Regulations on Number of Patients Per Caseload

Question: I work for a SNF that is very demanding of its rehab staff. Management has informed us that they feel we should be treating nine to10 patients a day. I feel that this is too much and conflicts with quality patient care.

The company feels that all treatment time should be either 55 minutes or 75 minutes unless the patient is very low level. Management also feels that each therapist should have at least two 75-minute treatments per caseload. I feel that the level of function of each patient should be considered. I feel that is a lot to take on in an eight-hour day plus documentation.

Does Medicare have any regulations regarding number of patients per caseload per therapist? Is it different between PTs and PTAs?

Answer: Medicare does not stipulate caseload although it has noted many times that it expects treatment, other than the group session to be one-on-one.Twice in the Federal Register (2001 and 2005) for the Final Rule on SNF PPS, Medicare has addressed concurrent therapy. Medicare stated that it was aware that concurrent therapy could be appropriate on certain occasions (meaning dovetailing of two patients, not multiple patients). Both times Medicare emphasized that it should be done because of the therapist's professional judgment, and not the mandate of management.

Effective Oct. 1, 2010, Medicare will dictate that while treatment of two patients at the same time may be appropriate, the facility's reimbursement will not be the same as if they are treating one patient at a time. Further, CMS is clear that if more than two patients are being treated at the same time, then reimbursement for that time will not be paid. The rationale is that it is not costing the facility twice as much to provide that care, therefore why should they be reimbursed twice their cost for concurrent therapy?

Question: When using electrical stimulation for a Part A patient, the minutes count toward total treatment time. Do the setup minutes also count toward the RUG, especially if they use this time to assess the patient for the modality in question?

Answer: For Part A Medicare patients, the guidelines for what minutes of therapy services can be counted and used in section P1b of the MDS to create a RUG level are identified in the RAI (Resident Assessment Instrument) Manual. The guidelines state, "The resident's treatment time starts when he/she begins the first treatment activity or task and ends when he/she finishes with the last apparatus and the treatment is ended." All minutes provided once the patient has started the first activity can be included in the total minutes for the day.

As therapists, we often do not give ourselves credit for what we do that is skilled and therefore billable. "Especially if they use this time to assess the patient for the modality in question" is actually the most skilled portion of the treatment. During this time we are collecting information that is necessary for us to determine the parameters of treatment we are going to perform.

Medicare states that assessment is skilled and includes the collection of data, including information obtained from the patient, as well as that collected through observation. Through talking to the patient we can determine the effectiveness of the previous treatment, the condition of the skin, the state of underlying tissue, etc. Based on this data, we then determine if the treatment needs to be modified in relation to the intensity and duration.

Not including all that is skilled in the treatment time also has a direct impact when billing Part B constant attendance modalities such as ultrasound. We constantly see in documentation review that the time spent on ultrasound is six, seven or eight minutes. This only accounts for the actual time of the modality, but gives no credit for the skill needed in observation, assessment and modification of the treatment based on that information.

Disclaimer: The answers provided 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.

If you have a question about Medicare reimbursement you would like the authors to address, send your question and contact information to Medicare Advisor, c/o Lisa Lombardo, ADVANCE for PTs & PTAs, 3100 Horizon Dr., King of Prussia, PA 19406; fax 610-275-8562;

Pauline M. Franko 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. As an associate in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance programs to rehab agencies. Danna Mullins is an associate and lecturer with Encompass. Contact the authors through the Encompass website at or by phone at 954-720-4087.


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