PPS: why you still need certified activity professionals - Medicare Prospective Payment Systems

Nursing Homes, Nov-Dec, 1998 by Catherine S. Selman, Karen B. Land

Some SNFs are replacing them - and may come to regret it

Skilled nursing facilities (SNFs) that replace Certified Activity Professionals with other certified professionals could be making a costly mistake.

With the implementation of the Medicare Prospective Payment System (PPS), many states are currently utilizing the Resource Utilization Group (RUGs-III) classification system for reimbursement - a system that relies heavily on the Minimum Data Set (MDS) to determine the rate of reimbursement received for a particular resident. The "PPS version" of the MDS includes additional sections that many states have not used until now. One of the sections causing much confusion is "Section T-Therapy Supplement for Medicare PPS."

With utilization of the revised MDS, an unfortunate turn of events has occurred concerning activity professionals and their employers. For reasons that remain unclear, under MDS Section T, recreation therapy is the first therapy listed under "Special Treatments and Procedures," leading many skilled nursing facility owners and operators to seek maximum reimbursement by terminating their activity professionals and hiring Certified Therapeutic Recreation Specialists (CTRSs). There are two flaws in this strategy.

First, unlike recreation therapy, activities are mandated by federal regulation through the Omnibus Budget Reconciliation Act (OBRA) of 1987. Activity programming is included and reimbursed in the resident's PPS per diem, but calculated differently from physical, occupational or speech therapy. In fact, in the long-term care continuum, there are a variety of professionals with a wide range of educational and experiential backgrounds who provide recreation and activity services. The federal regulations for nursing facilities participating in the Medicaid/Medicare programs define, in F-tag 249, the qualification standards for the professional who directs or supervises the activities program. Being a Certified Activity Professional or being a Certified Therapeutic Recreation Specialist is only one of five recognized criteria.

Second, facility populations, specific care settings and individual resident needs should determine which professional is needed for the position. Recreation therapy, by nature, can be more rehab-based, utilizing an active, individualized treatment plan to help the resident with the pursuit of leisure interests after discharge from the facility or unit. In most cases, the setting would be a true rehabilitation, short-stay or post-acute care facility, not a long-term care facility. However, activity services also employ an active care plan based on resident assessment, are therapeutic in nature and provide for quality of life for long-term nursing facility residents. The goal is to enable the residents to continue their previous lifestyles, enjoying the same activities and leisure pursuits as they did at home. In sum, both recreation therapy and activity services are goal-oriented and resident outcome-based.

In defining these terms, it is important to recognize that recreation therapy is truly a "therapy." Health Care Financing Administration (HCFA) guidelines define recreation therapy as "therapy ordered by a physician that provides therapeutic stimulation beyond the general activity program (emphasis added) in a facility. Recreation therapy can only be provided directly by a CTRS, or a CTRA under the supervision of a CTRS. The physician's order must include a statement of frequency, duration and scope of the treatment." The HCFA regulatory guidelines define activity potential as "the resident's ability and desire to take part in activities which maintain or improve physical, mental, and psychosocial well-being. Activity pursuits refer to any activity outside of activities of daily living (ADLs) which a person pursues in order to obtain a sense of well-being. Also includes activities which provide benefits in self-esteem, pleasure, comfort, health education, creativity, success, and financial or emotional independence."

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognizes activity services as being "designed to enable the client/resident to continue to enjoy the experience of life at his or her highest practicable level. Activity services include physical, spiritual, social, intellectual, creative, community and leisure activities and pursuits. Activity services are designed to be therapeutic in outcome."[1]

However, some facilities are attempting to capture reimbursement by submitting "routine therapeutic activities" as "therapy." Facilities involved in this practice could very well face audits. The General Accounting Office (GAO) stated in a recent report that "since a SNF is paid a fixed per diem rate for most services, it would be fraudulent to bill separately for services included in the SNF per diem."[2]

When asked why a nonreimbursable therapy item, i.e., recreation therapy, was included on the newly revised PPS MDS, HCFA responded that the agency was "collecting statistical data." Some well-established and valid therapy groups are wondering why HCFA is utilizing a federally mandated document, and individual provider staff resources and funds, to collect data regarding one particular therapy. It would make sense to collect data on all therapies that might benefit the resident. After all, shouldn't a resident be given every viable option available for rehabilitation and quality of life?