One of the best parts of being a therapist is variety, especially the variety of settings and the variety of patients therapists experience on a daily basis.
I remember being in PT school and thinking I would be an outpatient orthopedic therapist. I was an athlete and that seemed like a glamorous job. However, during one of my clinicals, I was exposed to the geriatric population and a sweet lady who had recently suffered a stroke. I was suddenly converted, and expanded my thoughts regarding where and with whom I wanted to work.
Clinicals are so important for students deciding what their future might look like. It gives them an opportunity to apply their knowledge, exposes them to the real world of healthcare and provides opportunities to see other settings and patient populations that they otherwise may not explore.
So how does this new payment model, the Patient Driven Payment Model (PDPM), in our skilled nursing facilities (SNFs) affect student affiliations/clinicals? It really shouldn’t, but it is no secret that the rules regarding students vary by payer, even between Medicare Part A and Part B. So it’s very important to be informed and understand what the rules are within each setting and across payers.
The biggest concern related to PDPM in the SNF is with the 25 percent combined limitation on group and concurrent modes of therapy, specifically around concurrent. The supervising clinician and student together are considered a “unit” when it comes to billing. Per the RAI Manual, Chapter 3, Section O.
When a therapy student is involved with the treatment and one of the following occurs, the minutes may be coded as concurrent therapy:
- The therapy student is treating one resident and the supervising therapist/assistant is treating another resident, and both residents are in line of sight of the therapist/assistant or student providing their therapy.
- The therapy student is treating two 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.
- The therapy student is not treating any residents and the supervising therapist/assistant is treating two residents at the same time, regardless of payer source, both of whom are in line-of-sight.
You might be thinking, “How often would that happen?” This would be most prevalent with the student completing their last clinical, months or weeks away from graduation and expected to function with a high level of autonomy. Yes, the licensed clinician is ultimately responsible for the student and supervision, but the concern is that the treatment time is constrained by the 25 percent limitation. The challenge in maintaining the 25 percent limitation occurs when both the student and the supervising clinician are treating patients simultaneously and all minutes must be documented as concurrent.
Fortunately, EMR systems do a great job of tracking compliance with the 25 percent limit on a daily basis. It’s important to increase the awareness of this requirement. More importantly, it’s critical to communicate the strategies used to ensure compliance so the new payment model doesn’t negatively impact student placement in the SNF setting.
The geriatric population has many needs that PT, OT and SLP can address, and they are so appreciative of what we as clinicians do. So having students exposed to these settings and these patients is critical to ensuring we continue to get skilled clinicians with a desire to serve this population.