September 22, 2009 Feature

Medicare Changes Nursing Home Rules

New regulations and payment revisions will affect skilled nursing facilities (SNFs) on Oct. 1, 2010. The Centers for Medicare and Medicaid Services (CMS) published the rules in the Aug. 11 issue of The Federal Register.

New rules for the Part A SNF prospective payment system address the method for recording "concurrent therapy" minutes, defined as "treating multiple patients at the same time while the patients are performing different activities." This treatment mode differs from traditional group treatment, in which the same services are provided to everyone in the group and patients perform the same or similar activities.

Under the old rules, CMS allowed concurrent therapy in SNFs with no restrictions on the number of patients treated simultaneously or the total number of minutes of treatment time recorded for each patient. The new rule limits concurrent therapy to two patients at a time; the total number of minutes for the session must be allocated between the patients (e.g., the number of minutes for two patients combined cannot exceed 60 for a one-hour session).

ASHA and other professional associations have identified a source of confusion in the examples in the final regulations for allocating minutes and have requested a meeting with CMS to clarify the rule. (Part A rules already limit group treatment to 25% of any patient's treatment per week/per discipline, with a maximum of four patients per group.)

Although concurrent therapy is used more often by physical and occupational therapists than by speech-language pathologists, ASHA submitted comments to CMS emphasizing that the choice of treatment modes should always be at the clinician's discretion, based on knowledge of the patient's treatment goals.

The new rules also eliminate the "look-back period" for determining a new SNF resident's resource utilization category. This category determines the resident's Medicare reimbursement rate by estimating the resident's projected need for therapies. Under the old rules, the amount of therapy received immediately prior to the SNF admission (i.e., the look-back period) affected the projected therapy estimate (and reimbursement category). CMS determined that the use of pre-admission services does not predict medical complexity for SNF residents and results in inappropriate utilization categories for many non-complex cases. This change, therefore, will result in lower payments to SNFs.

Fee Changes

New SNF Part A payments take effect every year on Oct. 1. The rates specify per-day payments for each resident and are not specific to payments for treatment sessions. Nationally, Medicare payments to SNFs are projected to decline by $360 million (1.1%), a figure that reflects a 2.2% inflationary increase. A large portion of the decrease was to compensate for intentional inaccurate coding of certain patient classifications to increase payments.

Mark Kander, director of health care regulatory analysis, can be reached at or 301-296-5669.

cite as: Kander, M. (2009, September 22). Medicare Changes Nursing Home Rules. The ASHA Leader.


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