Medicare ADVISOR Q&A

Concurrent Therapy in an SNF; Progress Notes; CPT Coding System

Question: How does CMS view concurrent therapy in a SNF setting billing Part A?

Answer: Until now, CMS has always identified that it considers concurrent therapy in the SNF setting as appropriate when driven by clinical considerations, not administration. They addressed this twice in past updates to the Final Rule for PPS, stating "We wish to convey that the therapist's professional judgment should not be compromised and concurrent therapy should be performed only when it is clinically appropriate to render care to more than one individual (other than group therapy) at the same time."

As we are now aware, starting next October with the implementation of the RUG IV system, CMS will define concurrent therapy as the treatment of only two patients at the same time. Therapists will have to distinguish concurrent therapy from individual one-on-one care and group therapy. In the most recent Final Rule it was also made clear that treatment of more than two patients concurrently was unacceptable (except for group therapy), and that the therapist could not report/count the time spent with any of the patients when that occurred.

That finally seems to be pretty clear to us!

Question: Currently we send our notes to the doctors every month to be signed. We are a facility that has contracts with schools, but we are Medicare certified so we follow those guidelines. We are trying to become paperless but if the notes still need to be signed then we have to print them. Is this still a rule or has it been dropped?

Answer: Medicare has no requirement that progress notes be sent to the physician for review and approval. Therefore, unless you feel that sending that information to the physician is beneficial for PR purposes, or a it is a requirement of your practice act, then you can happily cut down on your "paper" and go "green."

Question from the Web: I currently work at an LTAC. Recently, we had a team meeting in which my supervisor suggested that in order to increase productivity we should adopt a "modified" version of the 8-minute rule. For instance, normally 38 minutes equals three units of therapy. She suggested that if we see a patient for 31 minutes, we could potentially charge three units; i.e., two therapeutic activities and one gait within 31 minutes can equal three units. Another example is that one unit of therapeutic activities, one unit of therapeutic exercise, and one unit of gait given in 33 minutes can still equal three units.

I am concerned that this practice is not ethical and my supervisor has not given me evidence that this is a legal practice by all clinicians. Can you provide me with any written info that would support or refute this kind of billing?

Answer: Although hospitals are not paid based on the CPT coding system, it is utilized by most to create a standardized way of applying costs to services as the basis of the cost report. Any system that revises the 8-minute rule could be construed as fraudulent. The reimbursement for the CPT code system is based on a 15-minute unit, not any part of that unit.

This reminds us of the practice done by some companies in the 1990s, when the cost of therapy services escalated due to the practice of counting time as billable units, and billing the next unit if the time exceeded the 15-minute increment.

Disclaimer: The answers that we provide are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.

Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Consulting, Compliance and Training, based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. Danna Mullins is an associate and lecturer with Encompass. You may contact the authors through the Encompass website at or by phone at 954-720-4087.

Medicare Advisor Archives

I am working in a out-patient clinic. I see a mix of patients with different insurance. How do you properly bill concurrent physical therapy? I schedule one patient per hour, and sometimes there is a little overlap between patients. When there is an overlap, I put one patient on an unattended modality. Is it possible to bill for treatment for two patients at the same time? How can I appropriately bill for PT under a 60-minute session with these types of insurance together? Can you provide the literature to support your answer?

1. Two private insurance together (HMO or PPO)
2. Two Medicare insurance together
3. One private insurance, and one medicare together

Brian October 02, 2016

When working in a SNF, is it required that the PT to provide a visit on the 7th treatment day to a patient? When the PT sees the patient on the 7th session, is the PT supposed to treat them for the full amount of minutes that are scheduled or just ten minutes for gait training?

Ivyrose GoswickJanuary 27, 2016
Mt. Pleasant, PA

I am a newly certified PT in USA even though I have worked as a registered PT in Canada for nearly 20 years. As a staff PT working for a sub-acute rehab facility, we are often asked to treat HMO2 patients concurrently to keep 100% productivity ( Most of the time we are more 110%) as we are told to keep that it was legal to do so. Last week, I was asked to treat a Med A patient with an HMO2 patient concurrently which I told my director that I did not feel that it was legal, but I was told that it was; however, I did not do so for both times because I did not feel it to be legal or ethical. What must/should I do? You professional advice will be greatly appreciated.

Khanh June 09, 2014

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