Since the implementation of PDPM (the Patient Driven Payment Model), the reimbursement system for skilled nursing facilities (SNFs), on Oct. 1, 2019, the Centers for Medicare & Medicaid Services (CMS) has reinforced specific guidelines for the delivery of group and concurrent modes of therapy.
CMS states that individual therapy is the preferred mode of therapy provision for residents; however, CMS also recognizes group therapy can play an important role in SNF resident care and can serve as an adjunct to individual therapy. While group therapy isn’t appropriate for everyone, both group and concurrent approaches are valuable to residents while delivering quality, evidence-based therapy interventions.
Leonard: Marianne, let’s start with the basics for everyone. Can you explain the difference between group and concurrent therapy?
Hassen: Absolutely, Denise. Let’s start with some definitions:
- Group therapy is defined by CMS as the treatment of two to six residents who are performing the same or similar activities and are supervised by a therapist or assistant who is not supervising any other individuals.
- Concurrent therapy is defined by CMS as the treatment of two residents who are not performing the same or similar activities, at the same time, regardless of payer source, both of whom must be in line-of sight of the treating therapist or assistant. No more than two residents can be seen concurrently. And the constant attendance codes (CPT 97032 – 97039) can’t be used when treating another resident concurrently.
Leonard: And can you explain how group and concurrent therapy is handled under PDPM? Anything providers should take into consideration?
Hassen: Yes, there are limits to take into consideration. Group and concurrent delivery under PDPM has a 25% limit on group and concurrent therapy, combined per discipline, per patient in a covered Medicare Part A stay. This means therapy must be delivered on an individual basis at a minimum of 75% of the total treatment for a therapy episode, from the start of care through the end of care, for each discipline — occupational therapy, physical therapy, and speech therapy. For example: if a resident received 1,000 minutes of physical therapy, no more than 250 minutes of this physical therapy could be provided on a group or concurrent basis.
CMS continues to monitor the compliance of the 25% group and concurrent therapy limit for each therapy discipline as it is part of the Discharge MDS assessment. If the 25% threshold is exceeded, this is deemed as noncompliant in a communication to the provider as a nonfatal error on the validation report when the Part A PPS Discharge assessment is submitted. There is currently no penalty for exceeding the threshold. The communication is meant to alert the provider that their future practices must comply with these guidelines.
Leonard: The industry continues to be subjected to scrutiny and a variety of audits. Anything you recommend providers be aware of?
Hassen: Be aware of documentation requirements. When providing group and concurrent modes of therapy, clinicians are required to provide more detailed justification in their documentation for therapy that’s planned to be provided using a mode other than individual therapy. This justification is required at the start of care in the documented therapy evaluations/plan of care for each resident, and needs to include:
- The specific benefits for and documented type and amount of concurrent or group therapy.
- A description of how these modes of therapy will meet the resident’s needs and assist in reaching the documented goals.
- A description that demonstrates how services will attain the highest practicable physical, mental, and psychosocial well-being of each resident.
Documentation for each therapy encounter must include the number of residents involved in the therapy session and a description of the active goals and outcomes achieved.
If there is an observed change in the need for group or concurrent therapy after a plan of care has been initiated, CMS expects this to be reflected in the medical record in the therapy progress notes.
Leonard: Marianne, can you share some benefits of group and concurrent therapy from the resident’s perspective?
Hassen: Sure, there are several benefits of group and concurrent modes of therapy:
- It has a positive impact in the form of socialization especially after lengthy isolation.
- It facilitates the achievement of individual resident goals.
- It fosters a learning environment that encourages resident interaction, problem-solving, self-esteem, self-worth, and shared empathy.
- It creates a social environment that simulates the conditions in which individuals routinely perform daily tasks.
- It allows opportunities to experience more complex activity, allowing a clinician to assess judgment and problem-solving.
- It allows for the therapist to evaluate the resident’s ability to perform functional tasks more independently while still being supervised.
- When a patient is approaching a planned discharge date, group or concurrent therapy is beneficial to test independence level.
- It provides an opportunity to deliver education-based teaching and training to several residents at once.
Group and concurrent modes are effective methods of therapy service delivery when used for meeting resident needs. Clinicians must understand and adhere to the definitions, rules, and requirements to be compliant. Therapy providers need to have systems in place to monitor utilization, ensure skilled delivery, and provide justification through proper documentation of group and concurrent modes of therapy treatment.
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