Group Therapy in SNFs: What’s Changed Under PDPM?

On October 1, 2019, the Patient-Driven Payment Model went into effect, changing a number of the ways in which skilled nursing facilities and the providers who care for SNF residents are reimbursed by the Centers for Medicare and Medicaid Services (CMS). One of the areas affected by PDPM was group therapy.

Prior to PDPM, CMS defined group therapy as “four residents performing the same or similar activities, regardless of payer source, supervised by a therapist or an assistant who is not supervising any individuals.” Under PDPM, however, group therapy is now 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.”

Why Did This Change?

CMS reviewed the use of a less restrictive definition of “group therapy” in inpatient rehabilitation facilities (IRF) and outpatient settings and found:

• Therapists are capable of managing groups of various sizes.
• Therapists’ clinical judgment allows them to determine when a certain group size will benefit their patients clinically and demonstrably.
• Aligning the definition of SNF group therapy with IRF and outpatient group therapy covered under Medicare Part B should reduce providers’ administrative burden by allowing them to use the same or similar definitions across settings.
• Because there is a great degree of similarity between IRF and SNF when it comes to therapy intensity and patient acuity, the IRF definition of two to six patients performing the same or similar activities is more appropriate in the SNF setting.
• This new definition would provide therapists with more clinical flexibility to determine the appropriate number for a group without compromising their ability to manage or the patient’s ability to participate and benefit.

Examples of Group Therapy

CMS also provides some examples of group activities to illustrate when groups on the smaller or larger end of the “two to six people” definition would be appropriate. For instance, many patients benefit from the psycho-social aspect of groups. Functional therapy for patients who will be returning home, which might include working on skills related to cooking, dressing, or other ADLs, can be provided to a group of six, enhancing the patients’ psycho-social experience.

On the other end of the spectrum, patients with language difficulties following a stroke or head injury will benefit from a small, two- to three-person communication group that allows them to work on the social aspects of language, free from the distraction that a larger group might cause. These smaller groups offer additional benefits as well, such as providing patients with an opportunity to learn from each other and replicate each others’ strategies.

Documentation Requirements

Group therapy documentation must demonstrate that group therapy is medically necessary and appropriate. This means that your documentation should:

• Explain your reasons for choosing group therapy, including in each patient’s plan of care explicit justification for choosing group therapy as an adjunct to individual or concurrent therapy.
• Explain how the type and amount of group therapy will benefit the patient, including the specific benefits to that particular patient, such as how it will meet the patient’s needs and assist the patient in reaching the documented goals.

Daily treatment documentation should support group therapy and demonstrate continued benefit to the patient. You can use the following statement as a template for your documentation:

“Patient will benefit from [name of group] [number of times per week] to [document the benefits of the group] for [document the goal of the group].”

Recording Group Therapy

Since the updated definition changes group therapy from four patients to a range of two to six, it’s important to pay attention to the definitions of both group therapy and concurrent therapy to ensure that you are properly recording the minutes of treatment you provide to the appropriate section O item on the MDS.

• When two patients are being treated at the same time by one therapist or assistant and are performing different activities, concurrent therapy should be documented. The therapist or assistant must be in line of sight of both patients.
• When two patients are being treated at the same time by one therapist or assistant and are performing the same or similar activities, group therapy should be documented. The therapist or assistant must be in constant attendance, but one-on-one patient contact is not required.

Ultimately, individual treatment remains the preferred mode of treatment, but group therapy is effective and valuable as a supplement. Correct and appropriate documentation and coding will ensure not only that your patients receive appropriate care but also that the medical necessity of the services you’ve provided will not be denied in an audit.