Since October 1, 2019, for Medicare A recipients, the Resource Utilization Groups (RUGS) IV is out and the Patient Driven Payment Model (PDPM) is in. The first two years of the transition were complicated by COVID and the PHE. But since May 2023 when the PHE ended, things have been getting back to normal. It is important to remember that although the reimbursement model has changed, the regulations outlined in the Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual (MBPM) Chapter 8 have not changed. The delivery and evidence of supportive documentation of skilled reasonable and medically necessary services is imperative.
This two-part blog series will focus on the mode of therapy provisions for group and concurrent therapy for skilled nursing facilities under Medicare A. During the pandemic, most treatments were performed as individual due to the need for social distancing. However, since the end of the PHE, audits conducted by LW, Consulting Inc. (LWCI) have shown that not all therapists remember the difference between group and concurrent therapy. In light of staffing challenges since the COVID PHE, the use of group and concurrent has been increasing as a viable way to ensure that care delivery is being met.
A refresher in how to document effectively so that medical necessity guidelines are satisfied is a start. Despite the change in Medicare reimbursement, the provisions of ensuring that documentation meets medically necessary skilled guidelines is still being enforced and examined judiciously. In assisting with understanding if proper standards are being upheld, we thought it would be worth re-examining the role of concurrent and group therapy in skilled nursing facilities and reiterate a knowledge base of how to properly document supportive services using best practice guidelines.
This initial blog will focus on the mode of therapy provisions under PDPM and address the documentation guidelines regarding group and concurrent therapy. The second part of this series will then provide you with actual documentation examples that may not support group and concurrent therapy as skilled and reasonable.
Group and Concurrent Therapy Definitions
First, let’s discuss the definitions of group and concurrent therapy under Medicare A policy. Both definitions can be found in the RAI Manual, Pages O-23-O-25. After years of reform to the provisions of group and concurrent therapy, CMS currently defines group therapy for Part A as the treatment of two to six residents, regardless of payer source, who are performing the same or similar activities and are supervised by a therapist or an assistant who is not supervising any other individuals. When utilizing group therapy, it should be clear from the documentation as to why the patient would benefit from group therapy. Group therapy must be outlined on the initial plan of treatment, and it should be evident that the focus of the group relates to each patient’s outlined goals.
Concurrent therapy is defined as the treatment of two residents at the same time when the residents are not performing the same or similar activities, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant for Medicare Part A. The Resident Assessment Instrument (RAI) Manual October 2019 Section O, page 0-23, Modes of Therapy outlines best practice guidelines for choosing a particular mode of therapy.
Per the RAI Manual, 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. 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).
Concurrent therapy can be documented when the therapist is treating more than one patient during a specified duration and if the patient is appropriate for this mode. CMS specifies “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.”
Once a therapist understands what mode of therapy they are utilizing for the treatment, whether it be individual, group, or concurrent, best practice would be to clearly outline the components in the documentation that support the selected mode.
Documenting Group and Concurrent Therapy
Let’s break this down a little further. In order to code minutes to group or concurrent therapy, the therapist should first understand the definition. If he/she feels a particular resident can benefit from a certain mode, this should be clarified. For example, if group therapy is being utilized, it should be included in the list of interventions on the initial plan of care and/or an order including group therapy needs to be evident in the medical record. Once those steps are taken and the therapist administers group or concurrent therapy, it should be clear from the documentation why the resident is being treated using that mode, and how it aligns with this specific patient’s goals. Furthermore, the patient should be clinically appropriate for whatever mode is administered. If it is apparent from the documentation that the patient needs individual treatment, the minutes may be at risk for not being supported as reasonable and necessary. The need for one-on-one treatment could be due to requiring maximum physical assistance or continual cues due to a cognitive deficit or neglect. Some patients may not be a suitable candidate for modes other than individual due to their clinical status.
It is apparent that some therapists may not be documenting properly. In Part 2 of this series, we will review some actual examples to help you and your staff better understand how to effectively administer and document group and concurrent therapy.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
