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(December 2017 – Kelly, DOR)

Q: For Medicare Part A, what are the rules for moving an ARD and for Grace Days? If a RUG is not met on the last ARD date, but was met the day before, can it be moved back a day or is this backdating?

Answer:

(December 2017 – VB, Manager)

Q: Does CMS submit HCAPS surveys to SNF residents like they do for HH patients?  Do they post the results publicly?  If not now, do they plan to in the future?

Answer:

(November 2017 – Lindsey, MDS Coordinator)

Q: I’m in NYS and have a Case Mix question. When we fill out Section S of the MDS, we have to select if a resident is Managed Medicaid, Medicaid, etc. Which selections “count” in the Medicaid Case Mix?

Answer:

(November 2017 – Beth, Rehab Manager)

Q: Do SNF’s get reimbursed in any way for PT, OT or SLP Evaluations for a new admission covered under Medicare Part A? Our administrator is saying yes but I can’t find this information anywhere. Can you clarify whether SNF’s get reimbursed a separate rate for doing a therapy eval for Med A?

Answer:

(October 2017 – CB, Rehab Manager)

Q: Can you point me in the right direction where to find the “regulation/rule” that alarms are considered a restraint?

Answer:

(October 2017 -CB, Rehab Manager)

Q: I’d like to propose to the owner of our facility (SNF) to purchase an estim and an ultrasound machine. Can you point me in the right direction where to find information regarding the monetary reimbursement of these modalities??

Answer:

(September 2017 – Beth)

Q: How does a therapist “pick” the right medical ICD-10 code in the SNF? Does it have to match the MDS? Can it be different? Therapy picks their treatment code without issue based on the patient presentation, but there is question about the medical diagnosis we have to enter on our plan of care. Facility position is that the therapy medical diagnosis must match whatever the MDS coordinator picks as the primary diagnosis. Sometimes the code MDS picks is not available in the rehab software. Help!

Answer:

(August 2017 – Donna – RD)

Q: Can you please tell me what the regulation is on initial MD orders. I understand we have 30 days for signature on plan of care, but what is the time frame for eval and treat orders-how long do we have for the doctor to sign? I am being told 48 hours. And I looked at the SOM pub 100-02 chapter 15 section 220 and 230 but still unclear.

Answer:

(July 2017 – CC – DOR)

Q: In preparation for an OMIG audit we noted a MD order for “OT Evaluate and Treat” is missing. Is there anything the facility can do to fix this?

Answer:

(June 2017- Pasaan – DOR

Q: Can you clarify when Section O requires dashes in the Therapy End Date question? Our software automatically puts the last treatment date in this box and sometimes we have to edit this, especially if it is a “Short Stay.”

Answer:

(June 2017 – Jessica – SLP DOR)

Q: Do the Medicare A regulations state anywhere that the minutes for a Rehab RUG score can’t be exact – For example, does it say somewhere that a RU can’t be 720 minutes exactly? If so, where can I find this?

Answer:

This is a very timely question and my guess is that your administrator or manager is talking about this! CMS just released new data (SNF PUF) and a new plan of action for all SNF’s falling in target ranges of high % of RU and RV scores resulting from total look-back minutes within 10 minutes of the minimum threshold. For more info on this, please read this article explaining the full history, issues and CMS plan of action for this newest target.

To answer your question, CMS does have this in writing! Though it goes waaaaaay back to 1999…

When the SNF PPS Final Rule was published in 1999, specifics of the RUG system development were detailed, including the intent of the breakdown and therapy minute expectations. This was the Final Rule that introduced PPS and explained how the PPS RUG system would work. Here is the link…read it for yourself.

[Federal Register / Volume 64, No. 146 / Friday, July 30, 1999 / Rules and Regulations ]

The Final Rule stated: “The minutes used to classify beneficiaries into RUG–III groups are in no way to be taken as upper limits. The 720-minute threshold for the Ultra High sub-category is a minimum for purposes of classifying residents. In fact, during the demonstration project, there were beneficiaries who were receiving more than 1,000 minutes per week, and we expect that there will be similar instances during the national implementation. All of the groups were created based on a continuum of minutes being provided, including Ultra High. Just as we expect to see beneficiaries in the High Rehabilitation sub-category receiving 450 minutes per week, we expect that as many minutes as are needed will be provided to beneficiaries in the Ultra High groups.” (Federal Register 7/30/99 -Page 41663 – Top left paragraph)

This rule has never changed – though over the years since its’ implementation, the method in which therapy services are delivered in the SNF setting has – at least in enough SNF’s to call this a “problem.”

As you know, therapy RUG scores are based on the total number of minutes provided in the 7 day assessment window. Each RUG category has a range of minutes with a bottom and ceiling. Just one minute over the ceiling will get you into the next RUG category. For a more detailed review of RUGs, read this article.

Bottom line…provide and document exact minutes, based on what reasonable and necessary for each individual resident – based on what is in the therapy written plan of care. Otherwise you are providing services to hit a RUG score target, and that is exactly what the RAC auditors are now looking at.

(May 2017 – Kyle -OT Manager)

Q: Can a resident on Hospice receive therapy?

Answer:

(April 2017 – Rehab Manager)

Q: What’s the APTA and AOTA policy on when a therapist has a student?  Can the student take over the therapists caseload and the therapist take on more patients that they would then treat? How does the level of supervision work?  My understanding is as long as the therapist is in the room supervising the student the therapist can be treating another patient.  This also would increase the therapist’s productivity to over 100%, is this a problem? or justifiable?

Answer:

Students in the SNF setting can make documentation and billing a bit tricky. APTA and AOTA both defer to the supervising therapist to determine the capability of the student and how much can/should be delegated to him/her. It is possible for some students to carry a full caseload at some point in their clinical.

Aside from the APTA/AOTA position, what becomes the challenge is coding the treatment minutes correctly with daily documentation. Medicare Part A and Medicare Part B rules are very different when it comes to students, and the way the minutes are documented both in the therapy record and in the MDS, differ as well. The supervision requirements are also different for Part A and B. For those residents who are neither Med A or B, the RAI/MDS Manual states the Part A rules should be followed.

Here is a quick summary of the rules. I have also included the entire section on students from the RAI Manual which contains specific examples that will help clarify student situations.

Student Supervision:

Part A does not require “in room” or “line of site” supervision. This would then defer to your State Practice Act supervision requirements.

Part B requires “in the room supervision.” This is because Part B does not recognize students as being able to provide therapy and holds the therapist accountable for the full treatment session. The therapist does not have to treat but needs to be 1:1 with the student and patient, and can’t be doing anything else (including treating another patient).

Modes of Therapy:

When a student is treating a patient and the supervising therapist is treating another patient, the Modes of Therapy billed (on the therapy log and in the MDS) will be impacted. When a therapist and student are treating different patients, neither can be billed as Individual Therapy. Because the student is an extension of the therapist and NOT ” on their own,” Concurrent Therapy or Group Therapy will be billed. The only time Individual Therapy would be billed by the student is when the therapist is directly 1:1 with the student the whole time. Keep in mind that Concurrent Therapy would never apply to a Medicare Part B resident – the treatment would either be Individual or Group (for >1).

Productivity:

Productivity will be impacted with a student present. However, because the Modes of Therapy billed will be Concurrent or Group, the student and therapist should even out. The student and therapist productivity should be counted as if they were one vs two.

Take a look at the rules below. They are right out of the RAI Manual:

RAI Manual: Chapter 3 Section O Pages 0-23 to 0-26:  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 judgment, 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 may, 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 of a 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).

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.

Example:

• 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 or Mr. A. Mr. A.’s therapy may be coded as 30 minutes of individual therapy on the MDS.

Concurrent Therapy

Medicare Part A

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 of 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

• 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

Examples:

• 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. 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, the therapist would code each individual’s MDS for this day of treatment as follows:

— Mrs. Q. received concurrent therapy for 30 minutes.

— Mrs. R received concurrent therapy for 30 minutes.

• 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. 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, the therapist would code each individual’s MDS for this day of treatment as follows:

— Mrs. S. received concurrent therapy for 30 minutes.

— 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.

— Mr. R. received concurrent therapy for 60 minutes.

Group Therapy

Medicare Part A

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 providing treatment to any resident. In this case, the student is simply assisting the supervising therapist.

Medicare Part B

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 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.

Examples:

• A Physical Therapist provides similar therapies to Mr. W, Mr. X, Mrs. Y. and Mr. Z. at the same time, for 30 minutes. Mr. 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.

— Mr. X. received group therapy for 30 minutes.

— Mrs. Y. received group therapy 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.)

— Mr. Z. received group therapy for 30 minutes.

• 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 24 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.

Mr. S. received group therapy (Medicare Part B definition) for 24 minutes and individual therapy for 10 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.)

• 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.

— Mr. B. received concurrent therapy for 30 minutes and group therapy for 30 minutes.

— Mr. T. received group therapy for 30 minutes.

— Mr. E. received group therapy for 30 minutes.

(March 2017 – Kelly, SLP Rehab Manager)

Q: Is documenting total treatment minutes and CPT codes every day enough for Medicare Part A requirements?

(February 2017- Jill, PT)

Q: Do Medicare Part A progress notes need to be done weekly?

(February 2017 – PB, Rehab Manager)

Q:  I have worked for many therapy companies and they seem to all say something different about therapy orders. Some companies allow and or request that therapist write the orders for a range ex 5-7 x a week and other companies say that is] a “flag” for medicare and can cause a denial in payment.  Can you please let me know which is correct?

Answer:

It is understandable that you may have received conflicting information about therapy orders. See if this explanation helps. The answer is split into 2 parts, 1 for Medicare B and 1 for Medicare A.

1- Medicare Part B: Let’s start off with the black and white. The Medicare Benefit Policy Manual, Chapter 15, the Chapter that contains all the rules for Medicare Part B (in all settings) 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 therapists 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 would only cover 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).

Below you will find 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.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

220.1.2 – Plans of Care for Outpatient Physical Therapy, Occupational

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.

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 therapy coverage in a SNF under Part A, 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 6^th day that week (ie: RU) but the following week you needed the 6^th day 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 was cited.

Summary:

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!

In our opinion, 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.

(January 2017- MC, Rehab Director)

Q:What is the accurate billing approach for allocating evaluation time vs. treatment time?  Is it acceptable practice to designate evaluation minutes for the initial portion of the evaluation session and “diagnostic treatment” minutes for a majority of the time using treatment codes? Are there regulatory differences between Medicare A and Medicare B?

Answer:

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