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January 28, 2019 Article 4 min read
What does the 25 percent limit on concurrent and group therapy mean for SNFs and the overall financial impact of PDPM? Our expert Q&A unpacks the final rule.

Board members meeting 

The new Patient-Driven Payment Model (PDPM), going into effect on Oct. 1, 2019, sets a combined 25 percent limit on concurrent and group therapy per therapy discipline provided. What does this mean for SNF therapy delivery and the overall financial impact of PDPM?

Plante Moran Healthcare Consulting Partner Denise Gadomski sat down with Lyle Townsend of Impact Wellness & Rehab, an independent therapy consultancy, to unpack the final rule as it relates to concurrent and group therapy.

Gadomski: Lyle, SNFs have a lot on their plate regarding PDPM right now, with the implementation date drawing near. It might be helpful for readers to revisit what concurrent and group therapy is, what the new rule says, and how providers should think about it with respect to their facilities’ current therapy delivery models.

Townsend: Agreed, Denise. Let’s start with some definitions:

First, concurrent therapy is defined as one therapist treating two Medicare patients at the same time. For example, the therapist starts treatment directly with a patient, who is beginning a specific task. Once the patient can proceed with supervision, the therapist then works directly with a second patient to get him or her going on a different task, while continuing to supervise the first patient.

Group therapy is slightly different. Here, one therapist provides treatment for all patients who are working to develop a common skill so, for example, you might deliver group therapy for exercise, fall prevention, or for cognitive exercises. By the rule’s definition, a group can include up to four patients.

Gadomski: And, can you share an example of how the final rule treats group and concurrent therapy?

Townsend: Under PDPM, there’s a 25 percent limit on concurrent and group therapy per discipline so, as an example, if a resident received 800 minutes of physical therapy, no more than 200 minutes of this therapy could be provided on a concurrent or group basis.

Gadomski: It might also be helpful to remind readers of some of the background here, for context.
Townsend: Prior to 2010, the allocation of concurrent and group therapy was similar to how it will be under PDPM, with multiple patients seen by one therapist, less individualized treatment, and less therapy labor required to provide services.

After Oct. 1, 2011, CMS changed therapy-minute allocation to the following: total treatment minutes divided by two for concurrent and by four for group treatment. This change significantly reduced the use of concurrent and group therapy.

So, now is really an opportune time for SNFs to initiate discussions with their therapy departments and interdisciplinary care teams...

Gadomski: So, now is really an opportune time for SNFs to initiate discussions with their therapy departments and interdisciplinary care teams to determine which methods of delivering therapy are most beneficial for each resident.

Townsend: Absolutely. Administrators as well as in-house therapists and contract therapy companies should consider the following to ensure medical necessity and clinical appropriateness — and to comply with CMS rules:

  • Is concurrent or group therapy the best for the patient, therapist, and provider?
  • Is concurrent or group therapy appropriate for patients with greater medical complexity who are admitted for skilled rehabilitation?

Under the new rule, the use of concurrent and group therapy must include detailed justification in the resident’s plan of care (therapy evaluation), including:

  • The specific benefits to that particular patient for the use of concurrent or group therapy and the specific amount of therapy and discipline to receive.
  • A description of how this mode of therapy will meet the patient’s needs and assist the patient in reaching his or her goals.
  • A description of how services will attain the highest practicable level of patient physical, mental, and psychosocial well-being.

Per CMS guidelines, documentation also must clearly answer the following questions:

  • Is the delivered treatment complex and sophisticated enough to require the skills of a therapist?
  • Can treatment be safely and effectively performed only by or under the supervision of a qualified therapist?

CMS will monitor compliance with the 25 percent group and concurrent therapy limit for each therapy discipline as part of the discharge MDS.

Gadomski: Thanks for the helpful overview, Lyle. Going forward, administrators will want to continue discussions with their therapy group around these three questions:

  1. How do you plan to include concurrent and group therapy as part of your delivery model?
  2. How much concurrent and group therapy does your therapy group estimate they will be performing?
  3. Should any modifications to the therapy space be undertaken to be able to conduct group sessions?

You’ll want to consider how the new rule, your therapy group’s plans, and your residents’ needs might impact therapy contract negotiations.

Don’t wait to start having these conversations. You’ll want to consider how the new rule, your therapy group’s plans, and your residents’ needs might impact therapy contract negotiations. This process dovetails with the need to assess the overall financial impact of PDPM, so that you’re well-prepared to thrive under the new model.