3-24-09 Medicare Rules for Concurrent Therapy
Medicare Rules for Concurrent Therapy
Working with groups or providing one-on-one therapy to individuals in the same treatment area can be clinically appropriate and billable, when determined by the therapist as the best method for specific patients. Medicare A and B rules differ in some respects. However, all Medicare rules require that all treatment must be related to an individual's plan of treatment and be clinically appropriate. Therefore, occupational therapists must be able to make clinical decisions about which patients are appropriate to treat in this manner and must be able to justify the choices made for each individual patient.
Question: I am an occupational therapist in a skilled nursing facility providing Part A therapy. I sometimes work with more that one patient in the same treatment area. We are confused and unsure about when to bill for group and when the session can be considered one-on-one time, although concurrent. Can you help us to better understand the present policy for our Medicare Part A patients?
Answer: Here are the basics on deciding about concurrent therapy and group therapy under Part A.
Medicare Part A SNF
The Centers for Medicare & Medicaid Services (CMS) has stated in the updated rules for the SNF prospective payment system (PPS) that group and concurrent therapy are acceptable only within certain parameters.1 For both group and concurrent therapy, the amount of time documented on the Minimum Data Set (MDS) is the patient's time (versus the therapist's time) spent in receiving direct treatment. The determining factor between group treatment and concurrent treatment for Medicare Part A patients is whether the therapist is doing an actual group (group therapy) focusing on similar goals with all patients or whether he or she is going back and forth between patients, doing one-on-one distinct treatments (concurrent therapy).
Group Therapy: Medicare Part A SNF rules require that group therapy be limited to 25% of the patient's time spent in therapy (as defined by the 7-day look-back during MDS assessments) and that there only be a maximum of four clients per group per therapist or therapy assistant when appropriately supervised.
Concurrent Therapy: Medicare Part A allows for concurrent therapy or dovetailing where the therapist treats more than one patient during a specific time period. Generally, this occurs when the therapist has been working one-on-one with one patient, who is finishing his/her session and can proceed with a task or exercise independently, with the therapist supervising. The therapist may work one-on-one with a different patient in the same treatment area, keeping an eye on the first patient. The therapist may then go back and forth between the patients until the first patient finishes the activity, and then complete the second patient's session.2 If both patients were in the treatment area and performing therapy for 45 minutes, some of which may be overlapping time, the therapist can record 45 minutes for each. CMS has stated that the decision as to whether concurrent therapy is appropriate should be made at the treating therapist's discretion and should not be based on company policy or productivity concerns. The most recent CMS guidance on concurrent therapy in a Part A setting was issued in the August 4, 2005, Final Rule, and specifically stated:
We wish(ed) to convey that the therapist's professional judgment should not be compromised and concurrent therapy should be performed only when it is clinically appropriate to render care to more than one individual (other than group therapy) at the same time. We agree that, at times, such care can be provided concurrently with another therapy patient, as long as the decision to do so is driven by valid clinical considerations.
For Medicare Part A patients, therapists may wish to consider seeing a maximum of two patients concurrently to minimize downtime and to be accurate on timing. Some clinicians may attempt to see three or four Medicare Part A patients at a time and call it concurrent; however, it might behoove the clinician to make this treatment session a group. A group treatment session would enable the clinician to count all the time for the group for each patient, assuming that this would be 25% or less of the patients' time being spent in occupational therapy treatment (i.e., one group per week if the patients are being seen daily).
Question: I am an occupational therapist who works per diem for a skilled nursing facility. Generally I provide Part B services. I have sometimes been told that I must treat 16 patients in one morning (4 hours) and provide the therapy concurrently to them four at a time. If these patients do not have similar goals, are not working on similar items or need individual treatment, can I ethically bill the services as concurrent therapy? I am instructed never to use the group code. Is this appropriate?
Answer: Rules under Part B allow for the billing of group therapy in some circumstances and also for treatment that can be concurrent. But the choice of approach and the amount of time billed must be carefully calculated to meet Medicare's rules. Therapists must use clinical judgment and must be able to defend that judgment in their documentation.
Medicare Part B
By definition, most CPT codes require one-to-one therapy sessions for the Medicare Part B outpatient benefit, group therapy is acceptable and billed under CPT code 97150. Medicare Part B has no limit on the number of participants in a group per supervising therapist and does not limit the amount of time a patient can spend in group therapy. (Note that Part A is different and limits the time allowed in group per week.) However, it is more difficult to document the need for skilled services as the number of participants in the group increases. The therapist must use clinical judgment in determining whether group treatment is a valid option for each patient and document why that is an appropriate option in each person's plan of treatment. Such issues as common goals would be part of the appropriateness of group. The group treatment code is billed once per day per participant, regardless of the amount of time for the group.
When providing concurrent therapy under Part B, a therapist may provide one-on-one therapy to more than one patient in the same treatment area, but must count only the time the therapist was directly treating the individual patient. For example, if a therapist treats three persons over a 60-minute period of time, the therapist can work with each patient in rotation, but must bill for only the minutes of time spent in direct one-to-one treatment with each. The total units billed for all patients cannot exceed four units. The principle of one-to-one therapist/patient contact must be adhered to under Part B.
Question: In my skilled nursing facility, I am told that the company policy is to treat all patients concurrently and record the total minutes for all patients. I am not allowed to use the group code. For instance, I have been told to provide 1 hour of concurrent therapy to four patients who are working on different goals and record 60 minutes of therapy for each. Is this appropriate? What can I do?
Answer: Medicare A and B rules as stated above must be followed. CMS, as quoted above, puts the authority in the hands of the therapist to determine when concurrent or group therapy is appropriate to individual patient needs. This is a big responsibility, but therapists must be professional about adhering to the rules. If your company is forcing you to break payment rules or provide inappropriate therapy, you must adhere to the ethics of the profession and not violate Medicare laws. Seek the support of colleague therapists. Know and use the Medicare rules as stated above. If necessary, contact the Medicare Fraud hotline to report such activities (1-800-HHS-TIPS [1-800-447-8477]).
This AOTA Q&A was updated in March 2009 from a Q&A excerpted from the Gerontology Special Interest Section Quarterly (June 2003).
1 Medicare Program Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities-Update, Final Rule, (Fed. Reg., August 4, 2005).
2 December 2002 Revised Long Term Care Resident Assessment Instrument (RAI) User's Manual for the Minimum Data Set (MDS) Version 2.0 online at: http://www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp. This is a useful reference with detailed examples.