We came to you at the beginning of November with exciting news that three new caregiver training CPT codes were finalized for calendar 2024.

Wow, did the inquiries come in!

Folks are clearly thinking about how they can provide these services and I am here today to answer the top questions I have received from you all since that release.

Let’s start with the basics.

Question

What are the new CPT codes and how are they defined?

Answer

97550 — Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes.

97551 — Each additional 15 minutes (List separately in addition to code for primary service).

97552 — Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face with multiple sets of caregivers. 

Question

What is the “skill,” to say what does my intervention need to include and what must my documentation support to use these?

Answer

During a skilled intervention, the caregiver(s) is trained using verbal instructions, video and live demonstrations, and feedback from the qualified healthcare professional on the use of strategies and techniques to facilitate functional performance and safety in the home or community without the patient present. 

Skilled training supports a caregiver’s understanding of the patient’s treatment plan, ability to engage in activities with the patient in between treatment sessions, and knowledge of external resources to assist in areas such as activities of daily living (ADLs), transfers, mobility, safety practices, problem solving and communication.

Question

Do I need to identify this area of care on my treatment plan?

Answer

Yes, the expectation that a patient-centered treatment plan should appropriately account for clinical circumstances where the treating practitioner believes a caregiver’s involvement is necessary to ensure a successful outcome for the patient and where, as appropriate, the patient agrees to caregiver involvement.

Now, to the more specific areas you all are asking…

Question

Renee, what is a caregiver? How does the Centers for Medicare & Medicaid Services define this?

Answer

In CMS’s ongoing education and outreach work on the use of caregivers in assisting patients they have broadly defined a caregiver as a family member, friend or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.

After considering the public comments, they finalized a revised definition of caregiver to be “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability or functional limitation” and “a family member, friend or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”

Question

OK, so how often does the caregiver need to be involved in care every day?

Answer

A caregiver is an individual who is assisting or acting as a proxy for a patient with an illness or condition of short or long-term duration (not necessarily chronic or disabling); involved on an episodic, daily or occasional basis in managing a patient’s complex healthcare and assistive technology activities at home; and helping to navigate the patient’s transitions between care settings.

Caregiver understanding and competence in assisting and implementing these interventions and activities from the treating practitioner is critical for patients with functional limitations resulting from

various conditions.

Question

We are hearing that patients must consent? How is this accomplished when my patient is cognitively impaired?

Answer

You are correct. CMS states that they are finalizing, as proposed, that the patient’s (or representative’s) consent is required for the caregiver to receive Caregiver Training Services (CTS) and that the consent must be documented in the patient’s medical record. The reason to require the patient’s (or their representative’s) consent for CTS is because, unlike most services, the patient would not be present for the service.

CMS believes it is be important to make the patient aware, out of concern for patient privacy, that the service is furnished outside their presence and that any applicable cost-sharing would be

their responsibility.

Question

So, can we use general consent?

Answer

CMS leaders state they do not believe that the general consent to receive treatment would be sufficient to make a patient aware of the unique circumstances under which CTS are furnished.

For these same reasons, they continue to believe it is appropriate to require a specific consent for

CTS. The term “consent” as opposed to other recommended terms to remain consistent across other codes with consent requirements across the PFS. 

In cases of an Alzheimer’s or dementia diagnosis, it is encouraged providers obtain consent from the patient or their representative for CTS as early as possible in the diagnosis.

In closing, the unveiling of these codes not only addresses your queries but opens a pathway for a more comprehensive and collaborative approach to patient care, ensuring that caregivers are equipped with the tools and knowledge necessary for fostering optimal patient outcomes. 

As we move forward, let us embrace these changes with a commitment to enhancing the quality of care and support for both patients and their dedicated caregivers. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

These have now officially been finalized for use beginning Jan. 1, 2024 when used according to the following rules.

To begin, let’s review from a regulatory standpoint why these allowances are being made for the first time, allowing reimbursement in the absence of the patient present. 

The Centers for Medicare & Medicaid Services states specifically that they have continued to consider whether the caregiver behavior management training and similar caregiver training services could be considered to fall within the scope of services that are reasonable and necessary under section 1862(a)(1)(A) of the Act, in alignment with the principles of the recent Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers.

Furthermore, and as part of an U.S. Department of Health & Human Services-level review of our payment policies, use was found to identify opportunities to better account for patient-centered care, changes in medical practice that have led to more care coordination and team-based care, and to promote equitable access to reasonable and necessary medical services. 

CMS also states they believe it important for practitioners furnishing patient-centered care to use various effective communication techniques when providing patient-centered care, in alignment with requirements under section 1557 of the Affordable Care Act and in certain circumstances, caregivers can play a key role in developing and carrying out the treatment plan or, as applicable to physical, occupational, or speech-language therapy, the therapy plan of care (collectively referred to in this discussion as the “treatment plan”) established for the patient by the treating practitioner (which for purposes of this discussion could include a physician; NPP such as a nurse practitioner, physician assistant, clinical nurse specialist, clinical psychologist; or a physical therapist, occupational therapist, or speech-language pathologist).

Finally, they believe Caregiver Training Services (CTS) can be reasonable and necessary to treat the patient’s illness or injury as required under section 1862 (a)(1)(A) of the Act, therefore providing an opportunity to consider the best approach to establishing separate payment for the services described by the caregiver training codes, especially as it relates to a practitioner treating a patient and expending resources to train a caregiver who is assisting or acting as a proxy for the patient.

Now let’s move on to how the codes are defined!

Caregiver Training Without the Patient Present:

Caregiver training is direct, skilled intervention for the caregiver(s) to provide strategies and techniques to equip caregiver(s) with knowledge and skills to assist patients living with functional deficits. 

Codes 97550, 97551 are used to report the total duration of face-to-face time spent by the qualified health care professional providing training to the caregiver(s) of an individual patient without the patient present. 

Code 97552 is used to report group caregiver training provided to multiple sets of caregivers for multiple patients with similar conditions or therapeutic needs without the patient present. 

During a skilled intervention, the caregiver(s) is trained using verbal instructions, video and live demonstrations, and feedback from the qualified healthcare professional on the use of strategies and techniques to facilitate functional performance and safety in the home or community without the patient present. Skilled training supports a caregiver’s understanding of the patient’s treatment plan, ability to engage in activities with the patient in between treatment sessions, and knowledge of external resources to assist in areas such as activities of daily living (ADLs), transfers, mobility, safety practices, problem solving and communication.

97550 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face; initial 30 minutes.

97551 each additional 15 minutes (List separately in addition to code for primary service).

97552 Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face with multiple sets of caregivers. 

In closing, let us first understand the rules for use, implement them to ensure regulatory compliance, and use this opportunity to increase the quality of care we provide daily.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

One I have had for the past 20 years goes something like this …

I am ready to graduate, walk across the stage and start an official occupation as a speech-language pathologist, when someone at the university realizes I neglected to take a prerequisite course and my dreams are put on hold.

All my friends walk across the stage, smiles on their faces, and I am left, sitting in my seat wondering, thinking to myself, how did I miss a key experience needed to graduate? How in the world did a foundational course slip through the cracks?

Well, thankfully, I graduated on time. I have also been overly fortunate in my career to have mentors, colleagues and friends to guide my path, including a student rotation and an experience at a local VA nursing facility.

That experience, and its foundational impact, has had lifelong effects on my career path. 

What I recall most about that rotation compared to others is that there was an emphasis on the fact for many patients that we are guests in their home, we are here to support their journeys based on their disease process and separate from other settings we have the opportunity to develop solid relationships with patients, along with their family members and loved ones.

The purpose of this blog is to remind all of you out there to welcome students back into your skilled nursing facilities, back into patients’ homes, allow them into your life plan communities, and support them with the experiences they need to ensure the long-term successes of these unique settings we all love so much.

In our rapidly evolving healthcare environment, the role of therapists remains undeniably vital. The distinct nature of long-term care means that therapists aren’t just passing through a patient’s healing journey — they become an integral part of it. Unlike the more episodic interactions in hospitals or outpatient clinics, therapists in these settings can watch and assist as their patients evolve over extended periods. This continuity translates into more than just a working therapist-patient relationship; it blossoms into trust, understanding, and mutual respect.

Beyond the clinical benefits, the environment of life plan communities offers a precious glimpse into a patient’s daily world. Therapists gain an in-depth appreciation of the intricacies of their patient’s lives, from their favorite morning routines to the challenges they face every evening. Such insights prove invaluable when crafting therapeutic interventions that are not merely clinically appropriate, but also deeply personal and relevant.

A common obstacle to integrating students into skilled nursing facilities is the perceived web of regulations. To foster a more student-friendly environment, it is crucial to understand and communicate these regulations clearly. While communities should review local and state guidance a logical place to start is the Resident Assessment Instrument (RAI) Manual Section O guidance as follows:

Medicare Part A:

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. 

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.) 
• Physical therapy assistants and occupational therapy assistants are not precluded from serving as clinical instructors for therapy assistant students while providing services within their scope of work and performed under the direction and supervision of a qualified physical or occupational therapist.

In conclusion, nurturing the next wave of therapists via mentorship and placements is an investment in the future quality of care within skilled nursing facilities and life plan communities. With a clear understanding of regulatory directives, these institutions can not only offer a rich learning landscape for students but also tap into the fresh vigor, innovative perspectives, and boundless enthusiasm that these emerging professionals bring. 

With this peace of mind we can all rest well and dream big that there is a bright future in therapy for ours and the next generation to come. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee and is a member of the University of Kentucky College of Medicine community faculty, a member of the American Medical Association’s (AMA) Digital Medicine Payment Advisory Group (DMPAG), and an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

They are family members, parents, grandparents, aunts and uncles, essential in their communities, therefore how fortunate are we in the job we get to do in providing hands-on skilled therapy services to them daily. 

Each morning, physical, occupational and speech therapists across the world step into skilled nursing facilities with a unified purpose: to assist, uplift and rehabilitate. They not only touch the lives of their patients, but also impact the countless families and loved ones connected to them. In these facilities, therapists often say, “It’s not just a job. It’s a privilege.”

Physical therapy: More than just movement

To many, physical therapy may appear as a mere means of regaining physical movement. However, to a PT professional, it is about rebuilding lost hope, and being the pillar of support when a patient feels challenged. 

As therapists guide their patients through exercises, they’re doing more than just helping them regain mobility — they’re restoring independence. When a grandmother can stand up on her own to hug her grandchild, or a father can walk his daughter down the aisle, it’s a victory for both the patient and the PT.

Occupational therapy: Reconnecting with life’s simple pleasures

Occupational therapists also have a unique role. Their goal is to help patients perform day-to-day tasks and enjoy life’s simple pleasures, whether it’s buttoning a shirt, cooking a meal or crafting. Through occupational therapy, residents are reminded of the beauty in ordinary moments. 

Each mastered skill is not just a physical achievement but a reconnection to cherished roles — be it as a spouse, parent or friend. It’s about making sure individuals can continue to contribute to their families and communities in meaningful ways.

Speech therapy: Beyond words

Speech therapy often transcends the spoken word. It’s not just about helping someone speak again, but enabling them to express their feelings, needs and stories. Communication is a fundamental human need and speech therapists ensure that residents can continue to connect with their loved ones, share their histories and advocate for their own care. 

Each time a grandparent shares a story from their youth or a mother sings a lullaby, the importance of this therapy becomes palpable.

Bridging the gap between patients and families

Skilled nursing therapists don’t just work with patients in isolation. They play an instrumental role in bridging the gap between patients and their families. Therapists often become a primary source of information, hope and reassurance for loved ones. They’re there to answer questions, offer encouragement, and provide guidance on how families can support their relatives’ rehab journey.

Beyond the technicalities of rehabilitation, these therapists offer something equally vital – genuine human connection. In moments of vulnerability, a therapist’s encouraging word, a reassuring smile, or even a shared laugh can be transformative.

At the heart of it all, the work in skilled nursing facilities is about recognizing the inherent value of every individual, regardless of age or disability. It’s about witnessing and fostering the human spirit’s incredible resilience.

In essence, it’s not just a job therapists do. It’s a calling they get to answer every day, serving as a testament to the indomitable human spirit and the difference one person can make in the life of another. 

The ripple effect of their dedication touches not just the patients, but resonates deeply with the families who entrust their loved ones into their care.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee; is a member of the University of Kentucky College of Medicine community faculty; is a member of the American Medical Association’s (AMA) Digital Medicine Payment Advisory Group (DMPAG); and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

This focus allows all of us the opportunity to show appreciation to our PTs, PTAs and students for all they do to transform lives.

Physical therapy provides value to Americans across a variety of conditions at all stages of life. Physical therapists provide a wide range of services to help people maximize their quality of life. They work with people of all ages and abilities, and in a variety of settings.

NPTM is the perfect time for service events. The American Physical Therapy Association (APTA) also provides a ChoosePT toolkit packed full of resources to promote the profession

This year the theme of the month will be the “Value of PT.”

Per the APTA, its meaning goes beyond the cost savings of physical therapy to highlight the ways physical therapy improves quality of life. Furthermore, it shares a recently published cost data component highlighted in “The Economic Value of Physical Therapy in the United States,” an evidence-based report by APTA. 

This report investigates physical therapist services for eight different conditions, comparing physical therapy against an alternative course of treatment and quantifying the average net benefit in economic terms. For each condition, the estimates indicate the average net economic benefit of physical therapist services.

While I recommend you read the report in its entirety, some key highlights and findings related to key conditions we often see in post-acute care are as follows:

• Falls prevention: The average net benefit of physical therapy-based falls-prevention exercise is estimated to be $2,144 per episode of care. The cost per QALY (quality and duration of life) gained relative to the alternative of no intervention is estimated to be $13,425. Patients who participated in a physical therapy-led falls-prevention exercise program had a mean QALY of 0.009 higher and a mean medical cost of $121 higher than those who received no intervention, indicating the cost-effectiveness of physical therapist services.

• Osteoarthritis of the knee: The average net benefit of treating osteoarthritis of the knee with physical therapy is estimated to be $13,981 per episode of care. The cost per QALY gained relative to the alternative of intra-articular glucocorticoid injection is estimated to be $51,906. Patients who received physical therapy had a mean QALY of 0.07 higher and a mean medical cost of $1,024 higher than those who received injections, indicating the cost-effectiveness of physical therapist services.

• Low back pain: The average net benefit of treating acute low back pain with physical therapy is estimated to be $4,160 per episode of care. The cost per QALY gained relative to the alternative of usual primary care management is estimated to be $43,624. Patients who received physical therapy had a mean QALY of 0.02 higher than those who received usual primary care, indicating the cost-effectiveness of physical therapist services.

• Stress urinary incontinence: The average net benefit of treating stress urinary incontinence with physical therapy is estimated to be $10,129 per episode of care. The cost per QALY gained relative to the alternative of urethral bulking is estimated to be $2,265. Patients who received physical therapy had a mean QALY of 0.009 higher and a mean medical cost of $7,864 lower than those who received urethral bulking, indicating the cost effectiveness of physical therapists.

In closing, the report notes that physical therapy also can prevent unnecessary future health expenditures, which may be realized through avoiding a more costly alternative treatment and/or reducing the need for future medical intervention. The benefits of this can often be multifaceted, generated through both quality-of-life improvements for the patient and cost benefits for payers.

So, celebrate your physical therapy teams this coming month. For the skilled service they provide now, for the value impacts in the future, and the prevention of further risks for years to come. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty; is a member of the American Medical Association’s (AMA) Digital Medicine Payment Advisory Group (DMPAG), and an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

As a result of the case, the Jimmo Settlement Agreement clarified that when a beneficiary needs skilled nursing or therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits in order to maintain the patient’s current condition or to prevent or slow decline or deterioration (provided all other coverage criteria are met), the Medicare program covers such services and coverage cannot be denied based on the absence of potential for improvement or restoration.

Ten years later, therapists and providers continue to learn best practices for engaging patients in a skilled maintenance level of care.

Let’s review some of the top questions for clarity:

Question:

Are therapy services available under Medicare only for patients who are improving or expected to improve? 

Answer:

No. The Jimmo Settlement confirms that services by a physical therapist, occupational therapist and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled nursing facilities, home health and outpatient therapy, when the services are necessary to maintain a patient’s current condition or to prevent or slow a patient’s further decline or deterioration.

Question:

What qualifies a patient for therapist-provided maintenance services under the Medicare benefit?

Answer:

Since maintenance services are considered skilled care, the patient must meet the setting-specific qualifying criteria outlined in the law, regulations, and Medicare Benefit Policy Manual. Once those criteria have been confirmed, the qualified therapist will, after completion of a thorough assessment of the patient, select the focus of care in collaboration with the physician. If the patient is currently at a point where material improvement is not expected and decline is probable without skilled therapy care, a maintenance course of care may be developed and implemented.

Question: 

Does Jimmo apply only to specific medical conditions such as Multiple Sclerosis or Parkinson’s disease? 

Answer:

No. The settlement is not limited to any particular condition or disease. It applies to any Medicare patient who requires skilled nursing or skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s further decline or deterioration, regardless of the patient’s underlying illness, disability or injury. The settlement is not limited to people with chronic conditions and applies equally, for example, to patients who had a stroke. The fundamental issue for coverage under the standard clarified by Jimmo is whether the patient needs professional services to maintain function or to prevent or slow decline or deterioration.

Question:

Does the Jimmo settlement apply to patients who have dementia? 

Answer:

Yes. Dementia is not a disqualifying condition for Medicare coverage. If the patient needs skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s decline or deterioration, Medicare covers the therapy services, as long as all other coverage criteria are met. Skilled professional therapists are trained to work with patients who have dementia.

Question:

What qualifies a patient for discharge when receiving maintenance therapy? 

Answer:

A patient receiving therapy as outlined in the law, regulations and Medicare Benefit Policy Manual, is appropriate for discharge from skilled service when the patient no longer requires the skills of an occupational therapist, physical therapist, and/or speech-language pathologist.

“Skilled” services are those that can only be provided by a qualified therapist, due

to the complex nature of the needed therapy procedures and/or the patient’s special medical complications that require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled.

Ready to learn more? 

The Center for Medicare Advocacy is hosting a virtual meeting Sept. 27 to hear from advocates, providers, beneficiaries and others who will discuss practical tips and strategies for obtaining medically necessary services pursuant to the Jimmo settlement.

Register here to join the conversation and celebrate this monumental case with others in the industry!

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty; is a member of the American Medical Association’s (AMA) Digital Medicine Payment Advisory Group (DMPAG), and an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Over the weekend, our daughter, Emmy Grace, took part in her first hunter jumper 2-foot division horse show. During one of the jumps, her pony made an unexpected high leap, leading Emmy to find herself precariously positioned on the pony’s neck, just a misstep away from a potential fall.

Here’s where the lesson shines through. 

Emmy, with sheer determination, grace and composure, repositioned herself back in the stirrups, continued on, and finished the course, eventually winning class champion. 

This moment reminded me of a valuable lesson for our long-term care community, especially our hardworking therapists.

Come October 2023, skilled nursing facilities are preparing for significant changes to Medicare Part A payment structures. These shifts might feel like that unexpected high jump Emmy faced — jarring, surprising and potentially destabilizing. 

However, if Emmy’s experience taught me anything, it’s that the most remarkable feats come not from avoiding challenges but from navigating them with grace and determination.

Refining the Course: PDPM ICD-10 Code Mappings & Exclusions

A clear path and well-set boundaries can make all the difference in a riding course. 

The refined use of ICD-10 codes in the PDPM and the exclusion of certain therapeutic services from SNF consolidated billing provide a clearer, more tailored track for care and billing pathways.

Aim for Quality: SNF Quality Reporting Program

Every stride and jump counts in equestrian sports. 

Similarly, the SNF QRP measures introduced by CMS ensure that every step taken in patient care is of the highest quality. With new benchmarks in place, facilities are encouraged to continuously improve their performance, much like riders refining their techniques with each round.

Value-Based Rewards: Skilled Nursing Facility VBP Program

In riding, rewards aren’t solely based on speed but on technique, style and overall harmony with the horse. 

The SNF VBP program is structured similarly, focusing not just on outcomes but on the overall quality of care. The introduction of measures like the Nursing Staff Turnover and the Long Stay Hospitalization Measure show CMS’ commitment to a holistic view of care quality.

Reducing Administrative Burdens: Civil Money Penalties (CMP)

A smooth ride is often the result of countless hours of training, preparation, and removing potential obstacles from the path. 

By streamlining the CMP process, CMS aims to provide a smoother journey for SNFs, allowing them to focus more on care and less on administrative hurdles.

Stay the Course

The road ahead, shaped by the FY 2024 rule, is filled with both challenges and opportunities. But with determination, agility and a clear understanding of the changes, SNFs can not only adapt but excel, ensuring top-quality care for their patients and a promising horizon for their facilities.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

We know additionally, as the elderly demographic continues to grow, the incidence of falls and their associated consequences also rises. 

Backward disequilibrium, where individuals experience an unsteady feeling or tend to lean or fall backward, presents unique risks and complications. 

Skilled nursing facilities play a pivotal role in addressing these concerns, and one of the critical interventions they offer is physical therapy. Physical therapy stands out as a vital tool in both preventing these metaphorical “falls” and minimizing the repercussions when they do occur.

Let’s review the benefits of physical therapy and how it effectively reduces the risks associated with backward disequilibrium.

1. Improved balance and posture

One of the main causes of backward disequilibrium is poor balance. As we age, muscle strength, proprioception and vestibular function often decline. Physical therapy introduces exercises specifically designed to improve balance, coordination and posture. By reinforcing these aspects, seniors can navigate their environment with more confidence and a reduced risk of falling backward.

2. Strength training

Loss of muscle strength is common in older adults. Physical therapy programs incorporate strength training exercises tailored to the individual’s needs. This training can target core muscles, lower extremity strength and other areas essential for maintaining an upright position. As muscle strength improves, the chances of experiencing backward disequilibrium diminish.

3. Gait analysis and training

A shuffling gait or irregular walking pattern increases the risk of falling. Physical therapists can analyze a patient’s gait, identify issues and introduce exercises to correct them. Through gait training, seniors can achieve a steadier and more confident stride, reducing the likelihood of backward disequilibrium.

4. Education on fall prevention

Beyond the physical aspects, education is an integral component of fall prevention. Physical therapists provide advice on safe movement, strategies for getting up from chairs, correct footwear and potential home hazards. Armed with this knowledge, patients are better prepared to avoid situations that might cause them to lean or fall backward.

5. Use of assistive devices

Physical therapists are adept at recommending and training individuals to use assistive devices, such as walkers, canes and grab bars. These tools offer additional stability and can be particularly useful for those with significant balance or strength issues.

6. Enhanced confidence

The fear of falling can be paralyzing, often leading to decreased activity and further physical decline. As patients engage in physical therapy and experience improvement in strength, balance and mobility, their confidence also grows. This renewed self-assuredness encourages them to stay active and engaged, reinforcing their physical gains.

7. Addressing underlying issues

Many conditions, like Parkinson’s, arthritis or stroke, can increase the risk of backward disequilibrium. Physical therapy in skilled nursing facilities can address these underlying issues, offering exercises and strategies to mitigate their impact on balance and strength.

In conclusion, physical therapy serves as a multifaceted approach in skilled nursing facilities to combat the risks associated with backward disequilibrium. 

With a combination of strength training, balance exercises, education and personalized care plans, physical therapists offer seniors a fighting chance against the significant risks of falling. By investing in comprehensive physical therapy programs, we ensure that our elderly population has the tools and support they need to navigate their environment safely and confidently.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Teenagers up and out way too late with friends, hopefully staying out of trouble and then crashing until 2 p.m. the next day.

Little ones who are just plain exhausted after multiple evenings with cousins.

And parents just trying to keep it all together… “Now who is actually here at home tonight?” “Do we have any extras to care for?”  

These are real questions we ask each other most evenings. 

Sleep is important. We know this. 

Have we considered as caregivers the impact of sleep on those we serve daily?

As we age, achieving restful, uninterrupted sleep becomes increasingly challenging. For the elderly, sleep problems can be amplified due to factors such as chronic illness, medication side effects, or even the psychological stress of major life changes. 

While there are many conventional interventions to improve sleep quality, including sleep medications and sleep hygiene education, an unexpected player has emerged in this arena: occupational therapy.

Occupational therapists can help people improve their ability to perform tasks in their living and working environments. While traditionally linked with aiding physical or developmental problems, occupational therapy has increasingly been recognized for its potential to improve sleep quality, particularly among the elderly.

Our occupational therapists, as we are aware, are skilled in engaging our patients and residents in meaningful activities (aka occupations) to improve people’s health and well-being. 

Given that sleep is an essential daily occupation that many elderly individuals struggle with, occupational therapists can play a significant role in promoting better sleep habits.

How, you ask?

Firstly, occupational therapists can help the elderly establish regular sleep routines. Aging often brings about lifestyle changes that may disrupt sleep schedules, such as retirement, changes in physical health or the loss of a spouse. Occupational therapists are experts at analyzing and modifying routines. They can provide practical strategies to establish regular sleeping and waking times, enhancing the body’s natural circadian rhythm.

Secondly, occupational therapy addresses physical issues that can interfere with sleep. Conditions like arthritis, chronic pain or respiratory disorders are common in the elderly and can significantly impact sleep quality. Occupational therapists can provide personalized exercise programs to manage pain, improve flexibility, and enhance overall physical health, thereby indirectly improving sleep. They also can offer advice on adaptive equipment, such as orthopedic pillows or adjustable beds, to increase comfort during sleep.

Next, environment is key, and occupational therapists can evaluate and modify the sleep environment. Many elderly individuals face difficulties such as getting in and out of bed, adjusting bedding, or moving around at night. Occupational therapists can suggest environmental modifications like installing grab bars, using night lights, or rearranging furniture to create a safer, more accessible sleep environment.

Furthermore, occupational therapy can help manage mental health issues that impede sleep. Many elderly individuals suffer from anxiety, depression or stress, all of which can significantly affect sleep. Occupational therapists can teach coping strategies, such as relaxation techniques or mindfulness practices, to manage these conditions. The subsequent reduction in mental stress can contribute to improved sleep quality.

Finally, occupational therapists can provide education to patients, family members and loved ones on sleep hygiene. They can offer guidance on various aspects such as limiting caffeine, creating a conducive sleep environment, and incorporating relaxing pre-bedtime activities. Education on sleep hygiene can empower the elderly to make informed decisions that positively impact their sleep health.

By focusing on the individual’s daily routines, physical health, environment, mental health and sleep hygiene, occupational therapists can make a significant difference in enhancing sleep quality among our seniors.

In closing, sleep and sleep routine matters to us and to those we serve daily. With that said, I am off to my evening routine of counting heads in bed here at the Kinder house. One downstairs, one upstairs, one missing… two at sleepovers, and two furry friends ready to call it a day!

Good rest to you all.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

We have three new codes to be used for reporting the total duration of face-to-face time spent by the physician or other qualified health professional providing individual or group training to caregivers of patients.

This proposed rule marks the first time the Centers for Medicare & Medicaid Services will allow therapists to bill and receive MPFS payment for services without the patient present.

How are the codes defined, you ask?

Caregiver training in strategies and techniques to facilitate the patient’s functional performance (CPT® codes 9X015, 9X016, and 9X017):

• CPT® codes 9X015 (Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes), and add-on code), 
• CPT® code 9X016 (each additional 15 minutes (List separately in addition to code for primary service) (Use 9X016 in conjunction with 9X015)), and 
• CPT® code 9X017 (Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers) 

Great, how did we get to this point? What is the history, background, and valuation of these codes?

As with all CPT® codes, it’s a process. 

We have our specialty societies in the American Speech-Language-Hearing Association, the American Occupational Therapy Association, and the American Physical Therapy Association to thank for their continued advocacy and excellence in ensuring this code set was appropriately defined.

These specific services are reasonable and necessary when treating practitioners identify a need to involve and train caregivers to assist the patient in carrying out a treatment plan.

The American Medical Association (AMA) CPT® Editorial Panel first approved the codes during its October 2022 meeting followed by recommendations for valuation by American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC). 

The RUC is an expert panel of physicians which makes recommendations to the federal government on the resources required to provide medical services. 

When making recommendations to the federal government, the RUC considers work (including the time and intensity associated with a service), clinical staff time, supplies and equipment, and professional liability insurance associated with performing a service. 

CMS, in the case of these codes, has proposed to accept all RUC recommended values. 

Additionally, the proposed rule notes that three specialty societies sent surveys to a random sample of a subset of their members. The RUC recommended work values based on the survey median values and the key reference CPT® codes 97535 and 97130.

Based upon survey results and after discussion, the RUC recommended a work RVU 1.00 for CPT® code 9X015, a work RVU of 0.54 for 9X016, and a work RVU of 0.23 per specific patient represented. 

The RUC noted that the recommendation for 9X017 is based on a median group size of five caregivers. 

Fantastic, now what are some of the key rules we need to know about these codes? 

While the patient does not attend the training, the goals and outcomes of the sessions focus on interventions aimed at improving the patient’s ability to successfully perform activities of daily living. 

Activities of daily living generally include ambulating, feeding, dressing, personal hygiene, continence, and toileting. 

What are some of the skilled interventions provided during these trainings? 

As with all skilled therapy services, care begins with a comprehensive evaluation.

Therefore, these codes are to be used responsibly as part of an individualized plan of care with the caregiver trained in skills to assist the patient in completing daily life activities. 

These trainings to the caregiver include the development of skills such as safe activity completion, problem solving, environmental adaptation, training in use of equipment or assistive devices, or interventions focusing on motor, process, and communication skills.

During the face-to-face service time, caregivers are taught by the treating practitioner how to facilitate the patient’s activities of daily living, transfers, mobility, communication and problem-solving to reduce the negative impacts of the patient’s diagnosis on the patient’s daily life and assist the patient in carrying out a treatment plan. 

In closing, in preparation for CY 2024 the time to review these rules is now. 

Take time to share with your teams, consider how you can integrate into clinical practice and let’s show our highest level of skill in aligning and training caregivers in the coming year and beyond. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.