In part 2 of this two-part blog series “Group vs. Concurrent Therapy: Are You Documenting Accurately?” we will discuss actual documentation of examples that may not support group and concurrent therapy as skilled and reasonable. In part 1, we reviewed the definitions of group and concurrent therapy. Both definitions can be found in the Resident Assessment Instrument (RAI) Manual, Pages O-23-O-25. To refresh your memory, the Centers for Medicare & Medicaid Services (CMS) currently defines group therapy for Part A as the treatment of two to six residents, regardless of payer source, who are performing the same or similar activities and are supervised by a therapist or an assistant who is not supervising any other individuals. When utilizing group therapy, it should be clear from the documentation as to why the patient would benefit from group therapy. Group therapy must be outlined on the initial plan of treatment, and it should be evident that the focus of the group relates to each patient’s outlined goals.
Concurrent therapy is defined as the treatment of two residents at the same time, when the residents are not performing the same or similar activities, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant for Medicare Part A. The RAI Manual October 2019 Section O, page 0-23, Modes of Therapy outlines best practice guidelines for choosing a particular mode of therapy, including determining the appropriate mode, documenting the reason the mode was chosen and relating to the patient’s goals.
As promised, we will dive into some actual examples of how the documentation did not support the practice guidelines for documenting specific modes and neglected to support reasonable and necessary skilled care. Based on recent audits conducted by LW, Consulting Inc. (LWCI) , it is clear that not all therapists understand the difference between group and concurrent therapy and our hope is through reviewing some actual examples, therapists will have a better understanding of how to accurately document group and concurrent therapy.
Examples of Inappropriate Group vs. Concurrent Therapy Documentation
Below is an example of documentation that is not best practice in support of a patient who is not clinically appropriate for group therapy, and an auditor’s comment regarding the documentation.
The Physical Therapy (PT) daily note read: "AAROMEs of B LE x 20reps x 3 sets to improve strength and mobility of B LE. Patient needed stimulation because patient was a little lethargic."
Comment from auditor: The PT daily note on 11/19/19 does not support group therapy under 97150 for 15 minutes as documented. There is no mention that this patient performed these tasks in a group setting even though it was coded as a group on the MDS. A lethargic patient may not be a good candidate to participate in a group session as he/she would need continual cues and one-to-one attention in order to benefit from the skilled service.
Other findings include disallowance of minutes coded as group therapy when group was not included as an intervention on the plan of treatment or signed by the physician. There were no other orders in the medical record to support the implementation of group therapy; therefore, those minutes could not be supported as group minutes. They may be reasonable and necessary as individual minutes; however, the question is: what about the coding of the other patients in the group?
There were instances where concurrent therapy was noted on the service log, but there was no documentation to support the patient receiving the service or that the therapist was providing continual line of sight supervision. There were also instances where the patient was not suitable based on the increased need for individual attention or a higher level of physical assistance, and it was evident the patient clinically needed one-on-one care. There was no indication that the therapist intended to incorporate this mode into the plan of treatment.
Here’s an actual example of a finding:
The PT daily note read: “Poor carry over as patient exhibits listing to L side with head fully turned to R side. Difficulty with midline/frontal plane awareness. NMRE in semi reclined as therapist positioned patient in midline with body placed in neutral with bolster/pillows to align head also as patient has fully L sided neglect with head always turned to R side. Therapist required to reposition patient 5 x in 15 min."
Comment from auditor: The documentation does not support concurrent therapy as medically reasonable and necessary. The clinical picture of the patient presents challenges that should be addressed on an individual basis.
The Occupational Therapy (OT) daily note read: Patient completed B UE strengthening exercises of 4# dumbbell x 3 sets of 10 with rest breaks as needed throughout while sitting unsupported at edge of bed in the patient’s room to increase UE and core strength with focus toward improving ADLs. PT. performed functional mobility task with rolling walker and supervision to ambulate from patient’s room to therapy gym.
Comment from auditor: The documentation for therapeutic exercises on 11/5/19 states that the exercises were completed unsupported at the edge of the bed in the patient’s room. The auditor concludes that treatment was conducted in the patient’s room and the requirement for the therapist to be within line of site of the two patients being treated at the same time, was not met. Twenty-five minutes coded for exercises is not allowed as concurrent treatment. The therapist documented under treatment code, 97530 “the patient ambulated from the patient’s room to the therapy gym.” The auditor concludes that the second patient was not in line of sight of the therapist during the ambulating activity and ten minutes of concurrent therapy are not allowed.
Under the Patient Driven Payment Model (PDPM), group and concurrent therapy are allowed up to a combined 25% maximum per discipline which is based on the therapy minutes reported on the Minimum Data Set (MDS). The most important thing to remember with PDPM is that patient specific clinical care delivery is the driver in making this a winning reimbursement model. To achieve this win, facilities must know their baseline functional outcomes, provisions of therapy that have promoted these outcomes and documented accurately, demonstrate medically reasonable and necessary skilled care in the documentation and prepare for future opportunities to provide efficient, patient-centered, and cost-effective care.
How to Document Group and Concurrent Therapy Effectively
So, what can you do now with your team so that they have a better understanding of the various modes of therapy and can document more effectively?
- Review the guidelines of group therapy with the therapists and ensure they understand when performing group therapy that it should be first outlined on the plan of care.
- It should also be evident in the documentation that the patient participated in group therapy and the focus of the group should be clear from the documentation.
- The documentation should also show the benefits of the group to the specific patient needs.
- It should be evident that the intent of the group is aligned with the goals of the patient.
- Re-educate the therapists on the definition of concurrent therapy and when it may be an appropriate mode of treatment.
- It should be clinically appropriate to provide concurrent treatment, and this is determined on a case-by-case basis.
- Remind therapists that group and concurrent therapy are not the same under Medicare Part A. Because there is a cap on how much group and concurrent therapy minutes can be implemented, make sure your staff understands the provisions and how to document effectively so that each minute counts accurately.
- And above all else, the documentation must prove that it is medically reasonable and necessary no matter what mode of treatment is administered.
If you need assistance in managing through PDPM, guidance with audits or additional training for your therapists, please let LW Consulting Inc. assist you. Now is the time to act.
Need assistance managing PDPM, guidance with audits or additional training for your therapists? Call Deborah Alexander at 717-213-3122 or email DAlexander@LW-Consult.com.