Getting Ready for PDPM: Group and Concurrent Therapy

Introduction

Thank you so much for listening in on this very important topic. Now that we are in the throes of the Patient Driven Payment Model (PDPM), there is a lot of talk about group and concurrent therapy. I think we all are starting to understand the rules like the Interim Payment Assessment (IPA), the ICD-10, and the Case-Mix Index (CMI) and all those other acronyms that have been thrown at us. However, we need to talk more about group and concurrent, and when it is appropriate. How do we bill for it? How should we document? How do we justify this and marry that with the expectations of the provider for whom we work? And, what are Medicare's expectations? I think this is critical, and the most important thing. Everything that I am talking about today has been taken from various CMS (Centers for Medicare and Medicaid Services) documents, and some other resources that you have available to you in the reference handout associated with today's session.

Background

• The PDPM does not utilize minutes of therapy for classification
• Providers may be incentivized to emphasize group and concurrent
• CMS imposed a limit of 25 percent on concurrent and group therapy per discipline, per episode of care

Before we get into the nitty-gritty, I want to give a little bit of the background under the PDPM. If we go back, under RUG-IV there was no more than 25% of the therapy services delivered to SNF patients for each discipline that could be provided in a group therapy setting. And, there was no limit on concurrent therapy. This has changed significantly. Now, we know that the SNF PDPM is not going to be using minutes of therapy provided to a resident to classify the patient for payment purposes. We know that the payment is being driven by the characteristics of the patient. And because of that, it is possible, and this is coming directly from Medicare, that skilled nursing facilities may become incentivized to emphasize group and concurrent therapy over the kind of individualized therapy which is tailored to address each patient's specific care needs. I think we, as clinicians, oftentimes feel that this is the most appropriate mode of therapy for skilled nursing facility patients. So, in order to mitigate that potential effect of the PDPM, CMS imposes a limit of 25% on group and concurrent therapy. CMS has also distributed several fact sheets about this that you can get on their websites that explain it a little bit more. We will talk more about this, but that 25% is based on the episode of care per discipline and per episode. This means the entire length of stay for that particular patient.

• As per CMS, therapists are capable of managing groups of various sizes
• Clinical judgment should be used in determining the use of groups and size
• A group is primarily a supplement to individual therapy
• One-to-one care should be considered the primary mode and standard of care
• CMS planning a robust monitoring program to assess compliance with the 25% cap

CMS in the past had a lot of concerns specifically about group therapy. They had a concern that any group that consisted of more than four participants would not allow for adequate supervision of each participant, as well as cause some difficulty for participants to engage with one another in the most effective way. On the flip side, CMS maintained that a group of fewer than four individuals would not allow for effective interaction really to best achieve the goals of the group. And for those reasons, CMS has always historically defined group therapy as exactly four participants. Now fast forward, CMS found with some of the research that they have completed, that therapists do seem capable of managing groups of various sizes. Based on this research, they do believe the therapist has the clinical judgment to determine whether groups of different sizes would clinically benefit their patients which they should be able to demonstrate with adequate documentation. Thus, it is up to the clinical judgment of the therapist to determine how many patients can realistically be in a group. They also go on to say that while group therapy can play an important role in skilled nursing facility patient care for certain patients and for certain conditions, it is primarily a supplement to individual therapy. CMS continues to maintain that a therapist providing one-on-one care with his or her full attention on one patient should be considered the primary mode of therapy and the standard of care. And, CMS has gone on to say that they plan to implement, in their words, a robust monitoring program to assess compliance with the 25% cap, and they may address that in future rulemaking specifically as it relates to a penalty.

As Per CMS...

• As per CMS, therapists are capable of managing groups of various sizes
• Clinical judgment should be used in determining the use of group and size
• Group is primarily a supplement to individual therapy
• One-to-one care should be considered the primary mode and standard of care
• CMS planning a robust monitoring program to assess compliance with the 25% cap

CMS changed the definition of group therapy for the reasons that we just talked about, and effective October 1st, 2019, under the SNF Prospective Payment System, group therapy is defined as a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities. There have been some questions about what do with a student? How do we code that? I will just say that that has not changed. If you go back to the RAI, which is the Resident Assessment Instrument, it gives you specific instructions on how to code a student's time under Medicare Part A for concurrent and group. You are highly advised to refer to the RAI for that. Now additionally from Medicare, they indicate that SNFs should include in the patient's plan of care an explicit justification for the use of group rather than individual or rather than concurrent therapy. So if we are going to use a group for treatment, we need a description and justification. This should include the specific benefits to that particular patient, the documented type, the amount of group therapy, and how that prescribed type and amount of group therapy is going to meet the patient's needs and help him or her reach their documented goals. You are going to see throughout our conversation today the focus on documentation, rationale, and the justification for the group.

• CMS states that individual therapy is generally best for a resident
• No treatment minimums, but PDPM expects “Reasonable and Necessary care per Chapter 8 of the Medicare Benefit Policy Manual
• “We believe that individual therapy is usually the best mode… as it permits the greatest degree of interaction between the resident and therapist, and should, therefore, represent, at a minimum, the majority of therapy provided to an SNF resident.”

CMS also states that although they recognize that group and concurrent therapy may have clinical merit in specific situations, they believe that individual therapy is generally the best way of providing therapy to a resident because it is most tailored to that specific resident's care needs. To that end, this is where that 25% cap per resident's therapy minutes by discipline over the episode of care and the length of stay comes into play. They state, "We believe that individual therapy is the best mode as it permits the greatest degree of interaction between the resident therapist and should, therefore, represent at a minimum the majority of therapy provided to a skilled nursing facility resident." The other thing to keep in mind is chapter eight of the Medicare Benefit Policy Manual still applies. There are no treatment minimums. Remember under RUG-IV, it was 720, 500, and so on. Even though there are no treatment minimums under PDPM, CMS still expects reasonable and necessary care as per chapter eight. This chapter talks about what is reasonable and necessary and what is skilled care. None of that has changed. They took away those minute thresholds but nothing else as it relates to skilled care has changed.

Definitions

Let's go through now and talk a little bit about some definitions.

Concurrent Therapy

The first definition is concurrent therapy and this comes directly from the RAI manual. Concurrent therapy is defined as the treatment of two residents at the same time when the residents are not performing the same or similar activities, regardless of payer source, and both must be in the line of sight of the treating therapist or the assistant for Medicare Part A. When a Part A resident receives therapy, it is defined as concurrent therapy for the Part A resident, regardless of the payer source for the second residence.

• No more than two patients can be seen concurrently
• Clinical judgment of the therapist will determine which patients may benefit from concurrent therapy services
• Remember: Group and concurrent therapy combined cannot exceed 25% of the minutes per patient per discipline under the PDPM

This is saying that if you have two individuals together, one is covered by Medicare Part A and one is covered by some other insurance type the Part A resident must be documented as concurrent therapy because they are with another individual providing that the rest of this definition fits. To a degree, some of this is a little gray. What does "not the same or similar" mean? We can look at an easy example. Let's say one is doing an upper extremity therapeutic exercise program and somebody else is completing transfers or bed mobility. We do not technically bill CPT codes for our Part A patients because they are covered by consolidated billing, but I think it is the best practice. I think most of us probably use therapy logs, and we do code what we did with that person using CPT codes. While we are not technically billing them, we are applying a code to describe what it was that we did with that patient. In this example, the person who is doing the upper extremity exercise would be coded under 97110 for therapeutic exercise. The person that we are doing the transfers or the bed mobility would most likely be coded under 97530 therapeutic activities. However, what happens when you have one person working on bed mobility and transfers and are documented under 97530, and then you have another person that you are also going to document under 97530, but they are doing something totally different. They are completing reaching, bending, and lifting activities. The billing code is exactly the same. If I am a reviewer, I am going to say, "Well, they were doing the exact same thing. Shouldn't this be a group?" Well, no, it would be concurrent because they are different activities. This is when you go back to the documentation. Hopefully, that makes sense. In these "gray" areas, we need to make sure that the documentation is crystal clear. They need to be working on different types of activities with different goals. This is important when the billing codes or the CPT codes might be applied similarly, but definitely important when they are the same.

Again, concurrent treatment is defined as one therapist providing different treatments to two patients at the same time. The provision of concurrent does require that the therapist is in the room supervising and performing all minutes provided to each patient. I think this is also really important. They have to be in the line of sight. So, you could not have one person in the clinic that you are providing therapy to and another person still in their room and you are bouncing back and forth between the two. It does not work that way as they have to be in line of sight. Remember that no more than two patients can be seen concurrently. And, the clinical judgment of the therapist ultimately will determine which patients would benefit from concurrent therapy, and we will talk about that in just a little bit.

We are talking about Medicare Part A, the prospective payment system, in this session, but the question comes up quite a bit about Part B. How does that work? Medicare Part B residents may not be treated concurrently, and that is again directly from the RAI. The therapist can treat one person at a time. The minutes during the day when the resident is treated individually would be added up to get a total individual count. But, if you treat two people at the same time who are Medicare Part B, that has to be coded as a group session. There is no such thing for concurrent for Medicare Part B. Remember, group and concurrent therapy combined cannot exceed 25% of the minutes per patient per discipline under PDPM.

• Discharge assessment completed at the time of facility discharge
• Items O0425A1 – O0425C5 capture therapy start and end date, total individual minutes, total concurrent minutes, total group minutes, and total days of therapy by discipline
• If the amount of therapy provided exceeds 25 percent, then this would be deemed as non-compliance

You might be wondering how you are going to track all of that. There is a minimum data set discharge assessment that providers are already completing at the time of facility discharge. They have expanded section "O" of this assessment, and there are some new items, O042581 through O0425C5, in there. This is where we report the total amount of therapy broken down by therapy mode: individual, concurrent, and group. There is also a code treatment but that does not factor in here. It is also broken down by the therapy discipline (PT, OT, and speech) that the patient received during their entire Part A stay. This is the "look back" for that stay if you are familiar with that terminology.

How far do we look back when we count? The "look back" for those particular items, as we already said, is the entire SNF Part A stay starting at day one and finishing on the last day of Part A stay. Then once reported on the MDS, then the software calculates the percentage of the group and concurrent therapy combined. They will use this to see if it exceeds the 25% level. Any amount of therapy that is exceeds that 25% limit is deemed as non-compliant. If they are non-compliant, the skilled nursing facility will receive an error message when they send in that MDS. It is a non-fatal warning error, and we will talk about in just a second what that means. The important thing to note is that Medicare is going to be monitoring this to see where and when providers are going over that threshold.

Group Therapy

Let's switch gears a little bit and talk about group therapy. The group therapy definition is taken straight from the RAI and, is defined for Medicare Part A. It is 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. And before I go on, I want to point out that this applies to concurrent and to a group. So if you had a concurrent treatment where you had two individuals that you treated concurrently for 20 minutes on your log, you would give each person 20 minutes. Patient A gets 20 minutes, and patient B gets 20 minutes. This is the same thing with group therapy. If four Medicare Part A patients are treated by one therapist for an hour in a group setting, all four patients in the group are recorded for that full hour. In contrast with the RUG-IV system, concurrent minutes ended up getting divided by two. Or, group (total of 4 participants) minutes were divided by four. They were "allocated." In this current scenario, this is not happening. Again, if I put in 20 minutes of concurrent, the patient gets credited with 20 minutes of concurrent group therapy the same way. I think it is important to make that distinction between what we are doing today versus what we did under RUG-IV.

• Medicare Part A therapy is different from Medicare Part B
  • For Medicare Part B, the treatment of two patients (or more), regardless of payer source, at the same time, regardless of activity, is documented as group treatment.
  • For Part A patients, group therapy is specifically focused on meeting a common group goal or set of group goals.
  • Groups cannot exceed the ratio set by CMS. Under the PDPM, this definition is 2-6 patients per therapist.
  • Rehab Aides cannot run or bill for groups!

I also want to make a comparison between Part A and Part B. In order to be considered group therapy under Part A, the skilled nursing facility residents need to be performing similar activities. Under Part B, the therapeutic interventions can be similar or they can be different, it does not matter. Remember that the skilled nursing facility therapy services (Part A) are paid as part of a bundled PPS rate. They are not technically reimbursed under the Physician Fee Schedule as they are under Part B. Although, we do apply CPT codes to describe what skilled service we provided for that person.

Under Medicare Part B, as I already mentioned, the treatment of two or more patients, regardless of their payer source, would be documented as group treatment. Somebody said to me not long ago, "Wait a second, we're not allowed to provide groups to Medicare Part B." The answer is yes, but you technically can. You just have to recognize that the definitions are very different. Remember for Part A patients, a group therapy session again is specifically focused on meeting a common group goal or a set of goals. The group goal has been formulated and agreed upon ahead of time prior to offering it to the participants. The group therapy is performed for the therapeutic advantage for that group setting and how that group is going to be able to help that participant to meet his or her individual goals. If we are doing a group for Part B, the goals could be the same or different. The ratio of 2-6 of patients per therapist cannot be exceeded in PDPM. If we go over that, we violate that. Finally, remember that groups need to be administered by a licensed therapist or therapist assistant under the supervision of that licensed therapist. If you have a rehab aide or a tech, while they can certainly assist you with a group, they are not considered in the ratio. They cannot run the group or build a group. Just because you have a tech with you does not mean that you can bump that participant number up to 12. 

Clinical Rationale for Concurrent or Group

• Which patients would benefit from concurrent or group treatment?
• What are the clinical benefits to the patient from this mode of treatment?

The decision to provide a concurrent or group treatment to your patients really should depend on your clinical reasoning as a therapist. Which patients do you think are going to benefit from concurrent or group treatment? What are the clinical benefits to the patient from this mode of treatment? I have been a therapist for almost 30 years and groups historically have been an intervention. We have run groups and concurrent treatment for a long time. There are definitely therapeutic benefits to providing these types of scenarios for our patients.

Clinical Rationale for Concurrent Therapy

• Patients learn from one another, encourage one another, and motivate one another
• Allows therapists to assess and teach generalization and carryover of skills
• Improves participant’s awareness that his/her problems are not unique
• Provides self-monitoring skills/awareness through peer interaction and feedback

If you put two people together, they are going to learn from one another, encourage one another, and motivate each other. Typically, there is social interaction. This helps you as a therapist to not only assess their social skills, this can also be used to teach generalization and carryover of those skills that they learned in individual therapy. It also improves the person's awareness that his or her problems are not unique. When they are paired up with someone who is similar to them or maybe even dissimilar, they can see that they are not unique. Other people have some of the same issues, and they are working through them as an example. It can facilitate and promote healing through support from their peers. It also provides some self-monitoring skills and self-awareness through peer interaction and feedback that they would not necessarily get in an individual session.

Inappropriate Treatments

• Evaluations/Assessments
• Wound care
• Bedside treatments
• Procedures requiring one-on-one intervention, such as advanced gait and balance training

Treatments need to be clinically appropriate. Things that are inappropriate are evaluations or assessments, wound care types of treatments, bedside treatments, and any procedure that requires one-on-one intervention such as an advanced gait, balance training, or some sort of advanced ADL type training.

Clinically Appropriate

• Appropriate:
  • Medically stable
  • Alert and able to follow instructions
  • Able to complete activities with supervision
  • Higher level of function
  • Safely supervised without direct physical contact
• Inappropriate:
  • Significantly cognitively impaired
  • Lower functioning
  • Unable to be safely supervised
  • Safety concerns

Patients need to be clinically appropriate to be treated concurrently. They should be medically stable, alert, and be able to follow instructions (at least one-step instructions). They need to be able to complete activities with just supervision and have a higher level of functioning. Examples include a person who has an orthopedic condition, arthritis, or a higher level neurological type of condition. They need to be able to be safely supervised without constant direct physical contact with another person. If they need that constant contact, they may not be safe if you walk away to assist someone else or you step away.

Inappropriate patients might those that are significantly cognitively impaired. However, even if somebody has a level of cognitive impairment, this does not mean that they could not participate concurrently or in a group. When we say "significant" cognitive impairment, we are talking about late-stage dementia types of patients. It is going to really depend on the level of cognitive impairment. Your lower functioning individuals, especially those with a low-level neurological brain injury or spinal cord injury, may also not be able to be safely supervised without physical contact of another person.

CMS Guidelines

• Concurrent therapy may be performed by a licensed PT, OT, SLP, PTA, and COTA
• Both clients must be in line-of-sight of the treating therapist or assistant
• Concurrent treatment is coded using the CPT code that best reflects the treatment being conducted
• Constant attendance modalities (CPT codes 97032-97039) cannot be performed when concurrently treating another patient

Concurrent therapy may be performed by a licensed PT, OT, SLP, PTA, or COTA. Remember that both individuals must be in line of sight of the treating therapist or the assistant. Remember we do not bill it per se, but we code it to describe the skilled services. You use the CPT code that best reflects the treatment that is being conducted. People ask me, "Groups have a CPT code. What do I do for concurrent?" It depends on what you are doing. If you are doing an ADL task, you would document that under 97535. If you are doing something orthotic related, you would code it under that. You use the code that most reflects what the client is doing. You need to use constant attendance modalities thus the CPT codes 97032 through 97039 cannot be performed when concurrently treating another patient. And, we have already said that Medicare Part B does not recognize concurrent treatment. Again, remember that every person treated concurrently is credited with the total time that they participated in that session. It is not split or allocated.

Documenting Concurrent

• Specific benefits to the patient
• Amount of therapy
• How will this mode help to meet goals?
• How will this help to attain the highest level of function?
• What is the benefit to this patient?
• How do I expect that to be evident?

For Medicare, you need to include a detailed justification in the plan of care. This includes the specific benefits to that patient for the use of concurrent therapy and the specific amount of therapy and type. A description of how this mode of therapy will help the patient to attain their highest level of physical, mental, or psychosocial well being. Also, what is the benefit to the patient in performing an activity concurrently? Is it motivation? Is it increased independence? Is it peer support? How do you as the therapist expect that that might be evident? It could be improved performance, increased engagement, or better carryover of a skill.

Concurrent Example

Mrs. Jones was seen concurrently focusing on safety training during transitional movements, safety for task performance, activity analysis during meal preparation. Pt. demonstrated increased safety awareness and independence; requiring verbal cues.  Improved carry over noted from the last session. The session provided an opportunity to assess and demonstrate the carryover of learned skills.

Note the last sentence as that denotes a very skilled service.

Clinical Rationale for a Group

• Learning from one another
• Multiple goals can be addressed
• Practice in a practical setting
• Observe and teach generalization and carry-over
• Improve insight into problems/limitations
• Self-monitoring skills/awareness
• Social interaction

Let's switch gears and talk about the clinical rationale for a group. A lot of this is similar to what we just talked about. Providing therapy in a group has both clinical and operational benefits. Participants learn from one another, and they encourage and motivate each other. This implies that there are advantages to the participant being in a group. In a group setting, multiple goals can be addressed for a particular participant. For example in a cooking group, you could work on functional mobility, coordination, balance, safety, problem-solving, attention to task and the list can go on. And, you can work on a lot of different goals in one particular session. The group treatment also may allow the participant to practice tasks in a very practical, realistic setting which further prepares the participant for discharge to a less restrictive environment. As an aside, I have been looking at a lot of the different group protocols, and I am seeing a lot of groups that are really creative, engaging, and the patients seem to love them. It is very different from traditional therapy. Thus, this is a great opportunity to get creative and certainly have fun with our patients as well.

Some additional benefits of a group are that it allows us to observe and teach generalization and carryover. It makes them aware that their problems are not unique. They get peer support, self-monitoring, and self-awareness. It is also great for social interaction and improvements in social behavior. It provides a safe place to attempt a new behavior or communication skill, whether this is coming from OT or maybe we are partnering with a speech-language pathologist. A group is a place where the participant can learn how his or her behavior impacts others.

Disadvantages

• Group members may be disruptive and have a negative effect on others
• Some may stay on the fringes
• Groups may become a safe place and may prevent maximum changes

Group members could potentially be disruptive, and if they are, they are going to have a negative impact on the other people in the group. And, those unhealthy attitudes, unfortunately, are sometimes contagious. Participants who could benefit from the group activity may stay on the fringes of the group when we really want them to jump in. Thus, this may not be the best avenue for them. It also could become a safe haven for them and prevents maximum changes. Identification of who is going to participate in group therapy really should be a clinical decision to reduce the risks of these disadvantages.

Billing/Coding Group Treatment

In your documentation, there needs to be a clear distinction between what was done individually and what was done concurrently. These have to be coded separately on any logs that we complete in order to log it into the MDS because CMS is tracking that. For occupational therapy, the CPT code that would be utilized for documentation and recording purposes is 97150. And again, every person in the group would be credited with the total time that they participated in the group. You would not use other CPT codes only the group code. Additionally, anybody who is going to participate in group treatment should have "group treatment" included in their clarification order. I think most of us are doing this as standard practice. For example, "OT five times a week for four weeks for therapeutic activities, ADL retraining, neuromuscular re-education in either a group or an individual setting." Additionally, and I think this is important, participants can only be documented or coded as being in the group treatment if they are active in the group. If there is a person that is sitting on the fringes, did you provide anything to that person? Did they get any therapeutic benefit? They have to be active participants in order to have that documented.

Documentation for Group

• Medical necessity of treatment
• Group treatment has its own CPT code
• Each person participating must have an individualized treatment plan for group treatment including interventions, short- and long-term goals

All documentation for group treatments needs to be completed for the individual participant and incorporated into the daily documentation. I think most of us are doing this daily, and if we are not, we at least put that into a weekly note. It has to be part of that medical record. As with every therapeutic intervention that we are doing, the group treatment needs to be medically necessary. You always go back to the clinical need for that particular patient. How is this going to benefit them? Medical necessity is that term that is used to refer to a course of treatment that is most helpful for specific symptoms or impairments that the patient is experiencing. The course of treatment is determined by the patient and by the healthcare team in collaboration. We already talked about the CPT code, and that is what would be documented on the daily record of treatment. Remember, each resident participating in the group must have an individualized treatment plan for group treatment, including interventions and short and long term goals. Now, you may not have a specific group goal, but you do have to have some recognition of how and which goals might be best met by a group format. Some of us will, in fact, have group goals, while others will just have goals for the patient like we have always had. We need to show in the documentation how that group helped facilitate improvement towards that goal. In addition, we need to document how the group was the best avenue versus concurrent, individual, or other treatment to achieve that goal.

Consider the Following

• Number of minutes
• Number of people in the group
• Specific treatment technique(s) used in the group
• What did the group leader do?
• Progress made, modifications to treatment
• How were the goals met?
• Carryover of skills
• Justification for continuing group treatment
• A therapeutic benefit to group therapy

When you document the group, you need to consider the number of minutes that the person participated, the number of people, and what specific treatment techniques were used. What did you do as a therapist? What did you do to train, reinforce, cue, whatever either cognitively or physically to help that person to reach their weekly goals? On a weekly basis, you will document the residents' progress toward their individual and or group goals. You want to document any modifications that had to be made in that group and how the participant reacted to those. Explain if the participant's goals were met during the week and how that group assisted the client toward reaching those goals. You can document any important feedback outside of therapy that denotes the generalization of skills. This is showing that something that was done while in a group was then carried over on the nursing unit or maybe with their family. This is again showing that progress toward goals, the justification for continuing any sort of group treatment, and the participants' therapeutic benefit in group therapy. So again, a lot involved. 

Documentation Examples

Balance Group

• Participant responded well to group therapy as evidenced by the ability to consistently hit the balloon with left UE for 10 minutes without requesting a break; this allows the participant to achieve his/her goal to dry hair in 10 minutes. Four people in the group.
• Participant responded well to group therapy as evidenced by the ability to stabilize the trunk and maintain an upright seated position for 5-minute intervals without a physical or verbal cue while hitting the balloon.  This was the weekly goal required for an upright position while toileting.  Five people in the group.

Cooking Group

• Participant responded well to group therapy as evidenced by the ability to manipulate an orange while cutting and peeling it, able to pick grapes off stems with distant supervision demonstrating sufficient fine motor coordination for simple meal preparation procedures when returning home. Four people in the group.
• Participant responded well to group therapy as evidenced by the ability to use good safety judgment 80% of the time while cutting fruits without tactile or verbal cues in a distracting environment. Pt. needs these skills for a safe d/c to home. Three people in the group.

Calculating Compliance

• Step 1: Total Therapy Minutes, by discipline (O0425X1 + O0425X2 + O0425X3)
• Step 2: Total Concurrent and Group Therapy Minutes, by discipline (O0425X2+O0425X3)
• Step 3: C/G Ratio (Step 2 result/Step 1 result)
• Step 4: If Step 3 result is greater than 0.25, then the provider is non-compliant.

I want to go back and talk a little bit about that 25% threshold. The next couple of slides will go through how CMS is going to be calculating compliance with that group and concurrent 25% limit. Step one is taking the total therapy minutes by discipline. You can see these are the items directly from section O on the MDS. It is O0425123 and that X is in there just to show that it would be replaced by another letter. For example, physical therapy is C, speech therapy is A I believe, and OT is B. We will look at this again in just a second. The X is just noting that it would be replaced by a different letter. Step two is to get those total concurrent and group therapy minutes by discipline and figure out the ratio. So, take the step two result divided by the step one result. If step three is greater than 25%, then the provider is non-compliant. It really is as easy as that.

• Total OT Individual Minutes (O0425B1): 2,000
• Total OT Concurrent Minutes (O0425B2): 600
• Total OT Group Minutes (O0425B3): 1,000

Here is an example. OT is B, and the total individual minutes are 2000. The total concurrent minutes are 600. The total group minutes are 1000.

• Step 1: Total OT Minutes (O0425B1 + O0425B2 + O0425B3): 3,600
• Step 2: Total OT Concurrent and Group Therapy Minutes (O0425B2 +O0425B3): 1,600
• Step 3: C/G Ratio (Step 2 result/Step 1 result): 0.44
• Step 4: 0.44 is greater than 0.25, therefore this is non-compliant.

In this particular scenario, this is non-compliant. You need to do what is best for your clinical practice when deciding when and how you track that. I think most of us are using electronic medical records at this point, and probably the EMR is tracking that. This is something you definitely want to stay on top of particularly if you do a lot of group and concurrent at the beginning and then that patient is discharged early.

Non-Compliance

• What happens if you go over 25%?
  • No penalty
  • Warning edit: “The total number of group and/or concurrent minutes for one or more therapy disciplines exceeds the 25 percent limit on concurrent and group therapy. Consistent violation of this limit may result in your facility being flagged for additional medical review.”
• CMS will monitor in order to determine if additional administrative or policy action would be necessary.

What happens if you go over 25%? Right now, there is not a penalty for exceeding the 25% combined concurrent and group limit. However, providers have been cautioned that they will receive a warning edit on their assessment validation report. We will talk about what that means in a second. There is a minimum data set that needs to be completed and submitted into a system called the QIES ASAP system. When they try to submit it to QIES ASAP, the site will receive a validation report back saying whether or not it was accepted. On that validation report, if the provider has gone over 25%, they will have an error. "The total number of group and or concurrent minutes for one or more therapy disciplines exceeds the 25% limit on concurrent and group therapy." Consistent violation of this limit may result in your facility being flagged for additional medical review. What that saying is that CMS is going to be monitoring this therapy provision under the PDPM to look for those facilities that have exceeded the limit. What they are ultimately going to do, we do not know. But, what they have said is that they are going to try to determine if additional administrative or policy action with a penalty would be necessary. The best option is to not go over the 25% limit.

Types of Group Treatment

• Education/Information
  • The goal is to communicate educational information about the disability or injury
• Activity/Skill
  • Teaching functional activities

Let's talk a little bit more about the logistics of a group, starting with the types of group treatment. I think the first type of group you might see is an educational or informational type of group. The goal of this group treatment is to communicate educational information about disability or injury. This could be hip or shoulder precautions or it could be energy conservation or breathing techniques. Purse lip breathing, work simplification strategies, or other compensatory strategies are other examples. It can also be understanding disability or injury and related risk factors and prevention. An example here could be joint protection for arthritis. Remember, if we are going to do an education group or provide information, regardless of setting or mode of treatment, it has to be skilled. Providing education and resources may or may not be skilled. We have to show in the documentation why our skills as a therapist were needed and that no one else could have run the group.

The other type of group is an activity group or a skill group. This would include the teaching of certain functional activities like dressing or grooming, kitchen activities, transfers, ambulation, and wheelchair mobility. It becomes critical that the admission criteria, if you will, to this group is really clear. This is so you know what to expect and you are physically able to handle the participants to be able to achieve the group goals. The other thing is that for these types of programs the size of the group, the number of group leaders, and the number of people in the group need to be considered. If you are working on a skill that is a little more involved, maybe six patients are not the way to go. You may need to work with a smaller number. This is where your clinical judgment and rationale come into play.

Remember participants observe each other, all the successes and difficulties. They can help each other. I have done a dressing group where we practiced using some of the long-handled adaptive equipment. This gave participants a chance to view other people manage their deficits. This can be empowering to other individuals in the group.

Preparation

How do you prepare for the group?  The entire facility needs to be involved and really understand who does what as it relates to this process. If not everybody is on board, the full benefit of the group treatment is not going to be realized. We need to look at staff education, role delineation, treatment models, logistics, et cetera.

• Staff Education
  • Discuss clinically related advantages
  • Participant need drives group placement
  • Types of groups available
  • Ensure clinical readiness
  • Documentation and billing

When we think about staff education, we need to explain the clinically related advantages to delivering therapy in a group setting. This is not only educating other disciplines, but we need to educate ourselves as well. Some may have never used a group and are a little resistant to trying it or need help to see the clinical benefit. We need to stress the participant's needs and goals, and this will determine placement in a group. This is not about staff convenience or scheduling. It has to be based on the patient. We need to review the types of group therapy that might be beneficial to our patients as well as the documentation requirements. We need to make sure that individuals are clinically ready to be in a group. As OTs, we have been trained in group dynamics but not everybody has that same skill set. This is something we might need to look at. And again, we want to make sure that our daily record of treatment is complete and correct.

Role of the Therapist

• Identify participants
• Educate the IDT
• Document group activities
• Provide feedback
• Be aware of individual needs
• Evaluate behaviors as they occur
• Document and bill appropriately
• Demonstrate good interpersonal skills

The role of the therapist is to identify anybody who would benefit from group treatment. Again, as above, we need to educate the interdisciplinary staff. We want to employ compensatory strategies to help the client to achieve goals, and hopefully, to generalize skills outside of the group treatment. We need to document the activities of the group, the response to the patient, and the status of the goals. We need to provide feedback back to the facility about the patient's progress, as well as any modifications that we made to the plan of care. I think this is important to communicate because family members might wonder what their loved one is doing in a group. Thus, it is helpful to have the entire interdisciplinary team to understand why we are doing what we are doing. Therapists need to be aware of each individual participant's needs and the short term goals addressed by the treatment. We want to choose group activities that are going to build success, maximize therapeutic gains, and know who should be included and who might not be appropriate. We need to be able to reflect and evaluate behaviors quickly as they occur. You may have to address some behaviors in a way that does not harm the rest of the group. We need to facilitate the group in the right direction. The therapist also has to have good interpersonal skills and an accurate perception of the interactions in the group. I think OTs shine in this area as this is what we do. However, it takes something special to be able to facilitate a group, and that is something that we all need to be educated and trained.

Role of Nursing

• Ensure participants are ready
• Enhance learned skills
• Update therapists on carryover and generalization
• Receive education
• Document generalization in the nursing notes
• Help educate families/support

What is the role of nursing? I think this first one is really important. We need to ensure that participants are ready and available at the time that the group is scheduled to meet. If we are going to schedule a group, we need to talk to nursing. We may need to give them that information the night before, or at least the morning of, so that we have a fighting chance of getting everybody ready, collected, and together. This is whether it is two patients in your group or six. It is sometimes incredibly challenging to pull everybody together and transport them to your space. The more we can communicate, the better off we are going to be. This also goes back to where we talked about the importance of the group and concurrent therapy. The more that we can talk about that in a way that is very collaborative with nursing, the more they will help us.

The role of nursing too is to enhance those learned skills that they have acquired during the group. We are trying to get them to carry those skills over particularly if we are trying to facilitate discharge to a lesser level of care. Nursing should update the therapists on carryover and generalization noticed during non-therapy periods of the day. As much as we need to communicate to nursing, we want them to also communicate back to us. We need to present this in a way that is conducive to this partnership. I know the reality of what can be out there sometimes. Education can be really tough, but I think we need to approach it in a way that the nurses are ready to receive it. We can ask the nurses to document in the medical record and in the nursing notes. They can also help the therapists to educate the key family members and support in their participation in their progress as oftentimes those family members are coming in the evening when we are not there. 

Considerations

• Space for groups?
• Scheduling?
• Transportation to/from groups?
• Equipment needs?
• Contingency plans?

Here are some other considerations as it relates to groups. You want to think about the space needed for a group. This could be your therapy gym, an activity area, the dining room, or a day room. You need to also look at scheduling. Again, there is no hard and fast rule here. How many groups and how often are other questions that you need to ask. Are you going to do one a day? Or, are you going to do more than that? Which disciplines are going to do those? Again, this is something that you figure out based on the clinical representation of your patients. Transportation needs to also be coordinated. Not all of us are lucky enough or have the benefit of having a rehab aide or a tech to transport. Thus, we need to figure out how are we going to do that. Is nursing going to help us? Are we going to do that ourselves? Perhaps, the group member has a wheelchair mobility goal or an ambulation goal, and this is something that we can incorporate that into the group.

What are the equipment needs? Maybe you have something that you want to do that requires specific equipment. You also need contingency plans for when the group does not occur as scheduled or when the patient cannot tolerate or participate. Remember, they do have the option to refuse services. We need a backup plan.

And, what about weekends? This is something we really have not talked about. Are you going to do groups on the weekends? Or, are you going to do concurrent or individual treatments? Are the individuals who are working on the weekend as educated about groups like you? What do you need to put in place to help them to be successful?

Logistics

• What is the purpose of the group?
• What are the goals of the group?
• What discipline and staff level will lead and assist in the group?
• What are the criteria for admission and discharge?
• What is the appropriate ratio of participants to staff?
• What activities, equipment, and materials are needed?
• How will the groups be scheduled?
• What involvement will nursing play?

It is first necessary to identify the needs of the participants served in your facility. You can certainly develop all sorts of protocols, but I think you need to first start by looking at who is in your community. You could develop a wonderful arthritis program as an example, but if you do not have a single person on your caseload who has arthritis, then this is not the best group. The groups need to be identified by a participant's needs and indicated treatments. Then, you select the group that will apply to that particular person. Once the basic group treatment interventions have been identified, then you want to develop the specifics of the group. What is the purpose of this group? What are the goals? What discipline or disciplines and staff level will lead and assist in the group? Again, you could have a larger group where you have multiple disciplines involved like both OT and PT. You can certainly mix that up. It does not have to be one discipline. You also have to outline the criteria for admitting or including a person in a group and discharging them from a group. What is the appropriate ratio of participants to staff? What activities, equipment, and materials might be needed? How are you going to schedule them? And again, what involvement will nursing play? 

• Size
  • Dependent upon the functional task/activity being performed, as well as any safety issues involved in its execution 
  • Non-licensed personnel may assist but are not included in the participant ratio
• Scheduling
  • Coordinate treatment times of all disciplines
  • Length of group therapy should be determined by the needs and abilities of the group

The size of the group is truly dependent on the functional activity that is being performed, as well as any safety issues that might be involved in its execution. Remember that the group size ratio is one clinician to a two to six ratio. We already said this, but again, it is important to reiterate that while non-licensed personnel can certainly assist with your group, it is nice to have a second set of hands of course. However, they are never included in the participant ratio.

When you are scheduling treatment groups, there are a lot of different variables that you need to look at like the size of the group, the space, the staff schedule, and the number of groups that you are going to have. In order to schedule your groups and make it successful, you need to coordinate treatment times of the disciplines. I heard of a facility where PT had just finished their individual treatments with a certain number of people, and then they just stayed in the gym to then participate in the OT group. This makes a lot of sense for scheduling and transportation. Then, they broke off after the group, and they did their individual OT types of treatments. You have to coordinate and communicate if it is going to be successful for your patients. The length of the group therapy should be determined again by the needs and the abilities of the group. At all times, that group needs to be scheduled to maximize therapeutic benefits. Again, depending on the activity that you are doing, you may have a group that is only 20 minutes long, or you may have something that is longer than 60 minutes. You have to look at what it is that you are doing with the patient and how long that should be incorporated. 

Group Protocol Examples

Balance Group

• Persons who demonstrate impaired balance or a history of frequent falls
• Sample group objectives
  • Increase safety awareness during ADL
  • Decrease potential for falls and injury
  • Facilitate the use of compensatory strategies for resident specific deficits
  • Improve strength and ROM
• Contraindications: Inability to stand/walk
• Group Activities: functional mobility, instruction in the use of adaptive equipment, strengthening exercises, reaching for objects, obstacle negotiation
• Skilled Documentation/Performance Components: assistive device training, postural control, static/dynamic balance, crossing midline, motor planning, etc.

In this group, there would be individuals who have demonstrated impaired balance or somebody who has a history of frequent falls. What are the objectives for this particular group? Again, identify what you want out of the group. A group objective could be safety awareness during ADL and decreasing the potential for falls and injury. You can use compensatory strategies for very specific deficits. This could be their strength, range of motion, or something else. You might need to exclude those with contraindications like an inability to stand or walk.

Then, you need to start thinking about what is it that I want to do in the group. Some examples include functional mobility, instruction in adaptive equipment, strengthening exercises, reaching for objects, and obstacle negotiation. And as I said earlier, we have a lot of freedom here and can have a lot of fun with our patients.

Going back to the skill documentation, some examples of what we would document would be assistive device training, postural control, static or dynamic balance, crossing midline, motor planning, fine motor or gross motor coordination, environmental awareness, and any sort of functional mobility. Remember, we need to add in that skilled piece. What did you as a therapist do in this group that this patient could not have gotten on the nursing unit?

Education Group 

• Orthopedic diagnoses
• Sample group objectives:
  • Demonstrate understanding of precautions
  • Demonstrate body mechanics
  • Perform functional daily tasks
• Contraindications: Severe pain, limited attention, memory impairment
• Suggested topics: total hip precautions, exercises, joint protection, energy conservation, work simplification, pain management techniques
• Skilled Documentation/Performance Components: safety awareness, energy conservation, work simplification, dynamic balance, device education safety

This next one is an education example with the criteria of an orthopedic diagnosis such as a joint replacement or osteoporosis. What are your objectives for the group? These may be to demonstrate an understanding maybe of precautions, safety awareness, body mechanics. Or, they could be performing functional daily tasks with a demonstration of energy conservation, work simplification, pain control, and maintaining joint integrity. Who might not be included? Somebody who has severe pain, limited attention span, or significant memory impairment. Again, this list could be anything you want it to be including hip precautions, exercises, joint protection, energy conservation, work simplification, pain management, the list can go on and on. Even though this is an education group, what are we doing here that is skilled? Is it safety awareness, energy conservation, dynamic balance, device education, safety, maintenance, et cetera? You could have them do a return demonstration or complete a quiz. You could play a game or whatever to make sure that that person can do that.  

Home Management Group 

• Sample group objectives:
  • Improve home management skills
  • Promote safety awareness
  • Educate in the use of adaptive equipment
  • Facilitate sequencing, problem-solving skills, balance, etc.
• Contraindications: limited attention, direction following, limited mobility
• Group activities: home management skills, adaptive equipment, energy conservation, work simplification, safety
• Skilled Documentation/Performance Components: safety awareness, body mechanics, gross/fine motor coordination, sequencing skills, postural alignment/control, praxis, balance, bilateral integration, compensatory strategies

Home management groups can be fun. They can clean, sweep, do the windows, or cook a meal. These are very functional and prepare them for discharge. However, your skill documentation is not going to say that you cooked a meal. It is going to talk about body mechanics, sequencing, bilateral integration, compensatory strategies, and the like. We need to always go back to the skilled piece of it.

As you are looking at maybe developing some group examples or protocols, this is a nice format to follow in order to educate your peers as well.

Other Group Ideas

• Arthritis
• Energy Conservation / Work Simplification
• Gross Motor
• Household Mobility 
• Motor Control
• Neuromuscular 
• Pulmonary 
• Cooking
• Craft
• Upper Extremity Exercise
• Meal Planning/Dining
• Obstacle Course

For other group ideas, the sky is the limit. Arthritis, meal planning, dining, exercise, and craft groups are always popular. Household mobility and pulmonary obstacle courses are also a lot of fun. I could go on and on. You just need to develop something that is going to be medically necessary and be of benefit to your patient.

In Summary

• Delineated participant goals, participation and exit criteria, frequency of group, group leadership, activities included, and equipment needs
• Assess endurance for full participation
• Clarification orders
• Group and concurrent combined cannot exceed 25% of the therapy provided per patient per discipline
• Document in the daily notes

To summarize, and I think we have hit on these points quite a bit, make sure that we have clearly delineated the participant's goals, the mode of treatment, and their participation and exit criteria. Additionally, you need to clarify how frequently that group will be run, who is leading it, the activities, and the equipment needs. We need to assess the patient's endurance for a planned group to make sure that they can participate fully through the group's duration. Not every group going to be an hour-long, but you can have shorter groups as well. However, even if it is a 20-minute group, you have to make sure that that person is going to be able to fully participate in that group. Remember, if we are going to be providing a group, this should be included in the clarification orders, and make sure you do not exceed that 25% of therapy provided per patient per discipline for the length of stay. Finally, remember that you always have to document the group, concurrent, or individual session explaining the activity, how it met the client's goals, why it needed to be in that particular mode, and why it is skilled.