Date: February 17, 2011
Presenter: Karen Vance – BKD, LLP
The 2011 Home Health Prospective Payment System rule provided clarifications and new requirements for coverage of rehabilitation therapy services. Documentation standards reinforcing functional goals, objective measures and professional standards are clarified in this rule. New reassessment timelines are outlined, as well as requirements for what the reassessments must entail and include in the documentation of the assessment. This webinar reviews the new standards and applies them to examples informed by the professional standards of these rehabilitation disciplines.
Is it possible to clarify the following questions in regard to the therapy reassessemnt schedule?
1. Does 13th visit have to be performed on 13th visit only, or can it be performed on 11th or 12th visit if only one therapy discipline is involved?
2. If Resumption of care is performed on 12th visit, following short hospital stay, can that reassessment count as a 13th visit reassessment?
3. If pt is seen 2x week and 30 day reassessmentis perfomred, does a 13th & 19 visit reassessment have to be performed as well?
The rule states, “If a patient’s course of therapy treatment reaches 13 therapy visits … a qualified therapist (instead of an assistant) must provide the ordered 13th therapy service and functionally reassess…” The only exception written into the rule for single disciplines is for rural areas and for ‘extenuating circumstances’. In your example I would assume that means the assessment must be performed on the 13th visit.
The requirement for the reassessment on the 13th and 19th visits is to provide proof of continued need for skilled therapy services beyond the threshold for a higher payment. And, regardless of what day in the episode these visit numbers fall, a reassessment must be completed, “at least every 30 days”. So in your example, if the 13th visit occurs after the 30 day window, you will be reassessing the patient again on the 13th visit. Remember that the 30 day period resets no matter why a reassessment is done, so when the reassessment is repeated on the 13th visit in your example, the 30 day period resets.
If you have a Home Health patient that started before the 4-1-11 start date.. Do they need to be included in the changes on there recert date.. Or is it only the patients starting after 4/1/11
Regardless of the actual admission, or SOC date for the patient, any episode or recertification that occurs after 4/1 is when the new rules apply.
Is it possible to clarify a question regarding the therapy reassessments?
Are the therapy reassessment guidelines applicable to Medicare Advantage Plans as well as traditional Medicare plans?
The PPS Rules are only applicable to traditional PPS Medicare. However, it does not preclude other carriers from adopting the standards, but they would have to notify you of their intent to do so.
Ok I am very confused. ok i have a therapy company who is discharging a patient before the 13th visit and they did a reeval on the 8th visit. From my understanding of this new rule no reeval needs to be done if they do not reach that 13th visit. Am I correct on this or did they do right by doing the reeval on the 8th visit. Please Help.
First of all, the reassessment is to be done on the 13th visit, if the plan is to continue services beyond that point. If there are multiple disciplines, then the reassessment is to be done ‘as close as possible to but prior to the 14th visit.’ The 8th visit is not close enough. If there was no plan to go beyond that 8th visit, then the only assessment needed is the discharge assessment.
Can you please clarify this for me if we are only doing physical therapy and the 30 day re evaluation not only falls on the 12 visit and on a Friday and then come monday is the 13 visit do I have to send out the PT for another Re Evaluation?
This one is a little tricky. Technically, the 30 day reassessment must be done BY the 30th day, and if it is a single discipline, the reassessment prior to the 14th visit should be ON the 13th visit. However, we have been given SOME wiggle room with the 11-13 visit range under the ill-defined category of “extenuating circumstances” in a single discipline case. Still this early in the game, I know even CMS is still trying to work out such details.
For a single-therapy case, the therapist must do the reassessment visit exactly on the 13th and 19th visits, unless the rural or documented circumstances outside the control of the therapist exceptions apply as stated in 42 CFR § 409.44(c)(2)(i)(C). If neither exception applies, the PT would need to do the reassessment on the 13th visit as required by the regulations.
Question: A patient was seen 7x by the PT and then patient went to the hospital (say 8/22). During hospitalization, the 30th day reassessment was due (8/28). Patient came back and a resumption of care was done (by Nurse) on 8/28. PT went back to see the patient for an IE on 8/30 (eval and discharge-no further visits planned)…does PT need to do the 30th day reassessment if not continuing?
Thanks so much!!
A reassessment done for any reason resets the 30 Day Reassessment clock. If you did a reassessment following an inpatient stay, there is your reassessment.
If the patient is discharged from therapy on day 30, does that visit need to be a reassessment, regardless of the number of visits?
First of all, the purpose of reassessment requirement is to demonstrate the need for continued skilled therapy. If you are discharging, the point is moot. Secondly, a discharge visit would include an assessment to determine the need for discharge, so your assessment occurred anyway.
I am needing to know what the regulation on frequency ranges for home health therapy is and whet is that documented. I have been writing ranges of 1-3 x/wk x 4 weeks to maintain compliance with orders in case of missed treatments. I know that we can’t have range for duration, but where is it documented that frequency ranges are not allowed. In the cms guidelines there is allowance for ranges in skilled nursing visits. Please help ASAP! We are I’m the middle of an audit.
Please read the language from the Benefit Policy Manual, Chapter 7, on the topic of frequencies and ranges. The fact they use a SN example doesn’t mean it only applies to nursing and not to any other discipline:
30.2.2 – Specificity of Orders
The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.
EXAMPLE 1:
SN x 7/wk x 1 wk; 3/wk x 4 wk; 2/wk x 3 wk, (skilled nursing visits 7 times per week for 1 week; 3 times per week for 4 weeks; and 2 times per week for 3 weeks) for skilled observation and evaluation of the surgical site, for teaching sterile dressing changes and to perform sterile dressing changes. The sterile change consists of (detail of procedure).
Orders for care may indicate a specific range in the frequency of visits to ensure that the most appropriate level of services is provided during the 60-day episode to home health patients. When a range of visits is ordered, the upper limit of the range is considered the specific frequency.
In a 60 day cert period there will be a total of 43 therapy visits (PT, OT) I know that reassessments need to be done on 12th & 13th visits as well as 18th & 19th visits. When we reach the 20th visit, do we start with 1 again? If so, does the next 12th & 13th visits and the 18th & 19th visits also need reassessments? Or do we just stop counting @ 19 and do reassessments before the next 30 days?
Can the 13th visit reassessment be a brief paragraph on the progress note about the continued need for therapy or does it have to be more formal?
There is no required format as long as the elements listed in the final rule are satisfied. It must be objective and measurable and justify continued skilled therapy.
My advice: make it very obvious.
The 13th and 19th visit is counted per episode. It resets for every episode or certification period, not after the 20th visit. The reason for those visit counts is because the thresholds at the 14th and the 20th visits significantly increases the payment to Medicare. So anything after the 20th visit does not warrant additional justification to Medicare.
After the 19th visit reassessment, Medicare doesn’t expect to see another reassessment until 30 days after the date of the 19th visit reassessment. If the end of the episode happens before that next 30th day time frame, your recertification, or discharge eval would count for that next reassessment.
Let me know if this does not answer your question.
In a previous reply you state,”After the 19th visit reassessment, Medicare doesn’t expect to see another reassessment until 30 days after the date of the 19th visit reassessment. If the end of the episode happens before that next 30th day time frame, your recertification, or discharge eval would count for that next reassessment.”
The home health company I am working with is requiring a reassessment at the end/beginning of each 60 day certification….even if a PT reassessment was done a week or two before. This company states that no 30 day PT plans of care are allowed to “carry over” from cert to cert. If PT plans are allowed to carry over…can you find me written evidence of this example in the rules please?
The 30 day reassessment requirement is a separate issue from the plan of care developed for a certification period. Indeed, a plan of care for any discipline cannot carry over from one certification period to another, and an assessment is required to develop or revise a plan of care.
The new reassessment requirements simply state the expectation that a patient will be reassessed at a minimum of every 30 days. Even though a reassessment would be expected to revise a plan of care, the requirements for the 13/19 and/or 30 day reassessments are to demonstrate effectiveness of therapy and the continued need for skilled therapy, A complete, full evaluation is not required nor is there anything in the regulations requiring a particular format for those reassessments. As long as you are documenting objective, measurable progress, the requirements are met.
I am running into a lot of situations in the home care setting that are making my 30 day reassessments a few days late. Examples are: waiting for MD to authorize further visits as requested, pt in the hospital, and pt refusing tx for an entire week. Our billing department is putting everything on bill hold if the 30 say summary is not completed by the exact 30 days. If it is documented why the reassessment is late and the reassessment was completed prior to any further tx is this acceptable?
Example: Pt seen on 9/13 and this was the last MD authorized order. PT requested to continue with pt. Did not recieve the OK until 9/25 pm. Saw pt on 9/26 and performed reassessment on that date. My agency wants me to change the code and add my assessment in on 9/13 which is illegal per PT practice act. What does mediicare say about assessments being late if it is documented why?
What if the patient is admitted into the hospital 2 days after the PT Initial Evaluation and released from the hospital 2 days later and the PT does the post hospital does this restart the 13th and 19th visit count? 30 day clock? Or does the count pick up where it left off before the patient went into the hospital?
The visit count is not reset until the next episode. The 30 day count is reset with every assessment done by the qualified therapist.
A patient went into the hospital after 10 PT visits. Upon return home, a ROC was done by the nurse and the PT re-eval was done on visit #11, OT eval done on visit #12. Does visit #13 have to be a PT reassessment, or does the assessment done during the re-eval count since it is in the visit 9-13 window?
CMS has indicated in such instances, that the PT assessment would count as you have described.
The requirement is that the patient should receive a reassessment AT A MINIMUM every 30 days. It does not have to be ON the 30th day, just BY the 30th day. In your scenarios, I would have done the 30 day reassessment earlier to circumvent such very common occurrences. Remember that the reassessments completed to satisfy the 13th and 19th VISIT requirements resets the 30 DAY assessment clock.
BTW, it is illegal for you to change the dates of your assessments.
Should functional re-assessment be done on 11th or 12th or 13th visit or it must be only on 13th visit?
Likewise,about second time re-assessment;
Should functional re-assessment be done on 17th or 18th or 19th visit or it must be only on 19th visit?
When the patient resides in a rural area or when documented circumstances outside the control of the therapist prevent the qualified therapist’s visit at exactly the 13th visit, the qualified therapist’s visit can occur after the 10th therapy visit but no later than the 13th visit. Similarly, in rural areas or if documented exceptional circumstances exist, the qualified therapist’s visit can occur after the 16th therapy visit but no later than the 19th therapy visit.
Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the ordered therapy service and functionally reassess, measure, and document the effectiveness of therapy or lack thereof close to but no later than the 13th and 19th therapy visit. The 13th and 19th therapy visit timepoints relate to the sum total of therapy visits from all therapy disciplines. In multi-discipline therapy cases, the qualified therapist would reassess functional items and measure those which correspond to the therapist’s discipline and care plan goals.
When 2 disciplines are in can the Functional ReAssessments be done on the 10th and 11th visits respectively. Not rural. A missed visit snuck in and OT Functional ReAssessment what was supposed to be done on the 11th visit but was in actuality done on 10th visit.
Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the ordered therapy service and functionally reassess, measure, and document the effectiveness of therapy or lack thereof close to but no later than the 13th and 19th therapy visit. The 13th and 19th therapy visit timepoints relate to the sum total of therapy visits from all therapy disciplines. In multi-discipline therapy cases, the qualified therapist would reassess functional items and measure those which correspond to the therapist’s discipline and care plan goals.
Can you please clarify a Medicare Billing question. It is my understanding that the 11-13 and 17-19 reassessment for OT, PT, ST (which may total 6) are billable visits – correct? HHA in our area keep saying “We cannot bill for re-assessment visits”. Please clarify
Reassessment visits are billable visits. Remember that the skill from that patient’s plan of care will also be delivered during that visit by the reassessing qualifying therapist.
Does a 13th day reassessment still need to be done even if the patient will be discharged on the 14th visit? That seems a little redundant since there will be a discharge eval on the 14th anyway.
The regulations require a reassessment, “at a minimum of every 30 days”. It does not have to be ON the 30th day. In your scenario below, I would not wait until the last ordered visit to consider doing the assessment so a delayed order for continued visits would push you beyond the 30 days.
The purpose of the 13th visit reassessment is to justify hitting the 14 visit threshold at which point Medicare pays significantly more for the episode. So in this case, your 13th visit reassessment would be justifying the need for one more visit.
Question –
If PT and OT are both in on patient. Patient is due for 13th assessment. Question is – PT goes out on 11th visit and it ends up as DC therefore only leaves Ot in. How does OT handle their visit? Both of the following examples have happened and I would like to know if either or both are correct. 1st example – OT did the 12th visit on the same day as PT doing the 11th visit/DC and HHA counted it as the reassessment visit. 2nd example – OT waited and went out on 13th visit because HHA viewed it as OT being the only displicine in. Which is correct? and is there documentation to back this up. thanks for your help
Either scenario would comply with required regulation as it is written in the final rule.
If PT is the only discipline on the case, and PT Recertifies the pt, does the visits carry on to the new cert period? The pt had 15 visits and in the recert, do we continue counting the visits or does it reset? In the recert, would it start with the 16th, 17th, ect?
The reason for the reassessments is to justify a continued need for therapy into the high billing threshold tiers beginning with 14th & 20th visits. Since it is a billing issue, the visit count resets with the next billing period, in other words, the next certification period. So, in answer to your question (with explanatory notes), the visit count resets with a new cert period.
Could you differentiate between what is needed from the PT for the 30 day re-eval and the 13/19 day reassessments and the eval done for the Cert.
If 3 disciplines are seeing a pt and they need to do their reassessments for the 13#th visit, it might look like this for example, for OT #11, PT #12, and SLP on #13. Is that correct?
Also, if PT is seeing a pt for say 9 visits and OT just begins, sees a pt for 3 visits…..will OT have to do a re-eval because the pt is now at the 13th visit?
Since the reassessment visits required at the combined therapy total of 13 and 19, yes, in your scenario OT would be required to do a reassessment as near as possible to combined visit number 13.
The 2011 PPS Rule states what the reassessments should include. The timing of the reassessments do not differentiate the content, including the reassessment to determine whether or not to recertify. It is all meant to justify to CMS the continued need for skilled therapy.
The last scenario describing 3 disciplines in is correct.
Can you do a reassessment for 2 disciplines the same day? Ex. PT 12 visit & OT 13
or they have to be done different days?
The separate countable reassessment visits can occur on the same day.
A quick question:
Combined OT&PT visits account for more than 16 visits.
However, after a combined count of 13 visits, only PT will continue.
Does OT still need to reassess during his last visit (combined visit #12.) ??
Since the reason for the reassessment is to justify continued skilled need for that particular service, OT would not need to do a labeled “reassessment”. However, one would argue that the discharge visit is indeed an assessment to determine that the goals have been met and the plan of care need not continue.