The alarm clock is about to ring! Inpatient rehabilitation facilities (IRFs) are being required to report minutes and modes of therapy for all patients discharged on or after Oct. 1, 2014. With an average length of stay of about 13 days in these cases, this means that IRFs will need to collect and report this data for most patients who were admitted in mid-September, and even some prior to that.
In its final rule for the 2014-2015 federal fiscal year, the Centers for Medicare & Medicaid Services (CMS) finalized definitions for the modes of therapy treatment and confirmed the requirement to track minutes of therapy by discipline in each of the modes for the first two weeks of therapy.
The finalized definitions are:
- Individual therapy is the provision of therapy services by one licensed or certified therapist (or a licensed therapy assistant, under the appropriate direction of a licensed or certified therapist) to one patient at a time (this is sometimes referred to as ‘‘one-on-one’’ therapy.)
- Co-treatment is the provision of therapy services by more than one licensed or certified therapist (or licensed therapy assistant, under the appropriate direction of a licensed therapist) from different therapy disciplines to one patient at the same time.
- Concurrent therapy is one licensed or certified therapist treating two patients at the same time, with each patient performing different activities.
- Group therapy is the provision of therapy services by one licensed or certified therapist (or licensed therapy assistant, under the appropriate direction of a licensed or certified therapist) treating two to six patients at the same time, with each performing the same or similar activities.
Even well-prepared organizations should be watching this issue closely. The requirement that an intense level of rehabilitation services commonly demands a minimum of three hours of therapy, a minimum of five days per week, has been in place since the 1980s. The clarifications related to therapy minutes effective in January 2010 further defined this,, and with this additional reporting requirement, it will be possible for the Medicare Administrative Contractors (MACs) and Recovery Auditors (RACs) to perform an automated reviews of therapy minutes. Organizations that have experienced recent RAC reviews will confirm that the intensity of therapy service is under significant scrutiny, and this often results in technical denials that are difficult to defend. Now, we are essentially self-reporting the minutes and need to have very finely tuned real-time processes to ensure that patients are receiving the requisite minutes of therapy. In the absence of meeting the three-hours, five-times-a-week standard, IRFs must ensure that the medical record clearly documents any exceptions, the reasons they occur, and what is being done to make sure that the patient receives the appropriate level of therapy.
A Few Caveats
The definitions of concurrent and group therapy here differ somewhat from the definitions used in other clinical settings. It is essential to educate and continuously review these definitions with key stakeholders and staff. In essence, if more than two patients are being seen at any time by the same provider, the treatment is considered group therapy.
While CMS has not limited the amount of group therapy that can be provided to patients in the IRF, we believe that the data collection of the IRF will serve as the basis for identifying potential overutilization of group treatment. While there are appropriate times to provide group therapy, it is essential to document the rationale for group therapy, the specific goals meant to be achieved from group treatment, and patient progress toward those goals. Clinical experts agree that there are benefits to group therapy, but our medical records often lack documentation of the clinical rationale for the decision to treat in a group. Now more than ever, the rationale should documented in the record and should be included in treatment planning and team meeting discussions.
Tips for Compliance
IRFs can reduce the risk of missing the mark on requirements for intensity of therapy services by implementing a scheduling system that addresses the modes of therapy and minutes of therapy for every patient. Electronic systems streamline the process and allow for real-time monitoring and subsequent rescheduling of missed therapy time.
Tie your documentation of time spent to the treatment note, and whenever possible, document at the time of service to limit errors and discrepancies between times recorded in the medical record, on the IRF-PAI, and in timeframes that are billed.
Heighten your internal audit activities for the implementation of this requirement. Remember that when data is reported through the IRF-PAI it can easily be reviewed through electronic or automated auditing by the RAC and/or MAC. Do your own audits on compliance with the required intensity of service but also with the accuracy of the data reported.
Whenever possible, utilize the reporting capabilities in your electronic scheduling, billing, and documentation suites to provide you with real-time information that allows you to manage minutes of therapy and allocate the appropriate therapy resources to ensure that patients receive the desired level of service.
About the Author
Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has over 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.
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