The post-acute therapy world suffered a major setback on July 29 when the SNF PPS Final Rule for fiscal year 2012 was released. 

The implementation of Minimum Data Set (MDS) 3.0 and RUGs IV last fall modified minute recording, requiring individual, concurrent and group minute delineation. It also changed the definition and allocation of concurrent minutes.

Concurrent therapy was defined as two residents who are not performing the same or similar activities at the same time, regardless of payer source. Both must be in the line of sight of the treating therapist or assistant.

The minutes would be divided by two, allowing a therapist/assistant to only get credit for half of the minutes delivered to each resident. CMS recognized concurrent therapy as a valid method of service delivery but believed it was not being utilized properly. 

This change penalized everyone, creating the need for increased staff hours to deliver the same amount of therapy prior to Oct. 1, 2010. CMS made no changes to the parameters surrounding group therapy until now. 

In the Final Rule for Oct. 1, 2011, CMS changed the definition of group therapy to "the treatment of four residents, regardless of payer, who are performing similar activities and are supervised by a therapist or assistant who is not supervising any other individuals." 

The limitation of 25 percent per discipline per week still applies, but the minutes provided in a group setting will be divided by four. If four patients are in a group for 60 minutes, each will have only 15 of the 60 minutes apply to their rehab RUG category or count as "reimbursable therapy minutes" (RTM).

If a group is planned with four participants and one is not able to attend, the therapist can carry out the group, but the minutes will still be divided by four. The changes to both the concurrent and group parameters over the years is counterintuitive to the insistence by CMS that the therapy minutes should be based on the minutes of therapy the patient receives, not the number of clinicians necessary to deliver the service.

In addition to this change, the prospective payment system (PPS) will now incorporate a look-back period every seven days between the traditional assessments to validate that the patient continues to receive the same level of minutes as was established on the last scheduled assessment. 

If the resident's minutes no longer meet that level - for example, if the patient's RUG on the 14-day MDS was RU with 736 minutes and on day 7 after the ARD the patient had only received 702 minutes - a Change of Therapy Other Medicare Required Assessment (COT OMRA) would need to be completed to capture the RH that would begin payment the first day after the Assessment Reference Date (ARD) for the 14-day MDS. This process would continue until the next scheduled assessment.

Clarification to the End of Therapy (EOT) OMRA in the Final Rule states that if a patient misses three consecutive calendar days of all therapies for any reason, planned or unplanned, an EOT OMRA would need to be completed, and the missed days would not be covered by the Rehab Resource Utilization Group (RUG). This is regardless of whether the facility provides therapy five, six or seven days per week and whether it is still in compliance with the physician's order. 

The Centers for Medicare and Medicaid Services (CMS) has provided guidance that if therapy is likely to resume within five calendar days from the last treatment and will resume at the same level as was previously being delivered, the facility can complete the EOT-R (End of Therapy Resumption), and the therapist will not need to do a new evaluation and plan of care. 

However, if more than five days is missed or a clinical change has occurred, the EOT-R would not apply, and a new therapy evaluation would be required to resume treatment.

On a positive note, CMS has lifted the requirement of line-of-sight supervision related to therapy students in a skilled nursing facility (SNF) environment. It will be left up to the discretion of the supervising clinician as to what level of supervision the student requires. 

It is important to note, however, that the student and the clinician still are considered a unit and must adhere to proper billing parameters as such. This means that the student is not permitted to carry a caseload independent of the supervising clinician.

Leigh Ann Frick is vice president of clinical services at Heritage Healthcare Inc. in Greenville, SC.