April 7, 2020
IRF-PAI Therapy Information Data Collection MLN Connects® Call 1/12/17

IRF-PAI Therapy Information Data Collection MLN Connects® Call 1/12/17


[music playing]>>Female Speaker: Welcome
to this MLN Connects video on the IRF-PAI therapy information
data collection call. This presentation was
recorded at the MLN Connects National Provider Call on
Thursday, January 12, 2017.>>Nicole Cooney:
Hi, everyone. I’m Nicole Cooney from the
Provider Communications Group here at CMS and I’ll
be your moderator today. I’d like to welcome you to
this MLN Connects IRF-PAI therapy information
data collection call. MLN Connects calls are part of
the Medicare Learning Network. In the fiscal year 2015
in-patient rehabilitation facility, or IRF,
prospective payment system, PPS final rule, CMS
finalized a new therapy information section on the
IRF patient assessment instrument, P-A-I. At this time, it’s my
pleasure to turn the call over to Katie Derby
[phonetic sp] from our Division of Institutional
Post-Acute Care to deliver the welcome. Katie?>>Katie Derby:
Thank you, Nicole. Good afternoon and welcome
to everyone that is able to join us for today’s call. In the room from CMS, we
have myself, Katie Derby, my colleague Penny Gershman,
and our new director for the Division of Institutional
Post-Acute Care, Todd Smith, as well as our acting deputy
director, Susanne Seagrave, is joining us
on today’s call. We are excited to be able to
host this call at the start of the New Year. And we ultimately hope
everyone finds some benefit in today’s refresher
training regarding the therapy information data
collection on the IRF-PAI. Before we jump into our
information, we did want to just take a quick minute to
say thank you to everyone on this call. We sincerely appreciate your
patience with us while we continue collecting and
analyzing the therapy data as part of our process in
order to create and clarify Medicare policy. We could not adequately do
any of this without your help and expert knowledge
and for that we wanted to say thank you very much. If you are following
along with today’s slide presentation, I did want
to quickly direct your attention to slide three. While we will be only
fielding questions that are inside of the scope of
today’s call on the therapy information data collection
on the IRF-PAI, please feel free to contact our
IRF email box with any additional questions you may
have and we’ll be happy to respond at our
earliest convenience. At this time, I’m going to
hand the call off to my colleague, Penny Gershman,
as she will begin today’s presentation
with the agenda. If you are following along
with our slides, this starts on slide four.>>Penny Gershman:
Thanks, Katie. Good afternoon and good
morning to everyone. We’ll start by reviewing the
IRF-PAI therapy information collection sections,
specifically items O-0401 and O-0402. We will then respond to some
frequently asked questions we received as registration
came in for this call and finally, if there are any
related questions that have not already been answered,
we will open the phones for a live question
and answer session. Moving onto slide five, some
background information. In the fiscal year 2015 IRF
prospective payment final rule, CMS finalized the new
IRF-PAI therapy information section for data
collection purposes. We introduced items O-0401
and O-0402 at that time. If you are looking for more
information on that final rule, please use the link
found in this slide. On slide six, we will talk
about items O-0401 and O-0402. The gist of the final rule
mentioned on the last slide: effective for IRF discharges
that occurred on or after October 1, 2015, all IRFs
were and are required to report the amount and mode
of therapy minutes provided to each IRF patient
for each discipline. Specifically, IRFs are
reporting on individual, concurrent, and group
therapy, as well as co-treatment for all patients
seen by O.T., P.T., and SLPs. This information is reported
on the patient’s discharge assessment for two time
periods during the IRF stay, week one and week two. Moving onto slide seven. We’ve said this before and
we’ll probably repeat it again, but it is important
to note that the therapy items on the IRF-PAI are
used strictly for data collection exercises for weeks
one and two of the IRF stay. These items are not
documented as a way to verify the amount of therapy
provided to meet the IRF intensity of therapy
requirements. While IRFs are still
obligated to ensure that the coverage requirements
regarding intensive therapy are being met, once again,
these therapy items are not what is used to
document them. Slide eight shows a
screenshot of the IRF-PAI and specifically items
O-0401 and O-0402; this view should be very familiar
to all of you by now. Slide nine explains
item O-0401. Week one: total number of
therapy minutes provided. This item is completed
as part of the IRF-PAI discharge assessment. In this part, providers
record the total minutes of individual, concurrent, and
group therapy as well as co-treatment that the
patient — during week one of the stay. Week one is defined as a
seven consecutive calendar day period, starting with
the day of admission to the IRF and this item should
be completed regardless of whether the patient is in
the IRF for a full seven days. Slide 10 provides an example
that you can read along with me. “Mr. W is admitted to an IRF
on January 1st and is discharged on January 5th. Week one will include total
therapy minutes by mode and discipline provided
beginning January 1st, which is day one of the IRF stay,
through January 5th, which is day five of
the IRF stay.” Moving onto item O-0402:
week two documentation. We’re on slide 11 now. For week two, record the
total number of therapy minutes provided. Similar to week one, this
item is completed as part of the discharge assessment. In this section, the IRF
records the total number of individual, concurrent, and
group therapy minutes as well as co-treatment minutes
that the patient received in each discipline during the
second week of the IRF stay. And like week one, week two
is a second consecutive calendar day period,
starting with day eight of the IRF stay. Item O-0402 should be
completed regardless of whether the patient is in
the IRF all seven days of week two. Slide 12 provides
two examples. In example one, Mrs. C is
admitted to the IRF on January 1st and is
discharged on January 16th. When documenting the therapy
items, week one should include the total minutes of
therapy provided by mode and discipline beginning on
January 1st, which is day one of the IRF stay, through
January 7th, which is day seven of the IRF stay. Week two should be
documented with the total therapy minutes provided
beginning on January 8th, which is day eight of the
IRF stay, through January 14th, which is day
14 of the IRF stay. Example two gives us Mr. T,
who is admitted to the IRF on Jan 1st and
discharged on Jan 11th. This is an example of a
patient who isn’t in the IRF for a full two weeks,
nevertheless we can still fill out week one and
two of the IRF-PAI. Week one includes therapy
minutes by mode and discipline for therapy given
between Jan 1st and Jan 7th. Week two includes the
therapy minutes beginning on Jan 8th and ending
on Jan 11th. Let’s define the different
modes of therapy that we’ve mentioned until now. Slide 13 offers the
definition of individual therapy, that is: provision
of therapy services by one licensed or certified
therapist, or assistant under the licensed or
certified therapist, to one patient at a time. This can also be referred
to as “one-on-one therapy.” An example of an individual
or one-on — of individual or one-on-one therapy
can be found on slide 14. An SLP treats only patient A
for 30 minutes for aphasia therapy following a stroke. Patient A’s speech language
therapy would be coded as 30 minutes of individual
therapy in the therapy information section
of the IRF-PAI. Continuing onto slide 15,
concurrent therapy is defined as the provision
of therapy services by one licensed or certified
therapist, or assistant under the appropriate
direction of a licensed or certified therapist, who is
treating two patients at the same time who are performing
different activities and here’s where things get
a little complicated. When conducting concurrent
and group therapy sessions, start and end times don’t
need to be the same for all participating patients. The exact time spent for
each patient in a concurrent or a group therapy session
should be recorded as such. Any additional time either
prior to or following participation in a group or
concurrent therapy session that a patient receives —
that a patient receives — excuse me — one-on-one
therapy, should be reported as individual therapy. We believe this is
doable for providers. Slide 16 provides
an example of this. Patient A begins P.T. to address lower extremity
strengthening at 9:00 a.m. Patient B enters at 9:30 and
begins working with the same therapy on upper extremity
range of motion. Both patients
engage with the P.T. until 10:00 a.m. At this time, Patient
A leaves and Patient B continues her exercises
until 10:30 a.m. So, how do we record
this on the IRF-PAI? Patient A should be recorded
as receiving individual therapy from
9:00 to 9:30 a.m. and concurrent therapy
from 9:30 to 10:00 a.m. Because the two patients
are performing different activities, patient B
should also be recorded as receiving concurrent therapy
from 9:30 to 10:00 and individual therapy
from 10:00 to 10:30. So, both patients would
receive a total of 30 minutes of individual P.T. and 30 minutes of
concurrent P.T.>>Female Speaker: Moving
onto slide 17, group therapy definition. Group therapy is the
provision of therapy services by one licensed
or certified therapist, or licensed therapy assistant
under the appropriate direction of a licensed
of certified therapist, treating two to six patients
at the same time who are performing the same or
similar activities. Please take note, though,
the therapist may only provide therapy to one group
of patients at a time. For example, one therapist
is not allowed to provide therapy to two groups of
six patients; this would absolutely not meet the
definition of group therapy. Likewise, a therapist may
not have more than six patients in a group. We’ve received several
questions in our IRF email box regarding how providers
should document therapy for a group of eight patients. Again, a group of eight
patients would not meet any of our requirements for
group therapy, so that would not be documented on the
IRF-PAI, as it did not meet any of the defined
types of therapy. Moving onto slide 18, is an
example of group therapy as follows: a speech language
pathologist has patient A, B, C, and D in a group
working on communication. At 2:00 p.m. the group begins with all four patients present together. At 2:12, patient A needs to
use the restroom and later returns at 2:28 p.m. At 2:37, patient B needs to
leave for an appointment, but does not return. The group ends at 3:00 p.m. In this example, the IRF-PAI
should be coded as follows: patient A, who left for
a restroom break for 16 minutes engaged in therapy
for a total of 44 minutes, therefore on patient A’s
IRF-PAI, 44 minutes of group therapy should be recorded. Patient B was in the
group from 2:00 p.m. to 2:37, when they left for an
appointment and did not return. On patient B’s IRF-PAI, 37
minutes of group therapy should be recorded. Patient C and patient D were
in the group from start to finish, 2:00 p.m. to 3:00 p.m. Both patients’ IRF-PAI’s
should reflect 60 minutes of group therapy. Please note, if at any time
the group dwindles down to one patient from the
original group, then the same time with — then the
time spent with this patient would be coded as
individual therapy. For example: patient A went
to the restroom at 2:12 p.m. and never came back. Patient B left for an
appointment at 2:37 and never returned. Patient C fell ill in the
middle of therapy and could not continue, needing
to leave at 2:45 p.m. Only patient D is
left from 2:45 p.m. to 3:00 p.m. Patient D’s therapy time
should be recorded as follows: 45 minutes of group
therapy and 15 minutes of individual therapy. As slide 19 states, the
definition of co-treatment therapy is the provision of
therapy services by more than one licensed or
certified therapist, or licensed therapy assistant
under the appropriate direction of a licensed
therapist, from different therapy disciplines, to one
patient at the same time. We’ve had a few providers
ask us if two therapists from the same discipline,
such as two O.T.s or two P.T.s treating one patient, would
be considered co-treatment. Per our definition, no,
this would not meet the definition for co-treatment
as it specifically states “from two different
therapy disciplines.” We do not believe that
co-treatment is suitable for all patients. This type of therapy should
rarely be given and in those rare instances where it is
in the best interest of the patient, it should
thoroughly be documented as to why this therapy was
the best choice for the patient’s goals and the
patient’s progress. Additionally, please note
that co-treatment should not be used to satisfy
scheduling for the patient and/or the therapist. Moving to slide 20, an
example of co-treatment. A physical therapist and
occupational therapist do a transfer exercise with
Mr. D for 30 minutes. In this example, the
provider would indicate that the patient received 30
minutes of co-treatment for P.T. and 30 minutes of
co-treatment for O.T. on the patient’s IRF-PAI,
assuming both therapists use the full 30 minutes. It’s important to note that
each therapy discipline is documenting the appropriate
time spent with the patient. As a reminder, time
documenting or time waiting for another therapist to
complete an activity would not be documented
as therapy time. Slide 21. So, the next few slides that
we have are some coding tips that we have put together
for you providers. Therapy minutes
cannot be rounded. We are trying to collect
this data to create future policy and clarify future
— or, I’m sorry — clarify present policy that we have
and in order to do so we need to have the most
accurate data that we can possibly have. For example, a patient is
in an individual therapy session with P.T. beginning at 2:00 p.m. and needs a restroom break
at 2:13, but doesn’t return until 2:21. They finish out the therapy
session at 3:00 p.m. The total time recorded
should be 39 minutes, not 40 minutes, but 39 minutes
because that is the exact amount of time the patient
engaged in therapy. Therapy evaluations do count
as the initiation of therapy services and therefore they
do count as therapy time that should be recorded
on the IRF-PAI. We believe that therapy
evaluations are a very important part of
determining the patient’s goals and therefore we
definitely want providers to code that time
on the IRF-PAI. Family conferences do not
count as therapy time. We get this question quite
often in our IRF coverage email box and we just want
to reiterate that that time should not be coded on the
IRF-PAI in any capacity. We have some questions about
whether providers can code this and use the time to
document in the patient’s medical record. No, this time should never
be considered therapy time. Therapy time is time spent
in direct contact with the patient, so on that note,
significant periods of rest in between exercises should
not be coded as time the patient engaged in therapy. Lastly, unsupervised
modality should also not be coded on the IRF-PAI in the
therapy information section. Next, slide 22. We receive a lot of
questions on how to code therapy time when a patient
has an interrupted stay, because it “appears the
patient does not meet the intensive therapy
requirement.” First of all, I do want
to reiterate the therapy information section on the
IRF-PAI is a data collection section only; it is not for
CMS to make sure you are meeting the intensity of
therapy requirements. Therefore, the total number
of minutes that the patient received should be
accurately documented, assuming it meets the
definition of one of the types of therapy
we have defined. If the patient only received
80 minutes total before the interruption occurred, then
only 80 minutes should be recorded. Please keep in mind, too,
that providers should be documenting on the IRF-PAI,
in items 42 and 43, information if the patient
had an interrupted stay. Assuming that everything is
documented correctly, those days of interruption would
be subtracted and the data would be compared to data
for the same length of stay. Moving to slide 23, the next
few slides we included are some questions we’ve
received from providers since we have implemented
the therapy information section on the IRF-PAI and
our responses to them. We touched on this question
a little bit earlier, but thought it was interesting
to include since it discusses the patient’s
insurance coverage. Question one: “Can a
therapy — or can a therapy group-session consisting
of six Medicare patients include additional
non-Medicare patients?” It does not matter, our
answer is it does not matter what the patient’s
insurance is. A group of six patients is
considered group therapy. The second question: “In the
event that a patient meets the appropriate criteria for
an admission to the IRF and the admission is planned and
approved on a given day, can the therapist perform the
initial therapy evaluation in the acute care unit or
hospital the patient is being discharged from
if the time permits?” and our answer to that is
evaluations and/or therapy done in the referring hospital do
not count in the IRF for purposes of meeting the intensity
of therapy requirements. Slide 24. “Are the evaluation minutes
to be recorded in the total number of minutes provided
to each therapy discipline section, or is it just
the treatment minutes?” Again, we have covered this
question during the coding tips, but wanted to
reiterate that, yes, therapy evaluations should be
coded on the IRF-PAI. “Should the therapy be —
should therapy given on the day of discharge be coded?” Yes, as long as it meets one
of the defined therapy types and modalities and the last
question on this slide: “How would you code co-treatment
from the same discipline under the new IRF-PAI?” The definition of the
IRF-PAI training manual states “from different
therapy disciplines,” so this would not be an
example of co-treatment. Moving onto slide 25, “If
one therapist is treating three patients at the same
time but all three patients are performing different
activities, how should the modes be recorded?” The answer that we have is
three patients completing different activities with
one therapist meets none of our therapy definitions
outlined in the IRF-PAI training manual. Therefore, we would see
this as additional therapy received by the patient that
should be documented in the patient’s medical record,
but not in the therapy information section
on the IRF-PAI. You can only code therapy
time given as it meets one of the definitions we
have outlined in this presentation or in the
IRF-PAI training manual. If it does not meet those
definitions then you should consider it additional
therapy time, but it should not be reflected on the
IRF-PAI in the therapy information section and the
last question on slide 25: “If an SLP has a cognitive
group and one of the patients in the group is
also being seen by a P.T. working on balance and
sitting, how would you document time for
each discipline?” Again, this is not a
situation that should be occurring at all. The patient cannot be
in group therapy while receiving individual
therapy as well. This example meets none of
the definitions of therapy we have outlined in this
presentation or in the IRF-PAI training manual.>>Female Speaker: Thank you
for viewing this presentation. [music playing]>>Female Speaker: The
information presented was correct as of the
date it was recorded. This presentation is
not a legal document. Official Medicare program
legal guidance is contained in the relevant statutes,
regulations, and rulings. [music playing]

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