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Medicare Home Health Changes: Therapy Standards & Reassessment Rules

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.

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77 Responses to “Medicare Home Health Changes: Therapy Standards & Reassessment Rules”

  1. avatar JJ says:

    What haapens if the initial plan for PT was 1x/wk x 1wk, 2x/wk x 4wks (totalling to 9 PT visits in 30 days). After 3wks patient was hospitalized for CVA and was discharged from the hospital with new orders for PT, OT and ST evaluation and treatment. Part of my question is, are the PT eval, OT eval and ST eval counted as continuation of the previously planned and completed 9 visits? If yes, what happens to the reuired 13th, 19th re-evaluation? For example: If PT evaluated the patient first, then the OT then the ST after the hospitalization, is that counted as the 10th, 11th, 12th visits respectively? Then another re-assessment should be done from all PT, OT and ST to satisy the “prior to the 14th visit” re-assessment? Thank you in advance.

  2. avatar Karen Vance says:

    The return to HH from the hospitalization continues the count as you described. The reevaluations most likely would satisfy the language of “close to” but prior to the 14th visit. If you really wanted to rest assured, PT could do another reassessment on the 13th visit. Remember, it doesn’t have to be a full evaluation of the patient. The intent is to evaluate the effectiveness of the intervention provided in the plan of care in functional, objective, measurable terms.

  3. avatar jj says:

    Hi Karen,

    I thank you for the reply. I wrote another question but I think it got deleted. Anyway, my question is based on your previous webinar last Feb or March of 2011. This was regarding the 30 day re-assessment for PT, OT or ST. I think you mentioned that if for example you have PT for 2x/wk x 6wks (totaling 12 PT visits) completed in 45 days. You still need to complete the 30 day re-assessment. Isn’t it that the 30 day re-assessment clock resets after each each therapist’s visit/assessment/measurement/documentation?

    I also had a question regarding the term “close to”. How do you interpret that? Because like my previous question, if you have PT, OT and ST complete visits 10, 11, 12 respectively. Should all three discipline complete another visit to satisfy the prior to 14th visit requirement? Thank you again.

  4. avatar Karen Vance says:

    The only thing that resets the VISIT count is a new episode and a new visit frequency. Any reassessment done for any reason resets the 30 DAY count. If the reassessment was not completed prior to the 14th combined therapy visit total, then indeed all therapy visits until the reassessment visits are completed do not count. The count picks up at 13 when the reassessment visits are completed by all therapy disciplines that are currently on the plan of care and continue until the next reassessment requirement.

  5. avatar Karen Vance says:

    We apologize if we did not respond to a previous question.

    Indeed, in your example, 12 visits completed in a 45 day window would require a reassessment prior to day 30. The 30 day requirement resets with any reassessment completed for any reason.

    “Close to” is difficult to interpret, leaving some flexibility. In your example, all 3 would not need to complete a whole new assessment “closer”, but prior to the 14th visit. Whichever discipline did their reassessment on visit 10 might want to do another reassessment on visit 13, unless it was within just a couple of days. Remember too, this does not need to be a full blown re-evaluation using a full evaluation tool, it is intended to review the effectiveness of the intervention and to determine if there should be a change in the plan of care.

  6. avatar Deena Stevenson OT says:

    Hi Karen!

    I am currently on a committee at VNA working on some standardized tools to use for documention related to the eval/13th/19th re-assessments. Are you familiar with THE BARTHEL INDEX and have other OTs used that tool to support current levels of progress? I have been using it for a trial period and have found it a quick and easy way of showing progress. I would appreciate any feedback you have related to this tool. I know it has been around for years but cant find out if it is considered a standarized tool and exceptable by Medicare standards.

  7. avatar Karen Vance says:

    Hi Deena,

    The Barthel Index would certainly be acceptable for the Medicare requirements showing an objective measure of progress within the parameters it does measure. Medicare did not require standardized tools. If you mean to use a standardized tool for your own purposes, I don’t know if the Barthel Index is standardized for the home health setting. Investigating with the original validation literature for the tool would answer that. If it is not standardized for the home health setting, adapting it would render it un-standardized. But it does not preclude you from still using it as an objective measurement. Medicare simply wants functional progress measured in an objective manner.

  8. avatar peggy says:

    if patient is hospitalized and misses 30 day pt eval, do we have to discharge and re-admit?

  9. avatar Karen Vance says:

    No discharge and readmit is necessary. Assure adequate documentation within therapy assessments/notes of hospitalization dates.

  10. avatar Sheila says:

    How does an episode of home health effect, if at all, the patient also receiving services from a private therapy provider? Say, if the order from the physician is dated during a home health episode? If the private OT assesses and treats 3 visits total under Medicare B, do those visits interfere with the HH plan of care, reimbursement? I want to know if HH agency and the private rehab provider will be stepping on each other’s toes in any way.

    Also, do the therapy visits HH provides contribute to a cap in Medicare B services? Do the caps apply only to MCB services provided in nursing homes?

  11. avatar Rochelle W. says:

    hi Ms. Karen

    what if the last visit for the certification lands on the 19th visit and the therapist is planning to continue on the next cert (our policy doesn’t carry over frequency from the previous cert). does he have to do a re-eval for that 19th visit and again on the new cert. meaning there will be a back to back re-eval.

  12. avatar Karen Vance says:

    The reason for the reassessment visits on the 13th and 19th visits are to justify going beyond to the 14th and 20th visits (the next payment thresholds). So if visit #19 is the last visit in the certification period, there will be no 20th, correct? Therefore, no justification and no reassessment for THAT purpose. If you were going to discharge and not recertify, it would be the end of the story.

    HOWEVER, as you say it is your agency policy to not carry over the frequency, it is because Medicare does not allow frequencies to be carried over to new certification periods (episodes). As a matter of fact, Medicare expects an assessment at the end of an episode to determine whether or not recertifying for a new episode is necessary. That is why a recertification assessment with OASIS data collection is required by the agency within the last 5 days of any episode. It determines continued skilled need and the plan of care for the subsequent episode. But if you are not the skilled service completing the ‘Recert OASIS’, it is still necessary for all disciplines to assess for the need for their own continued skill services which is also when the plan of care (frequency/duration) is developed for the next certification period or episode.

    SO, in your example, a reassessment visit would be done on that mentioned visit, not because it is the 19th, but because it is the last visit prior to an intended recertification.

    NOW, realize that Medicare does not require that the recertification assessment by any discipline to be on the last visit, just prior to the end of the certification period to determine continued skilled need for that discipline.

    THEREFORE, in another scenario, let’s say a week prior to the end of the episode, it is the 30th day since the last therapy reassessment. Medicare wants a therapy reassessment at a minimum of 30 days. The required 30th DAY minimum reassessment that close to the end of the episode would also suffice for the recertification assessment.

    Good luck and happy counting,

  13. avatar Shari Pryor says:

    When you say the only thing that restarts the count is a new episode, does that mean a recertication episode or if we had discharged a patient and then did a new start of care? Our understanding was we do not restart the count upon a recertification.

  14. avatar Karen Vance says:

    The 30 DAY count resets with every reassessment done, regardless of when or what purpose.

    The 13 and 19 VISIT counts reset with every new billing period or certification, whether it is a new SOC or a recertification. Remember the reason for these reassessments are to justify moving to the higher therapy threshold for which Medicare will be paying a higher amount.

  15. avatar Carrie Crowley says:

    What happens when an FA cannot be done in a 30 day period? Our OTs often find themselves waiting in our rural area on DME companies and insurances to procure equipment and bracing, etc. If the OT only has one goal left having to do with a splint or tub bench but the tar is the hold up from an insurance perspective or DME provider, the OTs have a difficult time justifying a f/u visit when all f/u work is by telephone calls until the device comes in. All other goals have been met. If the documentation supports it after 30 days (OT services were on hold until equipment was procured) can we then bill for the next visit that is made if the FA is completed at the same time?

  16. avatar Karen Vance says:

    I understand that it appears that a follow up visit may not be appropriate until a delayed piece of equipment arrives. But Medicare would be concerned if an OT visit had not been made in entire 30 days. Even though the only remaining goal depends on a piece of equipment, a visit to evaluate the patient for current status and whether they have sustained the other goals achieved is very appropriate. CMS mandates a functional reassessment at a minimum of every 30 days, this is reasonable to demonstrate to CMS why you have not seen the patient for 30 days, but haven’t discharged.

  17. avatar Julie says:

    After reading one of the previous questions and answers I need some clarification. After a hospitalization, the home health agencies our company contracts with perform a resumption of care OASIS. Our policy has always been to discharge the patient and then do resumption of care evaluation. This ensures that the P.T. sees the patient after hospitalization prior to the PTA continuing care. The visit count continues as if there were no hospitalization. It sounds as if this evaluation by the P.T.after the hospitalization is not necessary? But perhaps a good idea to keep doing anyway?

  18. avatar Karen Vance says:

    There is no need to discharge a patient when hospitalized. A Resumption of Care is done when not discharged, a total readmit if discharged by the agency. If therapy is in with nursing, an agency Resumption of Care is completed, but a reassessment by all disciplines is expected due to the patient’s change in condition. If an assistant visit is made prior to the reassessment because you don’t know until after the fact the patient is returned from the hospital, no regulation has been breached. The reassessment should be done as soon as possible after the return from the hospital is known. If therapy is the only discipline in, the Resumption of Care OASIS, of course, must be done within 48 hours of the return, or as soon as possible upon knowledge of the return.

    The 13 and 19 visit count is not interrupted throughout the 60 day billing episode since it is a billing issue.

  19. avatar Monica Uran says:

    I’m a bit confused in regards to the 30 day reassessment with a Resumption of care being involved.. I have a case where they went into the hospital right after the OT eval was done, came back 2 weeks later so Day # 14 the OT Eval was done and Day 15 the PT eval was done, by the end of the frequency we would only have 12 therapy visits total so not enough for the 13th reassessment to be done, however total days after inital OT evaluation is 32 days. DO I STILL NEED A 30 DAY REASSESSMENT EVEN THOUGH I HAD PT AND OT EVALUATION ON DAY 14 AND 15 FOR THE RESUMPTION OF CARE?

  20. avatar anjanette says:

    A patient is seen by a physical therapist on the last week the patient got sick and the therapy ias on hold can the therapist extend ?

  21. avatar Karen Vance says:

    The 30 DAY count is not from the beginning of the episode, it resets with every evaluation done, no matter when. So for OT, the 30 day count begins with the evaluations done after resumption of care.

  22. avatar Karen Vance says:

    The reassessment requirements from the PPS Rule Updates do not preclude a therapist from extending the plan of care. As always, as long as the patient continues to qualify for continued skilled services, the plan of care may continue.

  23. Thank you, I have recently been seeking for facts about this subject for ages and yours is the best I have found so far.

  24. avatar Afreen says:

    Do 30 day reassessments, 13th visit and 19th visit reassessments
    need physician signature?

  25. avatar Karen Vance says:

    Physician signatures are only needed when the assessment/evaluation do not also serve as a change in the plan of care.

  26. avatar J Barney says:

    I am in Ohio and work for multiple home health agencies. I have been given different instructions on when an additional MD order needs to be written if there is a delay in the therapy evaluation. My question is regulation wise…..if the therapy evaluation occurs after 5 days, 72 hours, or 48 hours after the SOC or therapy order is originally written, which is it that an order needs to be done explaining why there was a delay? Most of the time it is due to patient request due to other appointments. Also, can you direct me to the CMS or HH guidelines that specifically states this? I have tried to work my way through those manuals and cannot find the clear cut answer.

  27. avatar Karen Vance says:

    This would be under §484.18 of the Conditions of Participation describing regulations for the Plan of Care. Below is the Standard that addresses your issue:

    “§484.18(b) – Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care.”

    From the State Operations Manual (guidance for state surveyors) “The expected outcome for this high-priority standard is that changes in patient status, including measurements outside of stated parameters, or any changes that suggest a need to alter the plan of care, are reported promptly to the physician. This includes notifying the physician of discharge when the patient’s needs have been met. Changes in the patient’s condition that require a change in the plan of care should be documented in the patient’s clinical record.”

    If you developed a plan of care stating an effective date, and the physician signed it, any changes to it warrants ‘reporting it to the physician’. Some agencies take a literal approach that reporting a ‘change in the plan of care’ warrants a new order. Others might argue that if a patient refuses a visit, it is not necessarily ‘changing the plan’, but rather responding to the desires of the patient. This should certainly be documented in the patient’s record, the reason for the delayed start of your plan of care, and could be handled by communicating the delay to the physician by way of a call, fax or communication note. Agencies have different policies in place to meet this regulation which, as a condition of your employment arrangement (employee, contractor, etc.) you are obligated to follow.

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Recent Comment

  • Karen Vance says:
    This would be under §484.18 of the Conditions of Participation describing regulations for the Plan of Care. Below is the Standard that addresses your issue: "§484.18(b) - Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care." From the State Operations Manual (guidance for state surveyors) "The
    February 24, 2011 on Webinars

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