O0425: Part A Therapies

Item Rationale

Health-related Quality of Life

• Maintaining as much independence as possible in activities of daily living, mobility, and communication is critically important to most people. Functional decline can lead to depression, withdrawal, social isolation, breathing problems, and complications of immobility, such as incontinence and pressure ulcers/injuries, which contribute to diminished quality of life. The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents.

• Rehabilitation (i.e., via Speech-Language Pathology Services and Occupational and Physical Therapies) and respiratory, psychological, and recreational therapy can help residents to attain or maintain their highest level of well-being and improve their quality of life.

Planning for Care

• Except in the case of an interrupted stay, code only medically necessary therapies that occurred after admission/readmission to the nursing home that were (1) ordered by a physician (physician’s assistant, nurse practitioner, and/or clinical nurse specialist as allowable under state licensure laws) based on a qualified therapist’s assessment (i.e., one who meets Medicare requirements or, in some instances, under such a person’s direct supervision) and treatment plan, (2) documented in the resident’s medical record, and (3) care planned and periodically evaluated to ensure that the resident receives needed therapies and that current treatment plans are effective. Therapy treatment may occur either inside or outside of the facility.

• In the case of an interrupted stay, code medically necessary therapies that occurred during the entire current Medicare Part A PPS stay that meet the above-noted criteria.

• For definitions of the types of therapies listed in this section, please refer to the Glossary in Appendix A.

Steps for Assessment

1. Complete only if A0310H (Is this a SNF Part A PPS Discharge Assessment?) = 1, Yes.

2. Review the resident’s medical record (e.g., rehabilitation therapy evaluation and treatment records, recreation therapy notes, mental health professional progress notes), and consult with each of the qualified care providers to collect the information required for this item.

NOTE: The look-back period for these items is the entire SNF Part A stay, starting at Day 1 of the Part A stay and finishing on the last day of the Part A stay. Once reported on the MDS, CMS grouping software will calculate the percentage of group and concurrent therapy, combined, provided to each resident as a percentage of all therapies provided to that resident, by discipline. If the combined amount of group and concurrent therapy provided, by discipline, exceeds 25 percent, then this would be deemed as non-compliance and a warning message would be received on the Final Validation Report.

Providers should follow the steps outlined below for calculating compliance with the concurrent/group therapy limit:

• Step 1: Total Therapy Minutes, by discipline (O0425X1 + O0425X2 + O0425X3)

• Step 2: Total Concurrent and Group Therapy Minutes, by discipline (O0425X2+O0425X3)

• Step 3: Concurrent/Group Ratio (Step 2 result/Step 1 result)

• Step 4: If Step 3 result is greater than 0.25, then the provider is non-compliant.

Coding Instructions for Speech-Language Pathology and Audiology Services and Occupational and Physical Therapies

• Individual minutes—Enter the total number of minutes of therapy that were provided on an individual basis during the entire Part A stay (i.e., from the date in A2400B through the date in A2400C). Enter 0 if none were provided. Individual services are provided by one therapist or assistant to one resident at a time. (For detailed definitions and examples of individual therapy, refer to O0400 above.)

• Concurrent minutes—Enter the total number of minutes of therapy that were provided on a concurrent basis during the entire Part A stay (i.e., from the date in A2400B through the date in A2400C). Enter 0 if none were provided. Concurrent therapy is defined as the treatment of 2 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. When a Part A resident receives therapy that meets this definition, it is defined as concurrent therapy for the Part A resident regardless of the payer source for the second resident. (For detailed definitions and examples of concurrent therapy, refer to item O0400 above.)

• Group minutes—Enter the total number of minutes of therapy that were provided in a group during the entire Part A stay (i.e., from the date in A2400B through the date in A2400C). Enter 0 if none were provided. Group therapy is defined 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. (For detailed definitions and examples of group therapy, refer to item O0400 above.)

• Co-treatment minutes—Enter the total number of minutes each discipline of therapy was administered to the resident in co-treatment sessions during the entire Part A stay (i.e., from the date in A2400B through the date in A2400C). Skip the item if none were provided. (For detailed definitions and examples of co-treatment, refer to item O0400 above.)

• Speech-Language Pathology Days—Enter the number of days speech-language pathology therapy services were provided over the entire Part A stay (i.e., from the date in A2400B through the date in A2400C). A day of therapy is defined as skilled treatment for 15 minutes or more during the day. Use total minutes of therapy provided (individual plus concurrent plus group), without any adjustment, to determine if the day is counted.

For example, if the resident received 20 minutes of concurrent therapy, the day requirement is considered met. Enter 0 if therapy was provided but for less than 15 minutes every day during the stay. If the total number of minutes (individual plus concurrent plus group) during the stay is 0, skip this item and leave blank.

• Occupational Therapy Days—Enter the number of days occupational therapy services were provided over the entire Part A stay (i.e., from the date in A2400B through the date in A2400C). A day of therapy is defined as skilled treatment for 15 minutes or more during the day. Use total minutes of therapy provided (individual plus concurrent plus group), without any adjustment, to determine if the day is counted. For example, if the resident received 20 minutes of concurrent therapy, the day requirement is considered met. Enter 0 if therapy was provided but for less than 15 minutes every day during the stay. If the total number of minutes (individual plus concurrent plus group) during the stay is 0, skip this item and leave blank.

• Physical Therapy Days—Enter the number of days physical therapy services were provided over the entire Part A stay (i.e., from the date in A2400B through the date in A2400C). A day of therapy is defined as skilled treatment for 15 minutes or more during the day. Use total minutes of therapy provided (individual plus concurrent plus group), without any adjustment, to determine if the day is counted. For example, if the resident received 20 minutes of concurrent therapy, the day requirement is considered met. Enter 0 if therapy was provided but for less than 15 minutes every day during the stay. If the total number of minutes (individual plus concurrent plus group) during the stay is 0, skip this item and leave blank.

Coding Tips and Special Populations

• For detailed descriptions of how to code minutes of therapy and explanation of skilled versus nonskilled therapy services, co-treatment, therapy aides and students, please refer to these topic headings in the discussion of item O0400 above.

Modes of Therapy

A resident may receive therapy via different modes during the same day or even treatment session. These modes are individual, concurrent and group therapy. When developing the plan of care, the therapist and assistant must determine which mode(s) of therapy and the amount of time the resident receives for each mode and code the MDS appropriately. The therapist and assistant should document the reason a specific mode of therapy was chosen as well as anticipated goals for that mode of therapy. For any therapy that does not meet one of the therapy mode definitions below, those minutes may not be counted on the MDS. The therapy mode definitions must always be followed and apply regardless of when the therapy is provided in relationship to all assessment windows (i.e., applies whether or not the resident is in a look-back period for an MDS assessment).

Individual Therapy

For a detailed definition and example of individual therapy, please refer to the discussion of item O0400 above.

Concurrent Therapy

For a detailed definition and example of concurrent therapy, please refer to the discussion of item O0400 above.

Group Therapy

For a detailed definition and example of group therapy, please refer to the discussion of item O0400 above.

Therapy Modalities

For a detailed definition and explanation of therapy modalities, please refer to the discussion of item O0400 above.

General Coding Example:

Following a bilateral knee replacement, Resident G was admitted to the skilled nursing facility in stable condition for rehabilitation therapy on Sunday 10/06/19 under Part A skilled nursing facility coverage. While in the hospital, they exhibited some short-term memory difficulties specifically affecting orientation. They were non-weight bearing, had reduced range of motion, and had difficulty with ADLs. They were referred to SLP, OT, and PT with the long-term goal of returning home with their spouse. Their initial SLP evaluation was performed on 10/06/19, and the OT and PT initial evaluations were done on 10/07/19. They were also referred to recreational therapy. They were in the SNF for 14 days and were discharged home on 10/19/2019. Resident G received the following rehabilitation services during their stay in the SNF.

Speech-language pathology services that were provided over the SNF stay:

• Individual cognitive training; six sessions for 45 minutes each day.

• Discharged from SLP services on 10/14/2019.

Coding: O0425A1 would be coded 270; O0425A2 would be coded 0; O0425A3 would be coded 0; O0425A4 would be coded 0; O0425A5 would be coded 6.

Rationale: Individual minutes totaled 270 over the stay (45 minutes × 6 days); concurrent minutes totaled 0 over the stay (0 × 0 = 0); and group minutes totaled 0 over the stay (0 × 0 = 0). Therapy was provided 6 days of the stay.

Occupational therapy services that were provided over the SNF stay:

• Individual ADL activities daily for 30 minutes each starting 10/08/19.

• Co-treatment: seating and transferring with PT; three sessions for the following times: 23 minutes, 18 minutes, and 12 minutes.

• Balance/coordination activities: 10 sessions for 20 minutes each session in a group.

• Discharged from OT services on 10/19/19.

Coding: O0425B1 would be coded 413, O0425B2 would be coded 0, O0425B3 would be coded 200, O0425B4 would be coded 53, O0425B5 would be coded 12.

Rationale: Individual minutes (including 53 co-treatment minutes) totaled 413 over the stay [(30 × 12) + 53 = 413]; concurrent minutes totaled 0 over the stay (0 × 0 = 0); and group minutes totaled 200 over the stay (20 × 10 = 200). Therapy was provided 12 days of the stay.

Physical therapy services that were provided over the stay:

• Individual mobility training daily for 45 minutes per session starting 10/07/19.

• Group mobility training for 30 minutes Tuesdays, Wednesdays, and Fridays.

• Co-treatment seating and transferring for three sessions with OT for 7 minutes, 22 minutes, and 18 minutes.

• Concurrent therapeutic exercises Monday-Friday for 20 minutes each day.

• Discharged from PT services on 10/19/19.

Coding: O0425C1 would be coded 632, O0425C2 would be coded 200, O0425C3 would be coded 180, O0425C4 would be coded 47, O0425C5 would be coded 13.

Rationale: Individual minutes (including 47 co-treatment minutes) totaled 632 over stay [(45 × 13) + (7 + 22 + 18) = 632]; concurrent minutes totaled 200 over the stay (20 × 10 = 200); and group minutes totaled 180 over the stay (30 × 6 = 180). Therapy was provided 13 days of the stay.