Eli's Rehab Report

Be prepared to dot the I's and cross the T's.

If your SNF is providing therapy co-treatment or planning to, here's what you should consider.

Background: An Oct. 1 RAI manual revision states: "For Part A: When two clinicians, each from a different discipline, treat one resident at the same time (with different treatments), both disciplines may code the treatment session in full."

CMS' John Kane, however, clarified that revision in a presentation for the agency's Nov. 3 national provider call. "As a formal definition, co-treatment refers to a case of two clinicians -- that is, two therapists, two therapy assistants, or some combination thereof from different disciplines -- treating one Part A resident at the same time with different treatments," Kane said.

"For example, a speech language pathologist and an occupational therapist do a meal with a patient. The OT is working on feeding skills and fine motor coordination of the utensils, while the SLP is working on swallowing skills," Kane added. "This would be an example of a proper co-treatment session. In such cases of co-treatment, both disciplines may code the full treatment session. Therefore, in the example just presented, both the OT and the SLP could code the full session as individual therapy."

A slide from the call also quotes from the RAI manual, which states: "The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented in the plan of care for each patient." "This is because," said Kane, "co-treatment, as defined here, would only be appropriate for specific clinical circumstances and not necessarily for every patient."

Garry Woessner, MA, MBA, CAS, points out that "until this past October, even if the co-treating therapists were working on different goals, they had to split the minutes on the MDS." Thus, "if they each provided an hour of therapy, they each would record only 30 minutes," he says.

The reason for CMS' clarification: Woessner thinks "CMS may be nervous about co-treatment since they currently have no way to know that two treatments were performed at the same time. There is nothing on the MDS or billing to indicate that the sessions occurred simultaneously," observes Woessner, regional director of rehabilitation at the Benedictine Health System in Minneapolis, Minn.

Use This Litmus Test

"The major reason you would use co-treatment is to help the person learn how to integrate various skills together at the same time and allow them to make more progress than they would with separate treatment sessions," Woessner explains. Thus, "ask yourself whether using the various skills together will accelerate achieving the treatment goals," he advises.

"One example of an appropriate co-treatment opportunity would be if the PT was working with the patient on gait training and standing balance while the OT was working on helping the person with daily hygiene ADLs, such as brushing teeth while maintaining their balance standing at the sink, reaching for items, shifting weight while dressing, etc.," Woessner says.

Also: "If the two therapists are working with the patient at the same time, they should only bill the minutes where they were actually providing treatment, coaching, or assessing performance on one of their discipline's goals," Woessner says. "If one therapist sits back while the other one is doing the treatment, the therapist obviously shouldn't include those minutes" on the MDS.

Don't Do This

One way Woessner could foresee co-treatment "being over-used and used for the wrong reason is strictly to improve productivity. For example, the therapists are under pressure to improve their productivity and treat patients together so they can see more patients in a single day. Or when a patient missed therapy in the morning because he was sick or at an appointment and it's the last day of the assessment reference period for the COT, the therapists may feel pressure to get 45 minutes each before the end of the day." So they "decide to do the afternoon treatment together during a single session," he adds.

Practice tip: "One practice we really like and encourage is co-evaluations," says Woessner. "You don't get to count evaluation minutes on the MDS for Part A (it is counted as a treatment day). But it's very efficient and effective to have two therapists do the evaluation together," he adds. "Often therapists ask the same questions and have the patient do some of the same activities and tests, such as for balance and muscle testing. And you can avoid the annoyance factor where patients don't like being asked the same questions over and over by multiple clinical staff."