Are you setting yourself up for success?

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Shelly Mesure, MS, OTR/L
Shelly Mesure, MS, OTR/L
Are you properly capturing set-up time? What on Earth am I talking about? I'm not referring to the time it takes to clean up the gym in the morning in preparation for a full day of treating patients. I'm talking about utilizing the regulation as outlined in the Resident Assessment Instrument, version MDS 3.0.

The RAI manual states, “the time required to adjust equipment or otherwise prepare for individualized (or group) therapy of a particular resident(s) is the set-up time and may be included.”

Unfortunately, the RAI manual does not provide any further examples or clarifications as to what exactly regulators are talking about, so this allows us to interpret their meaning and determine how best to apply this regulation.

A basic rule of billable time is that the patient must be present and within line-of-sight. I feel we are good about billing for treatment time when we go to a patient's room; transfer him or her from bed-to-wheelchair, perform upper body or lower body dressing, possibly some grooming tasks, sometimes toileting tasks, etc.

Most therapists will agree that is billable time. These tasks must relate back to the plan of care for each resident, however. If the resident has active goals in these areas, it is definitely billable time.

When I ask a therapist if he or she considers the transportation time as billable time, I get mixed results. The typical answer of yes is when we have the patient self-propelling a wheelchair, possibly ambulating to the therapy gym, etc. Some type of physical activity is usually agreed as billable time. So then I ask the question, “Do you consider transportation to the gym as set-up time?” Again, I get mixed answers. So, lastly, I ask, “Do you ever talk to your patients during this time?” The majority answer is always yes. So, then I ask, “What do you talk about?” This is where I'm asking the therapists to use their clinical judgment to decide if any patient/caregiver education has taken place. The majority of the time, the answer is yes.

So, let me create this scenario: You (the therapist or assistant) go to get your patient in the morning. The patient is ready and sitting in their wheelchair. You begin pushing him or her down to the therapy gym to begin treatment for the day. You ask the following questions:

1. How do you feel today?

2. Are you having any pain right now?

3. Have you taken your medications yet?

4. How did you sleep last night?

5. Here's what we're going to do in therapy today …

Okay, so No. 5 is not really a question, but that is a very typical conversation between a therapist/assistant and a patient on a daily basis. It counts as set-up time, and is, therefore, billable time. As the treating clinician, you need to know this information so you can modify or change the planned treatment activities according to the resident's answers. If the patient is feeling great, then I might increase the challenges of today's treatment, and vice versa.

If youre conversation on the way to the therapy gym had absolutely nothing related to medical status or treatment goals, then it does not qualify as patient/caregiver education and I would not recommend including this as billable time. If you discussed the latest movie you saw or your upcoming wedding, this is great for developing a strong patient rapport, but it would not qualify as relating to the patient's plan of care.

Hopefully, I've given you some food for thought. Use this definition from the RAI manual to the full extent, and on days when you really needed those extra minutes, make sure you haven't under billed for anything.

Shelly Mesure ("Measure"), MS, OTR/L, is the president and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.


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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.