Rehabilitation Delivery Methods - JE Part A

View clarification based on review findings for coverage and documentation requirements of common rehabilitation delivery methods. Inpatient SNF referenced below is for SNF PPS services and billing; SNF Patient Driven Payment Model (PDPM) regulations on group and concurrent therapy is effective October 1, 2019.

The most appropriate delivery method for each patient should be determined on a case by case basis. The delivery method chosen i.e., individual, co-treatment, group, concurrent therapy must be clinically appropriate and provided solely for the benefit of the patient. The delivery method may not be used for the accommodation of staffing schedules, company policy, or productivity concerns. In all instances, the medical record must clearly indicate the therapy services were:

• Medically necessary and at a level of complexity that required the skills and knowledge of a qualified clinician
• Clearly designed to meet the individualized needs of each patient.
• Provided in sufficient lengths of time to ensure appropriate skilled treatment in accordance with the plan of care.
  • It becomes increasingly difficult to document the need for skilled services as the number of participants' increases.
• Measureable, practical and of significant benefit to the patient's functional condition within a reasonable period of time.

Qualified Staff

Rehabilitation services must be provided by a qualified clinician:

• Physician
• Non-physician practitioner (NPP)
• Qualified physical therapist (PT), occupational therapist (OT), speech-language pathologist (SLP)
• Appropriately supervised and qualified physical therapist assistant (PTA) or occupational therapist assistant (COTA).

It is not appropriate to count minutes for skilled services that are overseen and/or provided by a therapy aide even though the aide may be supervised by a qualified clinician. Therapy aides do not meet the criteria for Medicare qualified staff. For additional information, see the Noridian article titled Therapy Students and Aides.

Provider Types

Coverage and documentation requirements for the different delivery methods are not the same for all types of therapy providers. This includes education for the following therapy settings: Inpatient skilled nursing facility (SNF), inpatient hospital, inpatient rehabilitation facility (IRF), long-term care facility (LTC), hospital-based outpatient therapy clinic (HTC), outpatient rehabilitation facility (ORF), comprehensive outpatient rehabilitation facility (CORF) and independent therapy clinic (ITC).

Individual Treatment

Individual therapy is the treatment of one patient at a time. The patient must receive the qualified clinician's full attention throughout the entire service. It is not appropriate to count individual therapy minutes when treatment is provided to more than one patient at the same time.

• Inpatient SNF, IRF - One-on-one minutes may occur continuously (15 minutes straight), or in notable episodes. For example, the therapist treats the patient in the morning for 20 minutes and again in the afternoon for 15 minutes. The total individual time for this day would be 35 minutes.
• Inpatient hospital, LTC, HTC, ORF, CORF, ITC - One-on-one minutes may occur continuously (15 minutes straight), or in notable episodes. For example, the therapist treats the patient 10 minutes now, 5 minutes later. The total individual minutes for this session would be 15. Since time-based code units are determined by total minutes of service, the end result would be one billable unit of time-based service.

Co-Treatment

• Inpatient SNF, IRF - Co-treatment is when two clinicians from different disciplines provide different treatments to one resident at the same time. For example, during a single 30 minute session with one patient the PT works on balance activities and the OT works simultaneously on fine motor skills. Both disciplines can appropriately code 30 treatment minutes.
• Inpatient hospital, LTC, HTC, ORF, CORF, ITC - Therapists or therapy assistants work together and provide continuous or notable episodes of the same or different service to one or more patients. Both clinicians cannot each bill separately for the same or different service provided at the same time to the same patient. For example:
  • A PT and an OT work together for 30 minutes with one patient on transfer activities. The PT and OT could each bill 15 minutes. Alternatively, the total 30 minutes could be billed by either the PT or the OT, but not both.
  • A PT and a PTA work together for 60 minutes with two patients on balance activities. The PT and PTA could each bill 30 minutes. Alternatively, the total 60 minutes could be billed by either the PT or the PTA, but not both.

Concurrent Treatment

• Inpatient SNF, IRF - Concurrent minutes may occur continuously (15 minutes straight), or in notable episodes. One clinician uses different treatment methods for a maximum of two patients that are performing different activities at the same time. Both patients must be in line-of-sight of the treating therapist or assistant. For example, when an OT within line-of-sight treats two patients that are performing different activities at the same time, the total minutes spent providing the services to both patients may be counted.
  • Note: CMS has not yet established standards for the provision of concurrent therapy services in IRFs, however, the standard of care for IRF patients is individualized therapy. A majority of concurrent therapy services provided in the IRF would not demonstrate that the intensity of therapy requirement was met.
• Inpatient hospital, LTC, HTC, ORF, CORF, ITC - Patients cannot be treated concurrently: A therapist may treat only one patient at a time.

Group Treatment

With group treatment the therapist moves back and forth between the patients in the group, spending a minute or two at a time, and provides occasional assistance and modifications as needed. The therapist does not track continuous or notable, identifiable episodes of direct one-on-one contact with any of the patients.

• Inpatient SNF, IRF - Treatment of no more and no less than four patients that are performing the same or similar activities. Services must be provided by a qualified clinician who is not supervising any other individuals. When 4 patients perform the same or similar activities over a 60 minute group session, the therapist should count the total 60 minutes for all participants.
  • For a SNF PPS setting, the calculation of the Resource Utilization Group only allows 25% of therapy minutes to be completed in a group setting.
  • CMS has not yet established standards for the provision of group therapy services in IRFs, however, the standard of care for IRF patients is individualized therapy. A majority of group therapy services provided in the IRF would not demonstrate that the intensity of therapy requirement was met.
• Inpatient hospital, LTC, HTC, ORF, CORF, ITC - Simultaneous treatment of two or more patients who may or may not be performing the same or similar activity at the same time. For example:
  • During a 30-minute group session, a therapist works with two patients and divides his/her time between the two patients. The therapist will appropriately bill each patient one unit of the untimed group therapy code.
  • During a 60-minute group session, a therapist works with three patients and divides his/her time between the three patients. The therapist will appropriately bill each patient one unit of the untimed group therapy code.

Note: When both CPT and Medicare requirements are met, for individual and group therapy services provided to the same patient on the same day, then both services may be billed. Documentation must clearly distinguish the group therapy activity/untimed minutes from the individual therapy activity/time-based minutes. Modifier 59 may be used as appropriate when all requirements are met.

Resources

• CMS Resident Assessment Instrument Manual (RAI) Version 3.0, Section O published October 2011
• CMS Medicare Learning Network, Medicare Outpatient Therapy Billing and Part B Billing Scenarios for PTs and OTs
• CMS Inpatient Rehabilitation Facility Follow-up Series 1-4
• CMS MLN Connects National Provider Call on 1/15/15, IRF PPS: New IRF-PAI Items Effective October 1, 2015
• 42 Code of Federal Regulations (CFR), Part 480, Subpart C, Section 484.4
• Federal Register (FR), Volume 76, Number 152, Part III, Section E-3