Could Your Therapy Frequency Cause a Medicare Part A Denial?

Question:

If a Medicare Part A resident is receiving skilled therapy services, and does not have skilled nursing needs, what is the rule for therapy coverage? Is 1 therapy discipline required to provide services a minimum of 5 days per week, or can multiple disciplines combine to provide the 5 days? In other words, can we combine disciplines to cover the 5 day-per-week requirement?

Answer:

The Medicare Part A requirement, found in Chapter 8 of the Medicare Benefit Policy Manual, states that in order to qualify for skilled services, the resident “has to have daily skilled nursing or rehab services in place.”

Medicare defines daily skilled services for nursing as 7 days per week, and defines daily skilled services for therapy as at least 5 days per week. One discipline is not required to provide 5 days per week if multiple disciplines are covering the 5 day span. It is acceptable to split therapy services between disciplines if medically necessary for the resident.

But don’t get caught in the trap…

CMS issues specific caution when using the “staggered therapy approach,” as quoted from Chapter 8, Section 30.6 – Daily Skilled Services Defined] which states:

Skilled nursing services or skilled rehabilitation services must be needed and provided on a “daily basis,” i.e., on essentially a 7-day-a-week basis. A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. If therapy services are provided less than 5 days a week, the “daily” requirement would not be met.”

“The daily basis requirement (for therapy) can be met by furnishing:

1. A single type of skilled service every day, or
2. Various types of skilled services on different days of the week that collectively add up to “daily” skilled services

However, arbitrarily staggering the timing of various therapy modalities through the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.” 

To meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on each of the days that the facility makes such services available. It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient’s medical needs indicate that daily therapy is required. For example, if physical therapy is furnished on 3 days each week and occupational therapy is furnished on 2 other days each week, the “daily basis” requirement would be satisfied only if there is a valid medical reason why both cannot be furnished on the same day.”

The basic issue here is not whether the services are needed, but when they are needed. Unless there is a legitimate medical need for scheduling a therapy session each day, the “daily basis” requirement for SNF coverage would not be met.”

 

What is the Take-Away?

If you are staggering therapy services between 2 or 3 disciplines for your Part A residents, additional documentation is required to avoid claim denial for not meeting the 5 day requirement, or for lack of “reasonable and necessary services.” Documentation must prove a “legitimate medical need for scheduling this way”, as CMS states above.

How Can This be Accomplished?

1. In addition to the individual therapy evaluations that establish the therapy frequency and plan of care, an additional therapy note is recommended to support the medical need for scheduling therapy services across 5 days. This note would need to be written after all therapy evaluations were completed and the frequencies established, and after the determination was made to stagger the services based on medical necessity. The note would likely be written by a therapist or therapy manager, and should include why sessions can’t occur on the same day. A note entry into the EMR after a team meeting discussing the scheduling for this resident would be sufficient.
   • For example, if PT recommended 3 days per week, and OT 2 days, the therapy note would have to establish why the resident can’t receive a PT and OT session on the same day. Why do the therapies need to be staggered? Include co-morbidities, limited activity tolerance or any additional reasons to justify the split.
2. Include the medical need in the MD order for therapy services.
   • For example, state the MD order as follows: “Stagger PT 3 days per week and OT 2 days per week x 4 weeks as resident is unable to tolerate 2 therapies on the same day. Medical reason: limited activity tolerance due to dialysis 3 days per week.”

Remember, it is the need for 5 calendar days per week that you are justifying. Why do they need 5 days of therapy? Why can’t PT and OT occur on the same day? If the need for 5 days is not justified, Medicare Part A criteria for skilled services will not be met and the full claim coverage may be at risk.

The PPS Medicare Part A Discharge MDS that is completed at the end of the Medicare Part A stay will include the total days and minutes of therapy for each discipline, and will easily identify services provided less than 5 days per week. This may trigger a chart audit to investigate skilled coverage further, especially if the Nursing Component HIPPS Code is in a low Case Mix Group. (ie: R-Y) Having adequate documentation in place to support this therapy practice, a practice that should be the exception and not the rule, will keep you ahead of the curve.

If you have any questions, submit them to the Just Ask Q&A Forum HERE.

In Your Corner,

Dolores

Dolores Montero, PT, DPT, RAC-CT, RAC-CTA

SNF Therapy & MDS Compliance Consulting