed to address an issue.}
  3. Teaching and Training Activities. “Teaching and training activities, which require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage their treatment regimen, would constitute skilled services.”
    • For residents who are not able to participate in teaching/training activities, for example, due to a cognitive deficit, this teaching and training would also apply to family and/or caregivers that require training to manage the resident’s regimen upon discharge from therapy and/or the facility.{This does not include teaching a C.N.A. how to do something basic that they are already trained to do…though it could include teaching a C.N.A. how to perform a task that is modified for a specific resident.}
  4. Direct Skilled Nursing Services to Patients.
    • This category is the easiest to grasp, as it pertains to the hands on skilled services that nurses and therapists provide. For example, wound care, gait training, swallowing therapy, functional training. This section of the Manual contains examples of direct skilled therapy services to patients, including skilled physical therapy, occupational therapy, and speech/language pathology therapy. {Keep in mind that just because something is performed by a therapist does not “make” it skilled}

Key Fact About Skilled Coverage

When the Manual was updated in January 2014, a key component about skilled care was stressed (which was a result of the Jimmo v Sebelius Settlement). This component is mentioned above and is further expanded upon here. This is an excerpt from the revised Manual.

Coverage for such skilled therapy services is not decided based on the presence or absence of a beneficiary’s potential for improvement from therapy services, but rather on the beneficiary’s need for skilled care. Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.  These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. If all other requirements for coverage under the SNF benefit are met, such skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of the rehabilitation services. While a patient’s medical condition is a valid factor in deciding if skilled services are needed, a patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled.

For so long, it was progress and/or the residents’ ability to participate that was drilled into each therapist. “Residents must make progress to continue therapy.” “Residents must be able to learn and retain information to qualify for therapy.” Haven’t you told at least one family member that lack of progress was the reason for therapy discontinuation? For years, therapists were basing coverage decisions on the residents’ ability to make progress, when in fact, the basis of coverage is determined by the residents need for the skills of the therapist to provide care. That changes things a bit, doesn’t it? It puts the focus back on the skills of the therapist, right where it should be.

Therapist time…therapist skill. Therapy continues as long as the skills of the therapist are needed, progress or no progress. Important stuff. {Thanks Jimmo}

 Ok, so now we know what skill is. But what can we “count?”

Since “count” equates to “bill,” we have to look at how residents are billed for our services, and this differs running with clockbased on insurance type. As a general rule, exact minutes (not rounded minutes) of a treatment are documented regardless of insurance type– Medicare Part A, Part B, HMO. Those minutes are then filtered into the billing system a bit differently depending on the type of insurance. Medicare Part A’s exact minutes filter to the MDS to determine a RUG score for reimbursement. The more minutes, the higher the category and reimbursement rate. Medicare Part B’s exact minutes filter into a formula to determine unit blocks of time, which are then paid using a fee per unit according to the Physician Fee Schedule. HMO’s typically have a “Part A” and “Part B” type fee model as well.

All skilled minutes make their way to the MDS 3.0, the mandated assessment and reimbursement tool used for all residents in long term care. The rules pertaining to the MDS can be found in the CMS RAI Manual Version 3.0 updated October 2016. In particular, Section O0400: Therapies, pages O-15 to O-35, has a specific rule set that coincides with the Medicare Benefit Policy Manual, as to what can and cannot be included on the MDS, or “counted.”

Section O0400: Therapies– What  Can You Count?

What Counts?

  • Only therapy minutes that were provided while the resident resided in the SNF — no minutes from the hospital
  • Re-evaluation minutes that are conducted as part of the treatment process are counted
  • Family education when the resident is present is counted and must be documented in the record. {Yes, this is a direct quote from the RAI Manual}.
  • Only skilled therapy time is counted on the MDS. Therapist time during a session that is non skilled (non skilled rest periods, bathroom breaks) may not be included.
  • Minutes provided by a qualified COTA or PTA may be included only if he or she is under the direction of a qualified OT or PT {PTA’s and COTA’s must know who they are under the direction of and this PT or OT must take documented responsibility for the direction of the assistant. This is per Medicare, not your State Practice Act}
  • Time required to adjust equipment or otherwise prepare the treatment area for skilled rehab is the set up time and is included in the count of minutes of therapy delivered to the resident.  This may be performed by the therapist, assistant or *aide (*only in states where aides are allowed to participate as deemed by the State Practice Act).
    • Now.. I must add here that we need to use common sense! Medicare is talking about things like: walking away from the patient to get weights, putting a sheet on the mat before the resident transfers, taking the armrests off the wheelchair prior to transferring, grabbing the correct assistive device from the closet, etc. Don’t push it! Medicare is NOT talking about instances when the resident is not present or things like deciding to disinfect the therapy equipment while the resident waits because someone forgot to do it, spending time searching for a wheelchair for the resident (get one ahead of time), rearranging the gym, etc.

What Does Not Count?

  • Regardless of insurance, all re-admissions need a new initial evaluation upon re-entry (not a re-evaluation). This resets the therapy episode. The key is “was the resident discharged from the facility?” If out > 24 hours, they were. Initial evaluation minutes are not included on the MDS. This is an MDS/ RAI rule. No ands, ifs or buts!
  • Time spent on documentation is not included
    • Again, some common sense is needed here. If you are evaluating and writing your findings down during the evaluation or upon completion of the evaluation while you are there with the resident, this is acceptable. If you are going back to your desk and inputting your scrap notes into the computer, this is not billable. Medicare does not expect therapists to memorize the treatment session and then document later off the clock. This is why point of service documentation is pushed…the time spent at your desk is not billable.
  • Services provided at the request of the resident or family that are not medically necessary shall not be counted on the MDS, even if performed by therapist or assistant. This is not considered skilled therapy.
  • When a resident refuses to participate in therapy, it is important for care planning purposes to identify why the resident is refusing. 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 Section O.
    • Now…there are times when a refusal may actually turn into a skilled billable session. Consider this….the nurse tells you your resident is not coming to therapy today because they are sick. You go up to speak to the resident to get more details and the resident tells you that they are having knee pain. Your current recommendations for this resident are “stand pivot transfer with assist of 1.” You spend 15 minutes assessing the knee to determine if the source of pain is musculoskeletal and you make the determination that the resident should have an x-ray, and you change your recommendation to 2 assist stand pivot transfers for safety until the x-ray result is in. THAT IS SKILLED CARE! That is a “billable” “countable” session that used the skills of a therapist to “Manage and Evaluate a Care Plan.” {assuming you document it}

Though there are many Manuals and many rules, some areas still remain grey, and require a little common sense and clinical judgment to determine if each particular instance “counts.” Use documentation to support what you are including on the MDS and billing. Show your skill. Some things, however, will not count…and just because we can’t “count” them, doesn’t mean we should not “do” them. Productive or not. Can a surgeon bill for the time he or she spends prepping for a procedure? Do those minutes count? They may not, but I sure as hell want a surgeon that takes the time to scrub up!

Our day is full of minutes…and all of those minutes come down to a balance of….. productivity…. billing…. and ethics.laterabbit

Bottom Line….Use your time {and your skill} wisely….and make a difference.

In Your  Corner,




  1. My department’s speech therapy student just asked, during a Lon tx session, “how is this skilled?” Our patient had declined and there was a question of diet modification, which we determined was not necessary. But to our student, it just looked like we were “feeding him.” Naturally, that got my back up. Your article gives a much better explanation of skilled vs unskilled services than I was able to come up with at that moment! I printed the article to share at our next rehab meeting and to have on hand for daily reference. My colleagues tend to sell themselves short, not always recognizing the skills they naturally apply outside of the specific goals on the initial evaluation. This article will help us to justify our services (to Medicare and to ourselves!) when things don’t go according to plan. Thank you.

    1. Glad the information will be helpful! It is sometimes difficult for therapists to see the skill in what they are doing particularly when the assessment outcome did not change the recommendations for care. However, the assessment and the “why” behind the recommendation change (or lack of change) is the true skill. Great comments!

  2. DO Medicare Part B discontinuation from therapy in a SNF need a MD order. It has always been require in the past. For Med A patients its not require unless the patient stays LTC. Then we need to discontinue services and new orders for services under Medicare Part B.

    1. If a Part B therapy service is ending prior to the duration end date on the plan of care, it would be best practice to notify the provider of the change, especially if the services are ending well in advance of the date originally set. Medicare Part B requires a Discharge Progress Report to be completed, and the reason for discharge should be included. It is not required that this document be signed by the provider, or that a discharge order is obtained. However, it should be shared with the provider.

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