Medicare Guidance for SLP Services in Skilled Nursing Facilities (SNFs)
Medicare Part A
Part A (hospital insurance) covers beneficiaries for the first 100 days of their stay in a SNF. The daily rate for the stay, including therapy services, is calculated and reimbursed under a Prospective Payment System (PPS) that was instituted in 1998.
Medicare guidance for Part A services is found in the Resident Assessment Instrument (RAI) Version 3.0 Manual. The manual provides specific direction about therapy services in Chapter 3, Section O. Even when institutional policies are based on Medicare guidelines, the interpretation and implementation can differ from facility to facility or manager to manager. SLPs should become familiar with the manual rather than relying on interpretations from others.
Completion of the Minimum Data Set (MDS)
The MDS is a comprehensive summary of the patient's mental and physical issues, completed by the fifth day after admission to an SNF. The MDS is typically completed by a nurse and triggers are provided for assessment of MDS elements by other professionals. However, other professionals may sometimes score specialty areas. For SLPs, those areas are cognitive patterns, communication/hearing patterns, and oral/nutritional status. Time spent on MDS assessment does not count toward therapy minutes.
A full description of how to score the MDS 3.0 is on CMS' website.
Therapy Treatment Minutes
SLPs, occupational therapists, and physical therapists recommend the frequency and length of sessions that they anticipate a patient will need. This is part of the MDS information about the patient's needs that is combined to determine the patient's RUGs (Resource Utilization Groups) level. The RUG levels are:
- Ultra High: at least 720 minutes. Minimum 2 disciplines; one at least 5 days.
- Very High: at least 500 minutes. Minimum 1 discipline 5 days.
- High: at least 325 minutes. Minimum 1 discipline 5 days.
- Medium: at least 150 minutes. Minimum 5 days.
- Low: at least 45 minutes. Minimum 3 days.
Rules for Recording Treatment Minutes
( RAI Manual, Chapter 3, Section O ; directly-quoted text is in italics)
- The therapist's time spent on documentation or on initial evaluation is not included (Page O 17)
- The therapist's time spent on subsequent reevaluations, conducted as part of the treatment process, should be counted (Page O 17)
- Family education when the resident is present is counted and must be documented in the resident's record. (Page O 17)
- Treatment minutes are recorded in the MDS in 1 minute increments (not 5, 10, or 15 minutes)
- Co-treatment—when two clinicians are each from a different discipline, treating one resident at the same time, both disciplines may count the session minutes in full.
- Group treatment—residents are performing the same or similar activities. A group may not exceed four residents. The allocation of minutes to each patient is calculated by dividing the total length of the session by four (regardless of whether four residents attend). For further clarification, see CMS' Updates and Training for FY2012 PowerPoint [PDF].
- Concurrent treatment—two residents (regardless of payer source of the second resident) are treated at the same time and not performing the same or similar activities. Both patients must be in line-of-sight. The minutes are divided by two after being coded in the MDS.
- Development of a maintenance program and training of caregivers prior to discharge.
The minutes that define a RUG level are a minimum, not a maximum. There is no Medicare penalty if a patient exceeds the number of minutes in the RUG in a particular week. Patients who receive fewer than the required minutes will be lowered to the next RUG level.
It is not acceptable to deliver unnecessary (unskilled, not medically necessary) or inappropriate (patient is ill, unresponsive, or refusing treatment) services in order to reach a particular RUG level or meet the weekly number of minutes.
Evaluation Time Does not Count as Minutes Toward RUG Level
- When prospective payment for Part A stays in SNFs was established, the RUG rate was based on observation of time actually spent by clinicians. Time spent on evaluation was included in the calculation of the RUG rates; therefore, evaluation minutes are already accounted for and are not to be reported.
- Instructions from administration or staff to limit evaluation time may be an indirect way of reminding clinicians to maximize therapy time (e.g., in an hour session, 45 minutes would be counted as therapy if the clinician did a 15 minute evaluation). If clinically appropriate, treatment can be performed on the same day as an evaluation and counted toward the therapy minutes.
- If the facility counts productivity using only the treatment minutes recorded in the MDS, the SLP's productivity may appear reduced because evaluation time is not counted.
What are considerations for the clinician with regard to performing evaluations in SNFs under Part A?
- Clinicians are ethically bound to deliver services that they believe are appropriate for a patient based on their independent clinical judgment.
- An inflexible rule governing clinical practice (e.g. "evaluations must never exceed 15 minutes") is inappropriate. Clinicians should conduct an evaluation that provides the information necessary to make a diagnosis and develop a Plan of Care.
- It should be up to the discretion of the SLP as to what comprises evaluation versus treatment. Valuable information may be gathered through dynamic observation of the patient performing therapeutic activities in addition to administration of standardized or formal testing.
Medicare Part B
Part B (medical insurance) services are often referred to as doctors' services and outpatient care; however, in SNFs, patients are reimbursed by Part B for therapy services after the first 100 days under Part A. Unlike Part A, services delivered under Part B are billed using CPT codes from the Medicare Physician Fee Schedule for each procedure. Most SLP codes are untimed. See ASHA's analysis of the current Fee Schedule. See more information below under Productivity.
Reasonable and Necessary Services for Medicare Part A and Part B
According to the RAI Manual (directly quoted from pages O18- 19),
- the services must be directly and specifically related to an active written treatment plan that is approved by the physician after any needed consultation with the qualified therapist and is based on an initial evaluation performed by a qualified therapist prior to the start of therapy services in the facility;
- the services must be of a level of complexity and sophistication, or the condition of the resident must be of a nature that requires the judgment, knowledge, and skills of a therapist;
- the services must be provided with the expectation, based on the assessment of the resident's restoration potential made by the physician, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, or the services must be necessary for the establishment of a safe and effective maintenance program;
- the services must be considered accepted standards of medical practice;
- the services must be reasonable and necessary for the treatment of the resident's condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable and they must be furnished by qualified personnel.
Although the RAI Manual provides no further detail about what constitutes "reasonable and necessary," it is addressed further in the Medicare Outpatient Benefit Manual [PDF] (see chapter 15, section 220.2). The Plan of Care must identify goals that would benefit the patient (or train caregivers) functionally. The frequency and duration of services must also be justifiable according to the documented severity of the patient's condition, responsiveness to treatment, and demonstrated change in function. See ASHA's webpage on Documentation of Skilled Versus Unskilled Care.
In addition, ASHA's Code of Ethics (Principle of Ethics 1, Rule I) states that Individuals shall evaluate the effectiveness of services rendered and of products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected. Principle of Ethics IV, Rule J also state that Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription.
Other Issues in SNFs
Productivity can be calculated in several ways. Although some facilities set productivity targets and incentivize or evaluate SLPs according to whether they reached a target, the SLP is ethically bound to use independent clinical judgment to identify an appropriate caseload and to determine the appropriate length of a session (whether shorter or longer than a "typical" session) and frequency of sessions. ASHA has developed resources in conjunction with the American Physical Therapy Association (APTA) and American Occupational Therapy Association (AOTA) to help clinicians defend the importance of using clinical judgment [PDF] and understand their reporting obligations [PDF] if compliance issues are identified.
For Part A, productivity is likely to be based on the total number of treatment minutes divided by the total time worked by the SLP. Spending more time on evaluations (which do not count as minutes) or time or activities where the patient is not present can affect productivity calculations. Some facilities may "give credit" for other activities (such as team meetings) as part of the productivity calculation.
For Part B, services are billed by CPT codes using rates established annually in the Medicare Physician Fee Schedule (see ASHA's Outpatient Medicare Physician Fee Schedule webpage). Each CPT code is calculated by relative value units (RVUs). Unlike OT and PT, the majority of SLP codes are not time-based. Some managers may assign a fixed number of minutes or RVUs to specific CPT codes. For example, if a manager calculates that all SLP treatment sessions last 30 minutes, the SLP would have to treat at least 12 patients to achieve 6 hours of productivity (75% productivity based on an 8-hour day). Some facilities may assign minutes or "give credit" for other activities that are not billable but are part of patient care (e.g., team meetings).
SLPs deliver individual treatment far more frequently than group or concurrent treatment, which may differ from PT/OT and result in differences in calculated productivity.
Instrumental Dysphagia Studies
Resistance to ordering videofluoroscopic or FEES studies for Part A patients may arise because the cost of the procedure (and transportation) is paid by the SNF out of the patient's per diem rate (called Consolidated Billing). The SLP must clearly justify the need for an instrumental assessment to identify the cause and severity of dysphagia, not only to identify possible aspiration risk and appropriate texture, but to identify effective compensatory strategies or treatment techniques that would be incorporated in the Plan of Care. In some cases, instrumental studies may not be warranted if clinical indicators suggest that the study is not likely to provide beneficial information (see ASHA document Clinical Indicators for Instrumental Assessment). Instrumental studies can potentially save money by preventing patients from being placed on unnecessarily restrictive diets or alternative feedings (Martin-Harris & Logemann, 2000, Clinical utility of the modified barium swallow. Dysphagia, 141, 136–141.) (Note that in most states an in-house FEES procedure requires a physician, nurse practitioner, physician assistant, or clinical nurse specialist to be immediately available.)
Payroll-Based Journal Reporting Requirements
CMS recently implemented a requirement of the Affordable Care Act (ACA), which requires SNFs to electronically submit direct-care staffing information (including agency and contract staff) on the basis of payroll and other auditable data. The data, when combined with census information, can then be used not only to report on the level of staff in each nursing home but also to report on employee turnover and tenure, which can affect the quality of care delivered. To facilitate this data collection, CMS has developed a system for facilities to submit staffing and census information called the Payroll-Based Journal (PBJ). This system will allow staffing and census information to be collected on a regular and more frequent basis than currently collected. It will also be auditable to ensure accuracy. All long-term care facilities will have access to this system at no cost. See also: CMS Requires Reporting on Staffing for Skilled Nursing Facilities
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