Growing up in the contract therapy world, it is my opinion that not enough training or monitoring is done to ensure the services delivered in Nursing Facility therapy departments are “skilled” as defined in the Medicare Benefit Policy Manual.  Even as a Vice-President of Operations, I may have heard “Medicare Benefit Manual” referenced only once or twice in 15 years. The focus was always “more minutes, more units, more productivity.” Moving to the provider prospective and becoming an expert in both Medicare Regulations and MDS coding, I can now say (with certainty) that a significant percentage of the treatment delivered in SNF therapy departments would NOT be considered “skilled” as defined by the Medicare Benefit Manual, The Code of Federal Regulation, Resident Assessment Instrument (RAI) Manual or Local Coverage Determinations (LCDs).   

See the Top 5 Regulatory Concerns with SNF Skilled Therapy Services:

#5.Therapy Assistants and Notes.
Therapy assistants (PTA’s or COTA’s) may not make clinical judgments about why progress was or was not made, but may report the progress objectively. For example: “increasing strength” is not an objective measurement, but “patient ambulates 15 feet with maximum assistance” is objective. For Medicare payment purposes, information required in progress reports shall be written by a clinician that is, either the physician/NPP who provides or supervises the services, or by the therapist who provides the services and supervises an assistant. (Medicare Benefit Manual Ch 15, 220.3.)  Therefore, progress notes are not just to be “co-signed” by the therapists.  Per Medicare guidelines, the therapist should be writing ALL skilled therapy progress notes.

#4. Delayed Reports.

If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period.  If the clinician did not participate actively in treatment during the progress report period, documentation of the delayed active participation shall be entered in the treatment note as soon as possible. The treatment note shall explain the reason for the clinician’s missed active participation. Also, the treatment note shall document the clinician’s guidance to the assistant or qualified personnel to justify that the skills of a therapist were required during the reporting period. (Medicare Benefit Manual Ch 15, 220.3.) 

#3. Holidays & Treatment.

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. (Medicare Benefit Manual Ch 15, 220.3.) This is one you will never hear from a contract therapy company.  Medicare states that a holiday can be omitted unless specifically addressed by the clinician (a physician or registered therapist) in the plan of care or progress note.  Most therapy companies mandate holiday treatments based only on financial reasons, not clinical need or treatment protocol.

#2. Vocational / Prevocational Assessment and Training.

When services provided by a therapist are related solely to specific employment opportunities, work skills, or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are not covered.  However, exercise care in applying this exclusion, because the assessment of level of function and the teaching of compensatory techniques to improve the level of function, especially in activities of daily living, are services which occupational therapists provide for both vocational and non-vocational purposes. (Medicare Benefit Manual Ch 15, 220.1.2.)  This includes hobbies and other activities not related to “functional” life skills essential for the patient after discharge.  Furthermore, services related to activities for the general good and welfare of patients, do not constitute therapy services for Medicare purposes. (Medicare Benefit Manual Ch 8, 30.2). Also, services not provided under a therapy plan of care, or provided by staff who are not qualified or appropriately supervised, are not payable therapy services.  So, all those therapy departments that are decorating Christmas trees, playing with Nerf Guns or playing video games should realize those are NOT skilled services under the current Medicare guidelines.  Those are great activities and may have some benefit, but should NOT be delivered as part of “skilled therapy services” billed to Medicare.

#1. Reasonable and Necessary Treatment. 

Rehabilitative therapy requires the skills of a therapist to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation. Services that can be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without the supervision of therapists are not rehabilitative therapy services.  (Medicare Benefit Manual Ch 15, 220.1.2.) Therapeutic exercises must be performed by or under the supervision of the qualified physical therapist, due either to the type of exercise employed or to the condition of the patient. Range of motion or repetitious exercises to improve gait, or to maintain strength and endurance, and assistive walking can be appropriately provided by supportive personnel, e.g., aides or nursing personnel, and would not necessarily require the skills of a physical therapist. Thus, such services are not inherently skilled. (Medicare Benefit Manual Ch 8, 30.4.2).   Therefore, a therapist cannot just do an eval and write a plan of care for the assistants to determine the treatments.  Each treatment delivered by an assistant should be developed and monitored by a therapist per the current Medicare guidelines. It also should be noted that simply "co-signing" a treatment note does not meet this supervision requirement.

Questions or concerns?  Feel free to send JMD Healthcare questions concerning therapy documentation or treatments to receive a FREE risk analysis with referenced Medicare Guidelines to help maintain compliance in your facility. 
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