2011 CMS regulations

2011 CMS regulations affecting student supervision with Medicare A/B recipients

These changes as well as other changes regarding MDS 3.0 took effect October 1, 2011. If you have questions regarding this provision or other provisions within MDS 3.0, please contact the APTA at advocacy@apta.org or at 800.999.2782 ext. 8533.

 

Content presented here was modified from the APTA website for the New York New Jersey Physical Therapy Clinical Education Consortium. January 25, 2012

Medicare Part A: Skilled Nursing Facilities

·         Therapy students are not required to be in line-of-sight of the professional supervising therapist/assistant (Federal Register, August 8, 2011).

·         Within individual facilities, supervising therapists/assistants must make the determination as to whether or not a student is ready to treat patients without line-of-sight supervision.

·         Additionally all state and professional practice guidelines for student supervision must be followed. Time may be coded on the MDS when the therapist provides skilled services and direction to a student who is participating in the provision of therapy.

·         All time that the student spends with patients should be documented

 

Individual Therapy: (1 :1) In order to record minutes of therapy provided to residents as Individual minutes, ONLY ONE patient can be treated by the student/CI team at one time. The supervising CI cannot be doing any other patient directed care during the billed minutes.  The student is an extension of the CI, and services are billed as if the student/CI are one person.

Concurrent Therapy: (2 residents)When a therapy student is involved with the treatment, and one of the following occurs, the minutes must be coded as concurrent therapy:

o   The therapy student is treating one resident and the supervising therapist/assistant is treating another resident, regardless of payer source, and both residents are in line of sight of the therapist/assistant and student providing their therapy; or

o   The therapy student is treating 2 residents, regardless of payer source, both of whom are in line-of-sight of the therapy student, and the therapist is not treating any residents and not supervising other individuals; or

o   The therapy student is not treating any residents and the supervising therapist/assistant is treating 2 residents at the same time, regardless of payer source, both of whom are in line-of-sight.

 

Group Therapy: (4 residents)

o   When a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes must be coded as group therapy:

o   The therapy student is providing the group treatment and the supervising therapist/assistant is not treating any residents and is not supervising other individuals (students or residents); or

o   The supervising therapist/assistant is providing the group treatment and the therapy student is observing the group session.

Recommended Skilled Nursing Facility Therapy Student Supervision Guidelines

(Medicare Part A)

 

 

·         The amount of supervision must be appropriate to the student’s level of knowledge, experience, and competence and

·         Students who have been approved by the supervising therapist or assistant to practice independently in selected patient/client situations can perform those selected patient/client services specified by the supervising therapist/assistant and

·         The supervising therapist/assistant must be physically present in the facility and immediately available to provide observation, guidance, and feedback as needed when the student is providing services and

·         When the supervising therapist /assistant has cleared the student to perform medically necessary patient/client services and the student provides the appropriate level of services, the services will be counted on the MDS as skilled therapy minutes and

·         The supervising therapist/assistant is required to review and co-sign all students’ patient/client documentation for all levels of clinical experience and retains full responsibility for the care of the patient/client and

·         Therapist assistants can provide instruction and supervision to therapy assistant students so long as the therapist assistant is properly supervised by the therapist.

·         Documentation: APTA recommends that the physical therapist co-sign the note of the physical therapist student and state the level of supervision that the PT determined was appropriate for the student and how/if the therapist was involved in the patient’s care.

 

 

 

Medicare Part A: Hospital or Inpatient Rehabilitation Facility

 

This is not specifically addressed in the regulations, therefore, please defer to state law and standards of professional practice. Additionally, the Part A hospital diagnosis related group (DRG) and inpatient rehab (IRF) payment system is similar to that of a skilled nursing facility (SNF) and Medicare has indicated very limited and restrictive requirements as described above.

 

Note: Each facility needs to make its own determination as to how to supervise students in their setting.

 

Sample Strategies for addressing supervision of students when patient/client services are covered by Medicare Part A

•  The physical therapist can do paperwork or other non direct patient care if they have determined that the student is qualified to treat patients without direct supervision.
• The physical therapist must be accessible to the student at all times.
• Use alternative means of clinical education that do not involve patient care such as    solving evidenced based patient problems or interacting with other disciplines

 

 

Medicare Part B: Skilled Nursing Facility

Medicare Part B—The following criteria must be met in order for services provided by a student to be billed by the long-term care facility:

• The qualified professional is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
• The practitioner is not engaged in treating another patient or doing other tasks at the same time.
• The qualified professional is the person responsible for the services and, as such, signs all documentation. (A student may, of course, also sign but it is not necessary because the Part B payment is for the clinician’s service, not for the student’s services.)

 

Medicare Part B Skilled Nursing Facility - Group Therapy: The treatment of 2 or more individuals simultaneously, regardless of payer source, who may or may not be performing the same activity is considered group therapy.  When a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes must be coded as group therapy:

• The therapy student is providing group treatment and the supervising therapist/assistant is not engaged in any other activity or treatment; or
• The supervising therapist/assistant is providing group treatment and the therapy student is not providing treatment to any resident.  
• Group therapy services performed by a therapist or physician may be billed when a student is also present “in the room”.

Strategies for student learning when patient/client services are not covered by Medicare

Students can learn a great deal by participating in non-billable experiences. The following are just a few examples:

• Comprehensive chart audits/reviews with analysis and reflection
• Practice documentation and receive feedback from the CI regarding quality/clarity
• Conduct/analyze patient satisfaction interviews or surveys
• Prepare and deliver  case study(s)  or evidence based in-service presentations
• Develop comprehensive home exercise programs or a given patient group
• Create patient education materials
• Create an orientation manual for future students
• Provide prevention/screening/education for specific patient populations or employee groups  
• CI might encourage the student to provide the CI feedback on treatment session rendered
• Develop skills in peer review, quality assurance, understanding administrative management, billing procedures, etc.
• Involve the student in observational experiences with other members of the health care team  During observational experiences, require the student to  record observations, analyze patient/client movement, hypothesize diagnosis, suggest interventions, ways to provide efficient care, evidence-based literature in support of interventions etc
• Consider how to enrich the clinical learning experience to include observation of clinicians performing components of the patient management model at varied levels of clinical experience/expertise.
• Have the student break down interventions in terms of the patient client management model: provide rationale for moving through the model.
• Provide opportunities for students to strengthen their clinical reasoning abilities by seeking evidence to justify care delivered; compare observational learning experiences of similar patient diagnoses, and to develop a systematic approach to patient examination.