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    CMS Proposes 'Group Therapy' Definition, Revision to Student Policy in SNFs

    Released yesterday by the Centers for Medicare and Medicaid Services (CMS), the nursing facility (SNF) prospective payment system (PPS) proposed rule for Fiscal Year 2012 contains 2 recommendations of significance to physical therapists—changes relating to the payment of group therapy services and the supervision of therapy students.  

    Specifically, CMS proposes to establish a standard that defines group therapy as therapy provided simultaneously to 4 patients who are performing similar therapy activities. The agency states that when a therapist treats 4 patients in a group for an hour, it does not cost the SNF 4 times the amount (or 4 hours of a therapist's salary) to provide those services. Therefore, if a therapist spends 1 hour with 4 residents in a group therapy session, regardless of payer source, then the time used to determine the appropriate Resource Utilization Groups, version 4 (RUG-IV) classification for each Medicare beneficiary receiving SNF care benefits as part of a qualified Part A stay, will be 15 minutes, or 60 minutes of total therapist time divided by 4.

    Regarding students, CMS proposes to revise its current policy such that a therapy student working in a SNF would no longer be required to be in the supervising therapist's line of sight. The agency invites comments on this proposed revision and states that it will continue to monitor the provision of therapy services in the SNF setting.

    CMS also examines recent changes in provider behavior relating to the implementation of the RUG-IV case-mix classification system and considers a possible recalibration of the case-mix indexes so that they more accurately reflect parity in expenditures between RUG-IV and the previous case-mix classification system. The proposal also includes a discussion of a non-therapy ancillary component and outlier research currently under development within CMS.

    APTA is currently reviewing the proposed rule and will provide a detailed summary in the coming week.


    Comments

    It is wrong thinking to believe that the only time spent on a group therapy session is during the group. A lot of planning takes place and then there is a lot of documentation to write afterward. The new proposal makes payment for group therapy worse that that for concurrent, with much higher stress on the therapist. This proposal is not acceptable.
    Posted by Debra Dreher on 4/29/2011 6:32 PM
    I do not see how you can only record 15 min of a 60 min time that the pt was participating in the group. That means that 45 min of their time is not counted towards minutues of skilled therapy? That is discounting the therapists skill involved in the group activity and the pt's benefit from the group itself. Group therapy is already only billed as 1 unit/resident participating, so taking away recording the actual minutes the person participated in calculating RUGs is ridiculous.
    Posted by Lori Anderson on 4/29/2011 9:29 PM
    Group therapy is beneficial for the resident, and the resident is involved the entire session. It is an injustice to penalize the business and the therapist by dividing the minutes. DO NOT ALLOW THIS TO PASS.
    Posted by Jim Bonds on 4/29/2011 10:10 PM
    I agree with the CMS proposal to revise its current policy such that a therapy student working in a SNF would no longer be required to be in the supervising therapist's line of sight. Given the education and training of PT and PTA students, I believe on site, readily available for consultation and assistance, is acceptable supervision for students.
    Posted by Jan Spigner, PT on 4/30/2011 10:58 AM
    Groups premits the low motivated patient to sit back,glide though a session, and not receive benefit from that group treatment. P.T.should NOT be a gym class. P.T. should be one to one skilled treatment which the P.T. adjusts/modifies per each patient during each treatment. Groups lower standards of care, enable corporations to over work therapists. I am in favor of the change.
    Posted by Marta "Marty" Krause,P.T. on 4/30/2011 12:00 PM
    Some group treatments are beneficial for the patients. It helps some unmotivated patients to participate more with group treatments. As long as the group treatments that the therapist is providing is a good quality group treatment, I think it is appropriate.
    Posted by Joseph Benzon Chua -> AKXaCO on 4/30/2011 4:12 PM
    As a physical therapist who is also a nursing home administrator, I disagree with extreme changes to the reimbursable treatment minutes reporting of Group minutes. CMS has not taken into consideration the time, planning, and scheduling the goes into putting together an effective group that is already non reimbursable. Effective group therapy can be very beneficial to specific residents and resident types. Having said that, as a consultant, I also have seen where some providers have over utilized and stretched the use of groups to create volume minute reporting-creating CMSs incentive to do this. We as a profession need to stand and speak out against the changes during the comment period and hold each other and the providers accountable for responsible utilization of reimbursement tools. I have spoken with CMS directly several times; they do not have a PT advisor in their ranks anymore and they simply don't get it. This will not change unless we educate them and each other on what is appropriate. I am pleased with the change to student reporting but it was a LONG time coming. There are other significant changes to MDS reporting between scheduled assessments proposed that will significantly negatively impact Therapy RUG levels. PTs need to read the proposed changes and speak out NOW.
    Posted by Tammy Kelly PT, LNHA, RAC-CT 3.0 on 4/30/2011 4:49 PM
    I agree with the proposal to no longer require a student to be in line of sight of the supervising therapist. As long as they are readily available, then there should be no problem with students working independently with patients/residents. In a busy facility with many patients, it's difficult to try and have the therapist everywhere when trying to ambulate or go and get a patient from their room for therapy. It's just a hassle. As long as there's no safety concerns regarding the student, then there should be no problem to accept this.
    Posted by Jessica Roell on 4/30/2011 5:16 PM
    For those who feel group therapy is a gym class, how many non-medicare beneficiaries attend group exercise for health. If they are a group of patients w/ stroke, PD, post-hip fracture should be leave this up to the gym teachers. I would hope not. How do you think we as PTs are going to manage the large # of beneficiaries as the # of elderly is increased & do it in a cost efficient manner. Can we do all this by individualized care? We need to be forward thinkers & consider alternatives to provide the necessary care that is not being delivered even today. Consider the benefits of circuit training to include functional mobility: bed, transfers 5x's, balancing, aerobic, strengthening, stretching. If we could add incentives for participation we can have healthier residents & perhaps reduce hospital admissions! Well planned programs--disease management-- should be reimbursed appropriately. But just seeing many patients at the same time should not be!
    Posted by Christine Brussock on 4/30/2011 6:48 PM
    Part A therapy has always been based on "time the patient participating in skilled therapy". Cost of the therapists duties has never been the issue. This is why documentation time and time coordinating with Dr's or nurses or family, etc, isn't covered if the patient isn't present and participating. CMS never cared about cost to the nursing home in these instances. But when it comes to activities that generate revenue, suddenly they feel the need to consider the "cost" to the nursing home? It's an obvious inconsistency, and of course it's based on the desire to cut Medicare expenses. Economically, this is backward thinking. One on one care is more expensive. We can argue if it's better or not - to me, if done right, limited group therapy is advantageous to the patient, but let's set that aside for a different discussion. Mandating one on one in all situations will drive up cost, or drive down utilization, either of which are bad for our patients, and ultimately bad for Medicare. Smart policy would make access to therapy easier, with fewer barriers, not harder. The big picture is this. The population is getting older, there's only so many dollars to go around, and frankly a shortage of therapists that are willing to work in long term care, especially in rural areas. Ever tried to hire a PT for a small town nursing home? If Medicare wants all of the future total knees and CVA's and Parkinson's patient's to have access to a physical therapist, there needs to be some sort of group therapy or concurrent or "non-one on one" option. Or, sadly, there just won't be enough hours in the day, and some people won't get the therapy they need.
    Posted by Shawn Docker on 5/1/2011 1:46 AM
    I don't understand this at all. Is CMS trying to kill therapy for SNF pts. If this change occurs there will definitely be a shortage of therapists because many will have to change jobs or careers to live
    Posted by G McCrory on 5/1/2011 9:19 AM
    I agree with the proposal to no longer require a student to be in line of sight of the supervising therapist. As long as the therapist is readily available in the facility, the student will be able to practice patient skills in a realistic environment, but only as they are competent.
    Posted by M. Muscarella, PT, DPT on 5/2/2011 2:06 PM
    If therapists were really worried about the patient welfare, the emphasis would not be on group therapy but on individual therapy. Patients in SNFs, more than in any other setting, need individual attention to get the same benefit from PT, than in younger adults. Instead of fighting the prposed group therapy rule change, we should fight for more reimbursement for individual treatment modalities.
    Posted by Raj, PT on 5/2/2011 3:44 PM
    I have some concerns reguarding the proposal to no longer require line of sight of the supervising therapist for students. Students are doing clinicals to learn, if it is a "hassle" maybe your institution is too busy to accept students. I also worry in these trying times that this will encourage the student to be used as an extra staff member instead of a student who is at your facility to learn. There is so much to teach a student and I don't think a PTA student will feel competent working with a CVA without direct supervision and I would be worried if the student did feel confident. I have been practicing for 29 years and I know when I was a student I was used more as an extra staff member and as the saying goes "If I would have known then what I know now." I was lucky to have a CI who came in before work and stayed after work to teach me because there was no time during the day.I don't know that would happen in our fast paced times. I feel we should be cautious of this proposal.
    Posted by Sherrie Coeyman on 5/4/2011 2:30 PM
    With experience in outpatient, acute care, IRF and SNF I only have a few comments to add. It is our judgement and clinical reasoning that allows PT's to provide skilled services. I teach my students to do the same and with my license on the line, I can choose to let students treat outside of my line of sight (in acute care). This proposal for students does not mean they will never see their CI, it means that it is within our judgement to given them that freedom when we deem appropriate. The many benefits of group therapy are listed above, using groups also allows for time to treat 1:1. It's a balance that we need to preserve to serve all of our patients best within our resources.
    Posted by Jan G, PT on 5/5/2011 1:38 PM
    It seems as though the proposed rule by CMS is in response to the overutilization of group therapy which can occur in therapy departments managed by rehab companies which are mandating it to increase staff productivity. It is similar to the reimbursement changes for concurrent therapy which previusly was the model used to maximize reimbursement levels and staff productivity.
    Posted by Diane Sweeney on 5/10/2011 8:11 AM
    I disagree with this proposed change for group therapy guidelines. I also disagree with therapists who feel that 1:1 treatment time is the only time that matters. I have worked in a SNF for a number of years and have found that some patients are not appropriate for group, and we don't put them into one, but many patients who are poorly motivated benefit from the group sessions as they feel part of a "team". The patients are more inclined to work together and often help to keep each other on track. This has a huge impact on them psychologically and will probably be taken away if the proposed guidelines are accepted.
    Posted by Jonathan K Young on 6/4/2011 8:40 AM
    To make an analogy, They think its fair to pay the same salary to a teacher that teachers 20 kids or 60 kids.
    Posted by Michael on 8/28/2011 1:42 PM
    What about our patients after 21 years in this business with client based model in my head....I know that our patients benefit greatly from group therapy...what about them.
    Posted by Mary Beth Steinke on 11/13/2011 3:42 PM
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