If you are an Occupational Therapy practitioner or even a Level II student at a skilled nursing facility, you have probably found it difficult to strike a balance between giving quality treatments in accordance with meeting a Medicare RUG (Resource Utilization Group) level. Typically, when a patient is admitted to a skilled nursing facility from a hospital, and has Medicare coverage, the MDS coordinator sets reference periods. If you are new to this area of practice, the reference periods are critical when establishing how many treatment minutes a client can/will receive for Physical, Occupational, and Speech therapy.
To give you a crash course with reference periods, there are different levels a patient can reach, dependent upon their therapy treatment minutes, nursing intervention (i.e., IV antibiotics), and the period of time the patient will be receiving these. Furthermore, the assessment period becomes Medicare's crystal ball. They have preset reimbursement rates, given the set criteria. For example, if the patient is receiving 150 minutes of therapy a day during a reference period, Medicare will reimburse accordingly. If a patient is receiving 30 minutes of therapy combined (OT/PT/SLP) and IV antibiotics, Medicare will reimburse according to the designated RUG level as well. Generally speaking, the more therapy treatment time the greater the reimbursement.
What becomes even more tricky is coordinating a patient's medical status (e.g., patient is nauseated and cannot participate with therapy on the day of admit), the amount of time Occupational/Physical/Speech Therapy has to evaluate and treat the patient upon admission (evaluation minutes do not count), nursing assessment (e.g., wound care or IV antibiotics), and how all of this can be combined to determine a patient's RUG level. Usually, the MDS Coordinator and Rehabilitation Coordinator work together when setting assessment dates and the treating therapists assist in carrying out the plan.
Now that you have a small background on what happens when a patient is admitted to a skilled nursing facility, it is time to tap into a frustrating area for Occupational Therapy practitioners. Many times OT clinicians feel the pressure to see patients for 75 minutes of therapy a day, from their rehabilitation managers. Rightfully, the patient's Medicare coverage is paying your facility based on the reference period RUG level for the patient's stay. This is the key reason you cannot see a patient for 75 minutes a day during a reference period and then immediately taper them down to 30 minute treatment sessions a day. This is a fraudulent act. The reason being, the crystal ball that I previously mentioned, Medicare wants assessment periods set to pay for future dates of therapy. If a patient was seen for 30 minutes a day by Occupational and Physical Therapy combined during a reference period, Medicare will pay that designated RUG amount for X amount of future days.
Many patients admitted to a skilled nursing facility from a hospital setting, were likely receiving inpatient rehabilitation (3 hours of therapy a day). Therefore, their expectations may be to receive a few hours of therapy a day. As an Occupational Therapist evaluating a new client, it is your responsibility to determine how much therapy this client can benefit from. It becomes overwhelming thinking you should see a patient for 50 or 75 minutes a day, as well as see your regular caseload of Occupational Therapy clients. So, how do you maximize your time with a client and help them reach quantitative results? Here are some tips:
- Start Early: Begin seeing patients at 7am to address ADLs. You may not be able to do the entire ADL, but you can initiate a portion each day (communicate with the nursing aid if you cannot complete a patient's ADL). Seeing 2-3 patients for an ADL each day, rotating the patients you see to address everyone, you will soon see carryover of treatment. This will also help eliminate the stress of seeing a patient for 50-75 minutes straight, who may not be able to tolerate that much time at once.
- Group Patients: Usually, a patient receiving Occupational Therapy can receive group treatment up to 25% of their regular treatment time for the week. Have set daily groups that your patients can benefit from. For example, set an adaptive equipment group up for 30 minutes on Tuesdays and address "How to Use Adaptive Equipment." Or have a weekly exercise group, home safety, homemaking, or community re-integration group. This will help utilize your time with a client for Occupational Therapy treatments, as well as aid a client in reaching a functional outcome.
- Dovetail: This is a term many Occupational Therapy Clinicians should become familiar with. Dovetail means you can see two Medicare Part A patients at the same time, but not charge them for a group treatment. Keep in mind, if you are having the clients do the same activity it is a group treatment. But if you are seeing 2 patients with different start/stop times this is considered a dovetail. For example, say you are treating John from 9am-9:50am and Jane from 9:30am-10:20am. Both are Medicare Part A clients receiving different types of treatment (e.g., e-stimulation, exercise...) and can be billed separately. This helps Occupational Therapy practitioners utilize their time more effectively, while still addressing goal-oriented tasks.
- Education: Much of our time as Occupational Therapy clinicians is spent communicating with family, staff, other clinicians, and the patient about the therapy plan of care or how to use equipment appropriately. If the patient is present, you can bill for this time. For example, educating restorative staff or family/patient on a splint wear/care schedule is billable time. Try to take advantage of this, as it will strengthen your documentation and justification for services, as well as improve the client's quality of care.
Keep in mind, all of the above tips and suggestions should be referenced in accordance with your facility's regulatory standards. Please consult with you rehabilitation manager or your policy and procedure manual to accurately determine how to best utilize your time with your client, in accordance with Medicare Part A guidelines.