Billing and Coding: Skilled Therapy Services in the SNF PPS Setting This
article is to clarify when Physical Therapy (PT), Occupational Therapy (OT) or
Speech Therapy (SP) minutes can be captured on a Minimum Data Set (MDS) for
patients in a Skilled Nursing Facility (SNF) Prospective Payment System (PPS)
stay.  
  
Medicare guidelines state that only treatment time requiring the skills of a
qualified skilled therapist can be billed as therapy services.  
  

  * The services must be of a level of complexity and sophistication and the patient's condition must be of a nature that requires the knowledge and skills of a therapists to complete the therapy modality.
  

  * These skilled services must be reasonable and necessary to treat the patient's condition; this includes amount, frequency and duration.
  

  * Services must not be dependent on the beneficiary's potential for improvement.
  

  
A service provided by a skilled therapists or therapy assistant does not
automatically make it a skilled service. If a service could be completed by an
unskilled person or safely self-administered, it would not be considered
skilled.  
  
Recently, Noridian has noticed an increased use of therapy minutes being
captured on the MDS without documentation supporting that these services
required the attended time of a qualified skilled therapists. Some of these
services include:  
  

  * Electrical Stimulation
  

  * Therapy assistive devices such as:
  
  

    * OmnicycleTM
  

    * Nustep
  

    * Recumbent stepper
  

    * Virtual therapy assistive devices
  

  
  
Although these modalities can assist in meeting therapy goals, only skilled
therapist time should be recorded on the MDS. If all the minutes for these
modalities are captured on the MDS, documentation must support why it was
medically necessary for the therapist/assistant to be in constant attendance
during the entire modality/procedure.  
  
Commonly, only some aspects of a therapy modality will be skilled. Generally,
a resident receiving electrical stimulation as a therapy modality for pain or
muscle strengthening/neuromuscular re-education is an example of such a
modality. The portion of time that can be recorded to the MDS would be if the
time spent for:  

  * Proper electrode placement
  

  * Establishing proper settings
  

  * Removal of the electrodes
  

  * Examining the skin before and after treatment
  

  
  
Documentation to support skilled services should be sufficient for the medical
reviewer to determine when:  

  * Skilled staff involvement/attendance is necessary
  

  * Services are reasonable and necessary for treatment and to promote the goals of therapy
  

  * Portion of the treatment time that was skilled

  
  
There are rare circumstances where these modalities would require constant
supervision or 1:1 time per industry standards, in which case all the minutes
would be considered skilled. In these instances, the documentation needs to be
very specific and clear as to the reason constant supervision or 1:1 time was
needed. Generalized precautions such as fall risk and confusion in most cases
will not support the need for constant supervision or 1:1 time. It is also
important to remember that documentation by the therapist supporting the need
for constant supervision must be supported by the rest of the documentation
provided within the chart.