A common question from Rehab Departments in skilled nursing facilities:

Can our treatment orders have a range in frequency?

What is acceptable?

  • Part A: 5-6x per week vs 6x per week
  • Part B: 2-3x per week vs 3x per week

We can all have our opinion on this topic…but let’s look at Medicare’s opinion…since they are paying {or not paying} the bill!

The answer is split into 2 parts, 1 for Medicare A and 1 for Medicare B.

Let’s start with Medicare Part B since the answer is pretty clear-cut.

1- Medicare Part B: The Medicare Benefit Policy Manual, Chapter 15, the Chapter that contains all the rules for Medicare Part B (in all settings including SNF) clearly states that the frequency should be set to strive for the most efficient and effective treatment. This phrase is repeated at least 3 times in the excerpt below. The Manual goes a step further to acknowledge that a patient’s frequency may change during the course of care, and that these changes should be based on the therapist’s assessment of daily progress. The Manual outlines the practice of “tapering” a frequency as an acceptable practice, and provides specific examples on how/why to do this.

Based on this information, establishing a therapy order as a range could lead to a denial. CMS is acknowledging that a patient’s frequency could change, and the Part B Manual presents a method to accommodate this by using “# of visits over a period of weeks”  via tapering. Medicare’s focus is covering “reasonable and necessary” services based on the patient’s need – not staffing or convenience of scheduling. In our auditing services, we have come upon denials for services where a range was used. Medicare Part B would only cover {pay for} the lower end of the range. (ie: Therapy order was for 2-3x/week. Medicare only covered 2 visits per week citing unclear medical necessity for the 3rd visit).

Here is the link to the Part B Manual with the key phrases listed. Ultimately your facility/company will have to set a policy for this and be able to back up their decision on audit.

This excerpt from the Manual will help clarify:

Section 220.1.2 – Plans of Care for Outpatient Physical Therapy, Occupational (Includes SNF Part B)

Therapy, or Speech-Language Pathology Services

  1. Contents of Plan

The plan of care shall contain, at minimum, the following information as required by regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)). (See §220.3 for further documentation requirements):

  • Diagnoses;
  • Long term treatment goals; and
  • Type, amount, duration and frequency of therapy services.

The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. The frequency refers to the number of times in a week the type of treatment is provided. Where frequency is not specified, one treatment is assumed. If a scheduled holiday occurs on a treatment day that is part of the plan, it is appropriate to omit that treatment day unless the clinician who is responsible for writing progress reports determines that a brief, temporary pause in the delivery of therapy services would adversely affect the patient’s condition. The frequency or duration of the treatment may not be used alone to determine medical necessity, but they should be considered with other factors such as condition, progress, and treatment type to provide the most effective and efficient means to achieve the patients’ goals. For example, it may be clinically appropriate, medically necessary, most efficient and effective to provide short term intensive treatment or longer term and less frequent treatment depending on the individuals’ needs. It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward an independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time. For example, treatment may be provided 3 times a week for 2 weeks, then 2 times a week for the next 2 weeks, then once a week for the last 2 weeks. Depending on the individual’s condition, such treatment may result in better outcomes, or may result in earlier discharge than routine treatment 3 times a week for 4 weeks. When tapered frequency is planned, the exact number of treatments per frequency level is not required to be projected in the plan, because the changes should be made based on assessment of daily progress. Instead, the beginning and end frequencies shall be planned. For example, amount, frequency and duration may be documented as “once daily, 3 times a week tapered to once a week over 6 weeks”. Changes to the frequency may be made based on the clinicians clinical judgment and do not require re-certification of the plan unless requested by the physician/NPP.

Medicare Part B would accept a fluctuation in frequency, whether the visits are front-loaded and then tapered, or would accept a frequency of 3x per week for a set number of weeks with a reduction in frequency to 2x per week when the therapist deems this appropriate. Setting your frequency on the initial evaluation and the plan of care with a range sends the message that you are not sure what’s best for your patient as you are stating that an “either / or” scenario will work. Make a solid frequency plan and if it needs to be changed, change it! Don’t write a frequency to cover all the “what ifs.”

Let’s take a look at Medicare Part A:

2- Medicare Part A: For Medicare Part A, you may have to read between the lines in the Manual for therapy specifics about frequency. However, the basic principles of medical necessity and “reasonable and necessary” are clearly stated and have to be proven by the therapist in order to justify coverage.

Here is a link to Chapter 8 of the Medicare Benefit Policy Manual where all the SNF Part A rules are located. Keep in mind that Chapter 8 speaks to “Skilled Part A Coverage,” which can be accomplished via therapy services and/or nursing services, so Chapter 8 does not have a “therapy section” like Chapter 15 does for Part B.

In order to qualify for skilled Part A coverage for therapy in a SNF, the frequency has to be at least 5 calendar days per week. This is a fact spelled out in the Manual. When you add a range to this frequency, similar to the info in Part 1 above, you raise the question of why? Why 5 vs 6 vs 7 days per week and why might the frequency fluctuate? Why would you need a range? Would it be based on the patient’s needs, or staffing needs, or RUG needs?

You have to be very careful with Part A due to the calculation of RUG scores based on total minutes. If you had a frequency range of 5-6 days per week and were able to achieve your RUG in 5 days so you did not use the 6th day that week (ie: RU) but the following week you needed the 6thday to achieve the RUG RU, this would pose a problem of potential “unreasonable and unnecessary” therapy. In the multiple lawsuits that have come to light in the last 2 years, this type of practice of misusing the therapy frequency was cited.

Part A audits have resulted in paying for only the lower end of a set frequency. This may not seem like a big deal…but if you understand the payment structure for Part A, you can only begin to imagine the nightmare of a denial for this reason and the snowball effect if may have.

Consider this scenario:

Your therapy frequency is written 5-6x per week for 4 weeks. Upon audit, CMS deems the 6th visit per week unreasonable and unnecessary and therefore eliminates the minutes for each 6th visit per week. This would then recalculate every RUG score for the period. No big deal? What if the recalculation now indicates that COT’s should have been completed? You can not go back and add missed MDS assessments, so now, not only would you be faced with a RUG score reduction for payment of days, you may also have days represented by a missing assessment, which then become “provider liable” days, meaning, payment for those days = 0. The potential 30 days of Part A coverage at RU can result in 14 days at RV and 16 days at a non-RUG/non-billable score.

Setting your Part A therapy evaluation treatment plan with a solid frequency, and then adjusting that frequency based on clinical need, is the way to go.


So, does either the Part A or Part B Manual state specifically that a range CAN’T be used? No. Does the language used and examples given in BOTH Manuals lean heavily toward a solid plan provided in the most efficient manner? Yes. Has Medicare actually denied Part A and Part B claims when a range was used? Yes!

If you are “on the fence” with establishing a frequency and are thinking about a range, consider using the higher of the range only. Then once the therapy plan is in progress, the clinician will have a better idea if the frequency needs to be changed after a week or so. Frequencies can be changed as often as needed with documentation to support the change. This change is part of providing reasonable and necessary therapy in the most efficient manner, and something that can only be determined by the therapist directly involved in the care for that resident.

Make a solid plan. Stick to it. If it needs to be modified, modify it. Then stick to the new plan until modification is needed again. Believe it or not, needing to modify the plan requires assessment and shows your skill as a clinician.

Any questions, submit them to our Just Ask Q&A Forum and one of our experts will help you out!

In Your Corner,


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

SNF Therapy & MDS Compliance Team


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