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If This is YOU, You Better Stop – Groups Have Defined Purpose

Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, April 17, 2014 Posted in: Inpatient Rehab

Group Treatment in Preponderance – No More!

Despite hearing over and over again that the specialty of inpatient rehabilitation is only medically necessary when a patient can tolerate no less than three hours of individualized therapy services, CMS believes group treatment is on the rise in IRFs and it needs to stop now!

In hearing Laurence Wilson, Director of Chronic Care Policy Group at CMS, speak at the AMRPA conference in early March, he led those listening to believe that more often than imagined IRF/Us are providing a level of care that is not in alignment with the expectations of ‘individual vs. group therapy’ services.

He stated that the expectations have not changed but that CMS feels practice may have changed. Of course to the average ‘thorough bred’ rehabilitation management person this sounds absurd; with caution, be certain the practices at your facility do not fall into question and if the patient benefits from group therapy make sure the clarifications that CMS provides are followed.

To this point we are expected not to provide group in ‘preponderance’; there is not a set rule as there is in SNF at this time. However, if this is the perception at CMS that IRFs are grouping more and more of therapy to reach the 3 Hour Rule, clearer expectations will be written into rule making. Was this a hint that it is coming? Not sure. It was one issue Mr. Wilson discussed in regards to IRFs that caught my attention.

Let’s refresh on the reminders about important points in providing GROUP therapy:

Clarifications from CMS Specific to Group Therapy:

Q: Clarification regarding the use of group therapies in IRFs.

A: CMS has not yet established standards for the provision of group therapies in IRFs. However, as we stated in the FY 2010 IRF PPS final rule, the standard of care for IRF patients is individualized therapy. We do not believe that an IRF providing the preponderance of therapy in the form of group therapy would be demonstrating the intensity of therapy required in an IRF.

Source: IRF Training Call Version 2, Page 1, Answer 1

Q: Clarification regarding the percentage of one-on-one individualized therapy that would constitute the ‘bulk’ of therapy.

A: We expect the preponderance of therapy a patient receives at the IRF to be individualized, one-on-one therapy. IRF patients require an intensive and complex level of therapy services designed specifically to their individual needs. We believe that individualized, one-on-one therapy most appropriately meets the specialized needs of IRF patients. We have not yet established a required percentage of one-on-one individualized therapy in the IRF setting because we are seeking more information on the amount of one-on-one versus group therapies that are most beneficial to patients. The specific benefit to the IRF patient of any group therapy that is provided must be well-documented in the IRF medical record.

Source: IRF Training Call Version 4, Page 10, Answer 36

Concurrent Therapy Clarification Discussion:

Q: Clarification regarding the use of concurrent therapies in IRFs.

A: CMS has not yet established standards for the provision of concurrent therapies in IRFs. However, we do not believe that an IRF providing the preponderance of therapy in the form of concurrent therapy would be demonstrating the intensity of therapy required in an IRF.

Source: IRF Training Call Version 2, Page 1, Answer 2

Co-Treatment Clarification Discussion:

Q: Clarification regarding how the minutes for co-treatment count toward the intensive rehabilitation therapy requirement.

A: If the patient receives 15 minutes of individualized therapy from an occupational therapist and 15 minutes of individualized therapy from a physical therapist, then the patient has received 30 minutes of intensive rehabilitation therapy. Co-treatment must be clinically appropriate and provided solely for the benefit of the patient. Co-treatment may not be used for the accommodation of staffing schedules. The specific benefit to the patient of the co-treatment must be well-documented in the IRF medical record.

Source: IRF Training Call Version 4, Page 11, Answer 39

Presently, we have these guidelines as to how Medicare Contractors should observe the use of groups, concurrent and co-treatments in an IRF. The billing associated to your services can be obtained by total charges per day of service by revenue code itemized on the bill. It may be fairly transparent on the bill for those providers that utilize ‘group’ in the mix of their charges. Because it is not a timed code but a comprehensive untimed unit of services it would still be hard to determine by the bill alone if you are at risk. But why give anyone another reason to ask for an additional development request and a manual review of charting?

It seems hard enough these days to demonstrate that IRF/U services are truly unique and individualized – lets not provide continued suspicion by over utilizing group in the care provided at an IRF. In every way possible, preserving IRF services can be chipped away by practices that dilute our specialized niche in the rehabilitation continuum.

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