New Nursing Home Rules Take Effect Speech-language pathologists treating Medicare Part A patients in skilled nursing facilities (SNFs) must adhere to new rules on supervision of students and size of treatment groups, effective Oct. 1. Medicare regulations that remove supervision restrictions for speech-language pathology students in SNFs (see The ASHA Leader, Sept. 20, 2011) are ... Policy Analysis
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Policy Analysis  |   October 01, 2011
New Nursing Home Rules Take Effect
Author Notes
  • Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org.
    Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org.×
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Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   October 01, 2011
New Nursing Home Rules Take Effect
The ASHA Leader, October 2011, Vol. 16, 1-4. doi:10.1044/leader.PA1.16122011.1
The ASHA Leader, October 2011, Vol. 16, 1-4. doi:10.1044/leader.PA1.16122011.1
Speech-language pathologists treating Medicare Part A patients in skilled nursing facilities (SNFs) must adhere to new rules on supervision of students and size of treatment groups, effective Oct. 1.
Student Supervision
Medicare regulations that remove supervision restrictions for speech-language pathology students in SNFs (see The ASHA Leader, Sept. 20, 2011) are more restrictive than described in the proposed regulations, according to guidance released recently by the Centers for Medicare and Medicaid Services (CMS).
The regulations state “each SNF would determine for itself the appropriate manner of supervision of therapy students consistent with applicable state and local laws and practice standards.”
However, in guidance on adherence to the new regulations, CMS clarified that the supervising clinician could not treat another resident or supervise another student while the student was treating a resident (Centers for Medicare and Medicaid [PDF]; slides 18–28, 33–34).
CMS then notes that ASHA (and the American Physical Therapy Association and American Occupational Therapy Association) provides recommended guidelines for student supervision, and provides links to the guidelines.
CMS restrictions on billing students’ services are based on two principles: for billing purposes, the student is considered an extension of the clinician, and only one billable service can be provided at one time by the student/supervisor. Billing guidance includes the following:
  • Code as individual therapy when the SLP or student is treating one resident, while the other is not treating/supervising any other residents/students.

  • Code as concurrent therapy (i.e., patients are performing different activities) if the SLP is treating two residents while the student is not treating any residents or if the student is treating two residents while the SLP is not treating any residents.

  • Code as group therapy (i.e., patients are performing similar activities) if the full group is conducted by either the supervising SLP or the student; the other may not be supervising any other students or treating residents.

These regulations apply only to Part A residents in SNFs; more restrictive student rules for Part B services (i.e., 100% supervision in the room) in SNFs and other settings remain unchanged.
Group Treatment
In its May proposal, CMS required that group size be four participants for Part A group treatment in SNFs (see The ASHA Leader, July 5, 2011). Under the proposal, the session length would be divided by four (regardless of how many patients actually participated in the group) for billing purposes. The final regulations were not clear on the requirement that every billable group session must be planned for four residents (see The ASHA Leader, Sept. 20, 2011). However, official guidance issued in August (Centers for Medicare and Medicaid [PDF]; slides 9–17, 24–26, 29–30) stipulates that:
  • Group participants must total four regardless of the patient’s payer source (e.g., Medicare, Medicaid, private health plan).

  • A group therapy session is not recognized unless it was planned for four patients (i.e., four patients are scheduled and group treatment is included as a service type in each patient’s plan of care).

  • If one or more of the four planned patients cannot attend (for any of various reasons), the number of minutes allocated to each individual patient must still be one-fourth of the total session time.

  • The rationale for the group treatment regimen must be included in the plan of care.

  • The longstanding group treatment limit of 25% weekly per discipline for each patient is unchanged and the number of allocated minutes (divided by four) is the basis for determining the patient’s group minutes.

These rules do not apply to Part B patients, although the rationale for group treatment is expected to be included in the plan of care in any setting. The 25% rule is included by some Medicare Administrative Contractors in their Part B local coverage determinations.
ASHA Student Supervision Recommendations

ASHA submitted the following guidance on supervision of students to CMS. The guidelines are not included in the regulation, but are referenced in implementation guidelines.

  • Graduate students who have been approved by the supervising speech-language pathologist to practice independently in selected patient situations can perform the selected clinical services without line-of-sight supervision by the supervising speech-language pathologist. The supervising speech- language pathologist must be physically present in the facility and immediately available to provide observation, guidance, and feedback as needed when the student is providing services.

  • The amount of supervision must be appropriate to the graduate student’s documented level of knowledge, experience, and competence.

  • When the supervising speech-language pathologist has cleared the graduate student to perform medically necessary patient services and the student provides the appropriate level of services, the services will be counted as skilled therapy minutes.

  • The supervising speech-language pathologist is required to review and co-sign all graduate students’ patient documentation for all levels of clinical experience and retains full responsibility for the care of the patient.

  • Supervising speech-language pathologists are required to have one year of practice experience.

  • Graduate students who have not been approved by the supervising speech-language pathologist to practice independently require line-of-sight supervision by the qualified speech-language pathologist during all services. In addition, the supervising speech-language pathologist will have direct contact with the patient during each visit. The graduate student services will be counted as skilled therapy minutes.

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October 2011
Volume 16, Issue 12