Concurrent and Group Therapy Limit

CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), effective October 1, 2019, which Medicare will use under the SNF Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. There is currently no limit on concurrent therapy for SNF under RUG-IV; CMS has updated these therapy services and imposed a limit of 25 percent on concurrent and group therapy under the new case-mix classification model of PDPM.

Definitions:

  • Concurrent Therapy: One therapist with two patients doing different activities
  • Group Therapy: One therapist with 2-6 patients doing the same or similar activities

Compliance with the concurrent/group therapy limit will be monitored by new items on the PPS Discharge Assessment (O0425) at the end of a SNF stay for all SNF Part A beneficiaries:

  • Providers will report the number of minutes, per mode and per discipline, for the entirety of the PPS stay
  • The look back for these items is the entire SNF Part A stay, starting at Day 1 of the Part A stay and finishing on the last day of the Part A stay
  • If the total number of concurrent and group minutes, combined, comprises more than 25% of the total therapy minutes provided to the patient for any therapy discipline, then the provider will receive a warning message on their final validation report

Calculating Compliance with the Concurrent and Group Therapy Limit

Providers should follow the steps outlined below for calculating compliance with the concurrent/group therapy limit:

  • How to calculate compliance with the concurrent/group therapy limit:
    • Step 1: Total Therapy Minutes, by discipline (O0425X1 + O0425X2 + O0425X3)
    • Step 2: Total Concurrent and Group Therapy Minutes, by discipline (O0425X2 + O0425X3)
    • Step 3: Concurrent/Group Ratio (Step 2 Result / Step 1 Result)
    • Step 4: If Step 3 Result is greater than 0.25, then non-compliant
  • Therapy calculation example
    • Total PT individual minutes (O0425C1) = 2,000
    • Total PT concurrent minutes (O0425C2) = 600
    • Total PT group minutes (O0425C3) = 1,000
  • Will the combined therapy meet 25% PDPM limitation?
    • Step 1: Total PT Minutes (O0425C1 + O0425C2 + O0425C3) = 3,600
    • Step 2: Total concurrent minutes (O0425C2 + O0425C3) =1,600
    • Step 3: Concurrent divided by Group ratio = 0.44
    • Step 4: 44% (0.44) is greater than 25% (0.25)
    • Results: non-compliant warning message will appear on assessment validation report

Documentation Requirements

PDPM does change:

  • The way patients are classified into payment groups under the SNF PPS
  • Any of the coverage criteria or documentation requirements associated with the skilled therapy service coverage under PDPM

More importantly, PDPM does not change the care needs of SNF patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies provided at a SNF.

  • Documentation must support accurate billing of timed and untimed codes; CPT/HCPCS code
  • Number of units, Occurrence codes and dates.

All therapy provided consists of skilled and medically necessary services and is appropriate to each patient's plan of care. The therapist reports the time the therapy assistant provides care, whether it is one-on-one care or delivered via the untimed codes, such as supervised modalities or group therapy.

Resources

 

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