With PDPM a hop, skip & a jump away…now is the time to brush up on the definitions of each SNF mode of therapy.

The modes of therapy are very clearly defined in the RAI Manual. If you are a SNF therapy professional and have not yet had the chance to read the 31 pages dedicated to therapy, now is the time!

Here is a link to the most recent version of the RAI Manual. The RAI Manual is an extension of the Part A  (Chapter 8) and Part B (Chapter 15) Medicare Benefit Policy Manuals. It contains all things MDS…and for therapy…it ties into billing. Please refer to pages [O-14 to O-45] for specifics on all therapy topics, including the modes discussed herein. You might be surprised with what you find in those 31 pages!

Modes of Therapy Delivery Overview – MDS Terminology

There are 3 main categories, or modes of therapy, for documenting therapy minutes on the MDS and in your therapy documentation:

  1. Individual Minutes
  2. Concurrent Minutes
  3. Group Minutes

And 1 additional mode that can be a component of the above:
Co-treatment Minutes

Each of these categories has its own definition set by Medicare policy and is outlined in Section-O in the RAI Manual, Section O0400: Therapies. This section explains the qualifiers for each mode of therapy and explains the differences between residents with Medicare Part A and Part B. It is important that all therapists understand the differences between each category, including all the nuances that go with each, in order to document and code the MDS appropriately. The MDS, remember, is the reimbursement tool that drives the payment for each facility. Miscoding or misrepresenting minutes on the MDS can have financial consequences that no one wants to be responsible for on an audit. This includes Medicare Part A payment and case mix reimbursement for states that use the MDS for determining Medicaid payment. Remember, regardless of all the other billing forms and minute logs you fill out in a given day, your entry of minutes onto the MDS….IS billing. When you {or someone else on your behalf} fill out and sign Section O, you are saying you provided skilled care and are billing for it in the specific category you select. {You knew that, right?}

Individual Minutes:
*RAI Definition: The treatment of one resident at a time. The resident is receiving the therapists’ or the assistants’ full attention. Individual minutes do not need to be done consecutively. The total number of individual treatment minutes should be added together for each treatment day. For example, if you saw Mrs. Smith alone for 20 minutes in the morning and went back after lunch and provided another 10 minutes one-on-one, your total individual minutes for the day would be 30.

*Payer Rules: The rules are the same for this category regardless of payer type (A,B,HMO, Private Pay, Managed Part B, etc.) All the minutes listed in this category are used when determining the reimbursement and RUG score.

*Comments: This may be the most straight forward mode of therapy delivery. It is the one we are most used to in many practice settings, and likely the most beneficial one for our patients. Based on all the changes Medicare has made in recent years to the reimbursement structure for the other modes, it is crystal clear that Individual Therapy is Medicare’s preferred method of treatment for their beneficiaries. {Yes, they have specifically said this…many, many times}

Concurrent Minutes:
*RAI Definition: The treatment of 2 residents at the same time. These residents are not performing the same or similar activities. Both of these residents are in line of sight of the treating therapist or assistant. The 2 residents do not need to have the same insurance.

*Payer Rules: Medicare Part A: This RAI definition above applies to Medicare Part A only.

Medicare Part B: Medicare Part B does not include concurrent therapy in its billing set up. Medicare Part B treatments are either individual, when the session is one on one, or group, when more than 1 resident is being treated at the same time. As you will see in the next category, the RAI Manual definition of Group and the Part B definition of Group are different.

*Comments: This category can get a little tricky since the definition of concurrent does not apply to Medicare Part B, but if a therapist is treating a Medicare Part A and a Medicare Part B resident together, the rule applies for the Medicare Part A resident.

To further clarify, the following are 2 examples right out of the RAI Manual (Section O):

1. PT provides therapy that is not the same or similar to Mrs. Q and Mrs. R at the same time, for a total of 30 minutes. Mrs. 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, how would you code the MDS?

    • Mrs. Q= 30 Concurrent Minutes
    • Mrs. R=30 Concurrent Minutes.

Simple, right? Now let’s see what happens when 1 of the residents in the pair has Medicare Part B.

2. PT provides therapy that is not the same or similar to Mrs. S and Mrs. T at the same time, for a total of 30 minutes. Mrs. 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, how would you code the MDS?

    • Mrs. S=30 Concurrent Minutes
    • Mrs. T=30 Group Minutes. (This is based on the Medicare Part B definition of Group Therapy, as you will see in the next section. Remember, concurrent therapy cannot be coded on the MDS for a resident receiving therapy under Medicare Part B.)

When entering concurrent therapy minutes onto the MDS, the total number of minutes is entered. However, currently under RUG-IV, the resident does not get full credit for minutes in this category. The software grouper will take the concurrent minutes entered and divide them in half, only actually counting 1/2 of the total concurrent minutes toward the billable minutes and RUG score for this resident. Under the current RUG-IV system, are you starting to see why it does not  pay to provide concurrent minutes? The minutes are reduced down to individual minutes anyway for both residents.

Group Minutes: *Please note that CMS updated the definition of Group Therapy for FY2020: New definition below.
*RAI Definition: 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. * Updated for FY2020 to now say “2 to 6 residents….”

*Payer Rules:

Medicare Part A: The RAI definition above pertains to Medicare Part A. Group therapy should be a “planned event” and requires a total of 4 residents now updated by CMS as 2-6 residents.…to qualify as a group treatment under Part A.

Medicare Part B: Group therapy as defined by Medicare Part B, is the treatment of 2 or more individuals simultaneously, regardless of payer source, who may or may not be doing the same activities. (2,3,4,10…any more than 2 is a group for Medicare B)

*Comments: This category can get a little tricky as well, since the definition of group is different for Part A and Part B. To further clarify, the following examples are right out of the RAI Manual (Section O):

1. OT provides similar treatment to Mr. W, Mr. X, Mrs. Y and Mr. Z at the same time for 30 minutes. Mr. W and Mr. X are covered under Medicare Part A, Mrs. Y is covered under Medicare Part B and Mr. Z is private pay for therapy.

Based on the information above, how would you code the MDS?

    • Mr. W= 30 Group Minutes
    • Mr. X=30 Group Minutes;
    • *Mrs. Y=30 Group Minutes
    • Mr. Z=30 Group Minutes.

*Please note that Mrs.Y would have 30 Group Minutes listed on the MDS for this session in accordance with the MDS rule for group therapy, but her billing log information for that day, the log that will be used to submit a claim to Medicare Part B by the facility, should reflect 30 minutes under the CPT Code 97150–Group Therapeutic Procedures. This CPT code is not time-based, and is paid at a flat rate regardless of the time spent in the group. It is the appropriate CPT code when two or more individuals are treated at once for Part B.

If you are billing ADL’s, exercise, or any other codes for this session, and these codes are making it onto the billing claim, you are not following CPT guidelines and are {fraudulently} over-billing Medicare Part B. Does your flow sheet or software have 97150 as an option for your Part B residents?

When entering group minutes on the MDS, the total number of minutes are entered. However, just like with concurrent minutes, the resident does not get full credit for minutes in this category. The software grouper will take the group minutes entered and divide by 4, only actually counting 1/4 of the total minutes toward the billable minutes and RUG score for this resident. Group treatment does have its place in the clinic depending on the resident situation. However, after providing 60 minutes of group treatment to 4 individuals and only being able to apply 15 minutes of credit to each resident, clinicians should question if group is the way to go….and clinicians should have the final say as to what would best benefit the resident. Consider group as an adjunct to individual therapy, not a replacement for it.

Co-Treatment: *Please note that this category does not impact payment at this time; however, it must be coded on the MDS.
*RAI Definition: When 2 clinicians (therapists or assistants), each from a different discipline, treat one resident at the same time with different treatments. 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.” [This is a direct quote from the Manual.]

*Payer Rules:

Part A: Both disciplines providing a co-treatment may code the treatment session minutes in full, as long as all policies regarding the modes of therapy were followed. The total number of minutes allocated under co-treatment on the MDS should be the same for the 2 disciplines that provided it. For example, if PT and OT provided a co-treatment for the same resident, the length of time they spent together co-treating must be equal. The co-treatment boxes on the MDS must match for both disciplines.

Part B: Therapists or assistants working together as a team to treat one or more patients cannot each bill separately for the services provided at the same time to the same patient. Medicare Part B is not compatible with the term co-treatment because CPT codes dictate billing. The therapist cannot bill for his/her services and those of another therapist when both provided services at the same time to the same patient. When a PT and OT both provide services to the same patient at the same time, only one therapist can bill for the entire service, or the PT and OT can divide the service units in half. ….So would a Med B resident ever have co-treatment minutes listed on the MDS? Nope!

The Modes and Students

If you have students treating Medicare Part A {or any} residents in your SNF, please refer to the RAI Manual pages noted above. Students change the whole dynamic of coding modes. For example, if the therapist is treating 1 Part A resident and the student is next to the therapist treating another Part A resident, this is billed as….. concurrent for both residents.

Please refer to the Manual for more student examples.

A Few Words About The Modes Of Therapy

The modes of therapy can be confusing, especially when the rules are different depending on the resident’s payer source. Therapists need to know the resident’s insurance when documenting and billing minutes. There are many rules and many payer types.

The RAI Manual states that if the resident’s therapy is not being provided under Medicare Part B, then the rules for Part A should be followed when determining modes and minutes.

A resident may have more than 1 type of mode in a given day or multiple modes when reviewing the 7 day look back period. It is essential that therapist documentation be organized and detailed. Each daily treatment provided should include the mode or modes of therapy that was provided. This is a requirement. A reviewer should be able to look at what you entered on the MDS and then look at your daily notes and logs, and come up with the same calculation of modes and minutes. The modes of therapy were established to be utilized as a “planned therapy event. The RAI Manual specifically states that the therapist plan of care must incorporate the modes of therapy that the resident will participate in and the reason & goal for each mode. So for example, if you are providing group or concurrent therapy sessions, those residents should have these mode types listed in the plan of care and the reason it is needed.

Concurrent and Group therapy modes should not be provided unless the resident will benefit from it in some manner. Medicare continued to reduce the reimbursement for these 2 categories over the years as they were heavily abused in the past when the payment structure was different….and it worked because therapy providers stopped providing these modes (less than .5% is/was provided!)

Be on the look out for situations that may occur where group and concurrent sessions are provided for the wrong reasons (ie: staff shortages, staff convenience, boosting productivity) or are provided to only one payer type (ie: HMO’s). Remember, Medicare states they prefer individual therapy….so why would it be ok to provide more group and concurrent to HMO’s and/or Medicare Advantage residents and less to Medicare Part A? This would appear to be for “reimbursement reasons” vs “clinical need.”

If you are providing treatment in any other mode other than individual, you must code the appropriate mode on the MDS , on the therapy billing log, and the billing claim. Most software systems have the mode of therapy rules incorporated into their design and even auto-populate the MDS. That is both good and bad. Good, because we don’t have to worry about it–everything will end up as it should be. Bad, because we never truly learn the rules and we are still responsible for knowing them.

PDPM and Modes of Therapy

With the transition to the Patient Driven Payment Model (PDPM), we know that reimbursement will no longer be driven by the volume of therapy provided. While PDPM may rectify some of the abuses in the system identified by CMS that have existed with the RUG-IV model {a.k.a. Everyone needs Ultra}, it may also create new incentives for reimbursement in the form of “cost savings” by maximizing use of the concurrent and group therapy modes. {a.k.a. Everyone needs Concurrent}

PDPM has safeguards in place to limit the total amount of non-individual therapy to 25% for each Part A episode of care. CMS has commented that they prefer individual therapy, and only included other modes to allow clinicians the option to provide alternate modes if it was determined this was in the best interest of the resident.  Both in the written Final Rule for PDPM and in subsequent Open Door Forum provider calls, CMS continues to advocate for the professional autonomy of the clinician {You…. Yes, CMS has been on your side all this time!}.

CMS has stated that providers have demonstrated over the past 10+ years of RUG-IV, that concurrent and group therapy modes have not been utilized much at all, and that they will be “robustly monitoring” for any increase in these alternate modes of therapy under PDPM. If these modes were not medically necessary, and/or reasonable and necessary before, why should they all of a sudden {when coincidentally the payment reduction component is lifted} be necessary for our residents now? Using concurrent and group as a cost-savings plan [get the full caseload treated in half the time or with half the staff] is not in the best interest of our residents. Therapists know that….now it’s time for them to document it.

YOU, the evaluating and treating therapist, should be the sole persons involved in determining what mode of therapy is best for YOUR RESIDENT. CMS said so!

Know your modes…

In Your Corner,

Dolores Montero, PT, DPT, GCS, RAC-CT

SNF Therapy & MDS Compliance Training

About the author


Leave a Reply