December 18, 2012 Columns

Bottom Line: Coding Medicare A and B in Nursing Homes

Speech-language pathologists who work in a skilled nursing facility (SNF) after working in a hospital, clinic, or private practice need to know about coverage and documentation rules unique to Medicare Part A patients in SNFs.

For Part B beneficiaries in outpatient settings, Medicare billing usually requires CPT codes (Common Procedural Terminology, ©American Medical Association).

For Part A services, however, coding primarily involves recording valid treatment minutes [PDF].

SNF residents can be classified as Part A patients for up to 100 days, as long as skilled services are needed. After 100 days, the resident assumes Part B status, and coding follows Part B rules.

Q: Students serving Part B patients require 100% in-the-room supervision. Are supervision requirements different for Part A residents?

SNFs are the only facilities that have student supervision rules for Part A patients. The most recent rules, implemented Oct. 1, 2011, do not require line-of-sight supervision, and allow each facility to "determine for itself the appropriate manner of supervision of therapy students consistent with applicable state laws and practice standards."

However, the student's supervisor cannot treat another resident or supervise another student while the student is treating a resident. Under this rule, the student is considered an extension of the certified SLP. The rule allows exceptions: The supervisor and student simultaneously treat one resident each or the student treats two residents simultaneously (and the supervisor is not providing treatment). In these instances, the services would be coded as concurrent treatment. For group treatment, treatment time may be billed only if the group is being conducted by either the supervising clinician or the student, and the other may not be supervising any other student or treating other residents.

Q: What is the difference between group and concurrent treatment, and how are the minutes coded?

CMS defines group treatment for Parts A and B as a clinician conducting the same or similar activities with four SNF residents. Concurrent treatment under SNF Part A is limited to a clinician using different activities to treat two residents (concurrent therapy treatment is not addressed in Part B rules). In both Part A situations, the minutes are allocated among the patients.

Q: Group treatment for SNF Part A patients is limited to 25% of therapy per week, per discipline, for each resident. Are there other group treatment restrictions?

CMS requires treatment groups to have four people. Regardless of how many actually attend the session, the treatment time per patient is the length of the session divided by four (the "25% rule").

For Part B patients, the 25% rule is in effect in some payer regions, but not all. Also, Part B payment is based on the fee associated with CPT code 92508, speech-language group, and not on treatment minutes. For Part A and B patients, the plan of care should include descriptions of therapy type (individual, group, concurrent).

Q: Is co-treatment allowed for SNF Part A residents?

Yes, two therapists from different disciplines may treat one patient at the same time. SNF Part A rules allow both clinicians to code for the full amount of time spent treating the patient. This regulation is different for Part B rules, which recognize the patient's total time in the treatment session, not total time of the therapists (this Part B rule does not apply to an SLP providing services under an untimed CPT code).

Mark Kander, director of health care regulatory analysis, can be reached at

cite as: Kander, M. (2012, December 18). Bottom Line: Coding Medicare A and B in Nursing Homes. The ASHA Leader.


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