The Centers for Medicare and Medicaid Services (CMS) issued final regulations for Part A services in skilled nursing facilities (SNFs) on July 29, 2011, effective October 1, 2011. Overall payments to SNFs in FY2012 will be reduced by 11.1%, mainly due to the overutilization of therapy payment categories compared to expected projections.
Reduced supervision of therapy students. CMS has removed specific student supervision restrictions in SNFs because hospitals have no such restrictions for Part A patients. The objective was to promote greater conformity with other inpatient settings. As stated in the proposed rule, the new requirement is that "each SNF will determine for itself the appropriate manner of supervision of therapy students consistent with applicable state and local laws and practice standards." CMS emphasized that a new, different method of supervision would in no way alter the individual's basic status as a student operating under the therapist's supervision and "the time the student spends with a patient will continue to be billed as if it were the supervising therapist alone providing the therapy."
Group therapy. The CMS proposal that defines optimal group treatment as requiring four-persons remains unchanged in the final regulation. Thus, if a group therapy session consists of two or three patients, the session length must be divided by four (e.g., a 30-minute session with three patients yields 30 ÷ 4 = 7 minutes counted toward the Resource Utilization Group (RUG) level of care). The proposed four-person group treatment standard was protested by ASHA, noting that there is no research to support the assumption that four persons are optimal. A longstanding SNF Part A rule remains, allowing up to 25% of therapy per discipline per week to be group therapy.
End of therapy OMRAs. Changes also affect Other Medicare Required Assessments (OMRAs). CMS proposed that an interruption of three days of therapy would require that the patient be discharged from therapy and require an OMRA when restarting therapy, whether or not the SNF maintained a five-day or seven-day therapy schedule. For example, if the patient received no therapy on Friday, Saturday, and Sunday then an assessment would be required, even though such an OMRA serves no purpose as a clinical management tool. ASHA pointed out that there are many reasons for a missed treatment on the last day of the work week – Friday (e.g., patient illness, therapist illness, patient refusal, visit to physician's office) extending the interrupted therapy to three days. We recommended the requirement be revised to four days to avoid many unnecessary discharges and reassessments, but the minimum missed treatment period will stand at three days.
The final rule [PDF] is posted on the Office of the Federal Register's website.