Billing and Coding: Skilled Therapy Services in the SNF PPS Setting

This article is to clarify when Physical Therapy (PT), Occupational Therapy (OT) or Speech Therapy (SP) minutes can be captured on a Minimum Data Set (MDS) for patients in a Skilled Nursing Facility (SNF) Prospective Payment System (PPS) stay. Medicare guidelines state that only treatment time requiring the skills of a qualified skilled therapist can be billed as therapy services. The services must be of a level of complexity and sophistication and the patient's condition must be of a nature that requires the knowledge and skills of a therapists to complete the therapy modality. These skilled services must be reasonable and necessary to treat the patient's condition; this includes amount, frequency and duration. Services must not be dependent on the beneficiary's potential for improvement. A service provided by a skilled therapists or therapy assistant does not automatically make it a skilled service. If a service could be completed by an unskilled person or safely self-administered, it would not be considered skilled. Recently, Noridian has noticed an increased use of therapy minutes being captured on the MDS without documentation supporting that these services required the attended time of a qualified skilled therapists. Some of these services include: Electrical Stimulation Therapy assistive devices such as: Omnicycle™ Nustep® Recumbent stepper Virtual therapy assistive devices Although these modalities can assist in meeting therapy goals, only skilled therapist time should be recorded on the MDS. If all the minutes for these modalities are captured on the MDS, documentation must support why it was medically necessary for the therapist/assistant to be in constant attendance during the entire modality/procedure. Commonly, only some aspects of a therapy modality will be skilled. Generally, a resident receiving electrical stimulation as a therapy modality for pain or muscle strengthening/neuromuscular re-education is an example of such a modality. The portion of time that can be recorded to the MDS would be if the time spent for: Proper electrode placement Establishing proper settings Removal of the electrodes Examining the skin before and after treatment Documentation to support skilled services should be sufficient for the medical reviewer to determine when: Skilled staff involvement/attendance is necessary Services are reasonable and necessary for treatment and to promote the goals of therapy Portion of the treatment time that was skilled There are rare circumstances where these modalities would require constant supervision or 1:1 time per industry standards, in which case all the minutes would be considered skilled. In these instances, the documentation needs to be very specific and clear as to the reason constant supervision or 1:1 time was needed. Generalized precautions such as fall risk and confusion in most cases will not support the need for constant supervision or 1:1 time. It is also important to remember that documentation by the therapist supporting the need for constant supervision must be supported by the rest of the documentation provided within the chart.

“If all the minutes for these modalities are captured on the MDS, documentation must support why it was medically necessary for the therapist/assistant to be in constant attendance during the entire modality/procedure.” “Documentation to support skilled services should be sufficient for the medical reviewer to determine when: Skilled staff involvement/attendance is necessary; Services are reasonable and necessary for treatment and to promote the goals of therapy; Portion of the treatment time that was skilled” “In these instances, the documentation needs to be very specific and clear as to the reason constant supervision or 1:1 time was needed.” “It is also important to remember that documentation by the therapist supporting the need for constant supervision must be supported by the rest of the documentation provided within the chart.”