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With the implementation of PDPM on October 1st, 2019 and the impact of the COVID-19 virus on skilled nursing facilities, therapy treatment time is being looked at more than ever.  Treatment time needs to be accounted for appropriately when reporting on the MDS, on the medical record and within any software system.

 

Here are the Top 5 Therapy Treatment Time Concerns:

#5.  Therapy Evaluation Minutes-  Chart review, obtaining MD orders, goal writing and other documentation (including care plan entering in PCC) are NOT billable treatment minutes.  Only those minutes the patient is present and participating in the assessment and examination can be billed under “evaluation time”.

#4. Therapy treatment time recording during the evaluation- Best practice would be a patient receives an evaluation and treatment in separate sessions on their initial evaluation day.  But that is sometimes not possible due to time and activity tolerance concerns.  Therefore, the evaluation ends when the therapist determines the patient’s current level of assist for a task and treatment starts when the therapist provides skilled services that include strategies, education, techniques, and interventions to improve the evaluated task.

#3. Recording treatment time in patient care conferences- Time spent by a therapist in a patient care conference when the resident is actively on their caseload and present and the discussion is related to the patient’s current treatment plan does count as direct treatment time for MDS purposes (skilled level of coverage).  However, the time cannot exceed the time spent in the conference and should not replace the patients physical activity treatment time for the treatment day.

#2. Recording staff education and caregiver training time- Staff or caregiver training treatment time is only billable when the patient is present and the education has therapeutic value to the patient. Also return demonstration of staff/caregiver understanding and utilization of education is documented in the clinical record.  As a general rule, goals on a patient’s treatment plan should not include caregiver or staff training but those activities should be documented in the medical record.

#1. Proper calculation of daily direct treatment time- Therapy time starts when the patient begins the first activity or task and ends when the last apparatus and treatment has ended.  All direct treatment time requires the patient to be present and participating in an activity of therapeutic value. Record actual minutes of treatment time.  Do not round therapy minutes to the nearest 5-minute increment (up or down).

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