Group and concurrent therapy under PDPM: what counts and what it costs you
The limit is 25% per resident, per discipline, across the stay, and your employer's counting method decides what it does to your number.
Group and concurrent therapy under PDPM may together make up no more than 25% of a resident's therapy minutes in each discipline. PDPM is the US Medicare payment model for skilled nursing facility (SNF) stays under Part A. Treating more than one resident at a time also changes your productivity number, and how much depends on how your employer credits the minutes.
Everything below is a US Medicare rule. Outside the US, your employer and your national payer set the rules for treating more than one person at a time.
The definitions under US Medicare Part A
Individual therapy is one therapist or assistant treating one resident.
Concurrent therapy is the treatment of 2 residents at the same time who are not doing the same or similar activities. Both residents must be in the line of sight of the treating therapist or assistant. The rule applies regardless of who pays for each resident.
Group therapy is the treatment of 2 to 6 residents who are doing the same or similar activities. The therapist or assistant running the group must not be supervising anyone else at the time.
Under Part A, what the residents are doing decides the mode. Two residents doing different tasks is concurrent. Two residents doing the same task is a group.
Part B is different
Under US Medicare Part B, treating 2 or more people at the same time is group therapy. The activity they are doing makes no difference. Part B has no concurrent category.
The group therapy 25% limit
For each resident, group minutes plus concurrent minutes, called mode minutes here, may not exceed 25% of that resident's total therapy minutes in each discipline. The limit is per resident and per discipline. It is not a limit on a therapist or a department. A therapist can run groups for much of the day without breaching it, as long as no single resident goes over 25% in that discipline.
The limit is measured over the whole SNF Part A stay. It is reported in item O0425 on the PPS Discharge assessment of the MDS. An interrupted stay counts as one stay.
Going over 25% is treated as non-compliance. The facility receives a non-fatal warning message on the MDS Final Validation Report. There is currently no payment penalty attached to the limit.
A worked example of the 25% check
Example: a resident has 300 individual minutes, 60 group minutes and 40 concurrent minutes of physical therapy so far in the stay.
- Mode minutes (group plus concurrent): 60 + 40 = 100 minutes
- Total therapy minutes: 300 + 100 = 400 minutes
- Mode %: 100 ÷ 400 = 25.0%, exactly at the limit
One more 30-minute group session takes the resident to 130 ÷ 430 = 30.2%. The Concurrent and Group Therapy Calculator runs this check for one resident and shows the headroom left.
A resident on a short, low-intensity plan reaches 25% fastest, because each group session is a larger share of a small total. A resident with 100 individual minutes reaches the limit after about 33 mode minutes (100 ÷ 3 = 33.3). A department that only checks totals for each therapist will not see this.
How the minutes are recorded
Each resident's MDS records the full session minutes, coded by mode, with no splitting. Two residents in a 30-minute concurrent session each have 30 concurrent minutes recorded. Six residents in a 45-minute group each have 45 group minutes recorded.
How to calculate therapy productivity in a SNF with group sessions
How your employer credits those minutes to your own productivity is a separate question, and employers answer it differently. Some count the session time once. Some count resident-minutes, the session time multiplied by the number of residents. Some apply a discount between the two.
Example: a paid day of 480 minutes, with 300 minutes of individual treatment and one 45-minute group of six residents.
| Counting method | Credited minutes | Productivity |
|---|---|---|
| Session time counted once | 300 + 45 = 345 | 345 ÷ 480 = 71.9% |
| Resident-minutes | 300 + (45 × 6) = 570 | 570 ÷ 480 = 118.8% |
The same day scores 71.9% under one method and 118.8% under the other. Where resident-minutes are used, group treatment raises the number far more than individual treatment does. That creates pressure toward groups that has nothing to do with the residents' needs.
Ask your employer which method it uses before you compare your number with anyone else's. The Concurrent and Group Therapy Calculator compares the methods side by side, and the guide to calculating group and concurrent minutes works through more examples.
The documentation cost
A group or concurrent session does not cut documentation in proportion. Every resident still needs a note that justifies skilled care for that resident. The note also records the mode and explains why the mode was clinically right for them.
A six-person group is one session and six notes. Your employer may credit the session generously while you write the six notes after hours. Then part of the productivity gain is paid for with your own time. The documentation time calculator shows what those notes add up to over a week.
Documentation that holds up
A note for a group or concurrent session does everything an individual note does, plus two more things. It names the mode, and it justifies the mode for that resident on that day.
"Group therapy" on its own does not explain why group was the right mode. A stronger note names the clinical reason and ties it to the resident's goal. Examples are peer modeling for a resident reluctant to mobilize, functional practice in a social setting, or graded challenge under supervision.
Write the reasoning for each resident in each note. A run of notes with identical justification text, on the same days the department was short-staffed, reads as a staffing decision.
SNF therapy billing has been examined before. In 2010, before PDPM, the US Department of Health and Human Services Office of Inspector General published a report on it. It found that SNF payments for ultra high therapy rose by nearly 90% from 2006 to 2008.
The clinical judgment
Both modes have clinical uses. Group work can give peer motivation, social contact and functional practice that an individual session cannot. Concurrent treatment suits residents working on independent tasks who need intermittent supervision.
Neither mode is a fix for a staffing gap. "The department was short" is not a clinical reason, and the notes go out under your name. If you are directed toward group treatment for reasons that are not clinical, raise it in writing with your manager. The guide to the supervision conversation covers how to have that discussion.
The scheduling effect
A group changes how the day is built. The residents have to be gathered, which means transport, seating, equipment and coordination with nursing. That setup time is not treatment time, and on some days it takes as long as the session.
As an example, a clinician who starts running groups may see productivity dip at first, while the setup routine settles. If your department is introducing groups, say so in advance, so that the dip is not read as a performance problem.
Practical points
- Record the mode at the time of the session, not later.
- Check that your facility tracks the 25% limit for each resident, in each discipline, across the stay.
- Ask how group minutes and concurrent minutes count toward your productivity figure.
- Give the clinical reason for the mode in every note, not only the first.
This is general information about how these US modes are defined and commonly handled. It is not billing, coding, legal or compliance advice. Your facility's compliance team, your payer's rules and the current CMS guidance decide, and the detail changes.