Archive for July 19th, 2010

July 19, 2010

CMS proposes payment changes to HH services for 2011

CMS is proposing major changes in therapy qualifications, documentation and “effectiveness” of therapy in the 2011 proposed HHPPS rule. It is also proposing case-mix changes and payment changes.

This post gives an overall view and focuses on payment aspects.

The Centers for Medicare & Medicaid Services (CMS) announced late last week in its Home Health Prospective Payment System Rate Update for Calendar Year 2011 Proposed Rule a number of changes for HHAs and Hospice regarding certification, case-mix, therapy and skilled service documentation and requirements, and payment rates.

The proposed rule has a 4.75 percent decrease in Medicare payments to home health agencies (HHAs) for calendar year (CY) 2011. Based on updated data analysis, instead of the planned 2.71 percent reduction for CY 2011, CMS proposes to reduce HH PPS rates by 3.79 percent in CY 2011 and an additional 3.79 percent in CY 2012.

The agency estimates that this could be a $900 million decrease compared to payments HHAs received in CY 2010.  The decrease is a combination of market basket update, a wage index update, reductions to the home health prospective payment system (HH PPS) rates and other factors.

The Affordable Care Act (ACA) mandates a 1 percentage reduction to the CY 2011 home health market basket amount. The ACA also changes the existing home health outlier policy through a 5 percent reduction to HH PPS rates, with total outlier payments not to exceed 2.5 percent of the total payments estimated for a given year.

Among the proposals that could help lower payments is a proposal to pull two hypertension codes, 401.9 and 401.1, from the case-mix list. CMS is also proposing far more specific, and restrictive language regarding therapy. The proposals include clarifications on the roles and duties of therapists and assistant, specifics on therapy for rehabilitation or maintenance that moves toward written goals, that all therapy visits must be considered reasonable and necessary, and what constitutes assessment, documentation and goals.

“The new HH PPS provisions will help ensure more accurate payments under Medicare and reflect prudent financial stewardship of the Medicare Trust Fund,” said Jonathan Blum, director of the Center for Medicare and deputy administrator for CMS.

In CY 2010, CMS finalized a policy that requires HHAs that change ownership within three years of initial enrollment to obtain a new State survey or accreditation.  CMS now proposes exceptions to the 36-month provision for certain types of ownership transactions.  CMS is also clarifying the quality reporting requirements for the CY 2012 HH PPS rate update, as it relates to the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Survey.

Home health payment rates are updated annually by the home health market basket percentage increase.  CMS uses the home health market basket index, which measures (and tracks) inflation in the prices of an appropriate mix of goods and services included in home health services.

Read my post on the HTN case-mix proposal.

Read my post on proposed documentation and therapy roles.

Read about CMS’s specific skilled services wording aimed at reasonable and necessary therapy.

Find out more at www.healthcare.gov.

Read the full proposed rule.

Comments are being accepted until Sept. 14 on this proposed rule, CMS-1510-P. To send comments, go to http://www.regulations.gov.  Follow the instructions under the “More Search Options” tab.

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July 19, 2010

CMS wants to clarify therapy plans and skilled service roles

CMS is proposing major changes in therapy qualifications, documentation and “effectiveness” of therapy in the 2011 proposed HHPPS rule. I will cover the main points of the therapy requirements over several posts.

Establishing plans and clarifying skilled service roles

In the 2011 proposed  HHPPS rule, CMS works to clarify  “accepted practice” and “effective treatment” so HHAs know the agency’s expectations regarding PT, SLP, and OT. This section of changes deals with assessment documentation and reassessment requirements for therapists and assistants.

This proposal language specifically also calls out that therapy is NOT reasonable and necessary if the patient’s function is temporarily lost and would be regained as a patient’s health improves (watch out, those of you who have been using generalized weakness as a code to “justify” therapy). It also looks at the need for assistants vs. therapists in maintenance plans and with regard to setting up plans.

Current language for §409.44(c)(2)(iii) links therapy and reasonable improvements in the patient’s condition or a safety management maintenance program. The current language is:

(iii) There must be an expectation that the beneficiary’s condition will improve materially in a reasonable (and generally predictable) period of time based on the physician’s assessment of the beneficiary’s restoration potential and unique medical condition, or the services must be necessary to establish a safe and effective maintenance program required in connection with a specific disease, or the kills of a therapist must be necessary to perform a safe and effective maintenance program. If the services are for the establishment of a maintenance program, they may include the design of the program, the instruction of the beneficiary, family, or home health aides, and the necessary infrequent re-evaluations of the beneficiary and the program to the degree that the specialized knowledge and judgment of a physical therapist, speech-language pathologist, or occupational therapist is required.”

Regarding the first sentence, in the proposed rule, CMS would clarify the concept of rehabilitative therapy to include “recovery or improvement in function and, when possible, restoration to a previous level of health and well-being.”  

… “We are proposing to clarify the regulatory text so that if an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration of therapy services required to achieve such potential, therapy would not be considered reasonable and necessary, and therefore would not be covered as rehabilitative therapy services.”

CMS also proposes to clarify the regulatory text to describe that therapy is covered as rehabilitative therapy when the skills of a therapist are necessary to safely and effectively furnish or supervise a recognized therapy service whose goal is improvement of an impairment or functional limitation.

Under proposals, therapy would not be covered where a patient suffered a “transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.”   Also, if at any point in an episode treatment is not rehabilitative or legitimately require a qualified service, therapy ceases to be covered.

§409.44(c)(2)(iii) currently covers OT, PT or SLP if the services are “necessary to establish a safe and effective maintenance program required in connection with a specific disease.” CMS wants to add text stating that the specialized skill of a therapist is required to develop a maintenance plan. That plan should include patient, family and caregiver training, and re-evaluation plans. Maintenance plans should be included where applicable.

The proposal also talks about maintenance in a skilled nursing case: “We propose that when a patient qualifies for Medicare’s home health benefit based on an intermittent skilled nursing need, a qualified therapist may develop a maintenance program to maintain functional status or to prevent decline in function, at any point in the episode.  The services of a qualified therapist would not be necessary to carry out a maintenance program, and would not be covered under ordinary circumstances.  The patient could perform such a program independently or with the assistance of unskilled personnel or family members.”

However, if carrying out a maintenance plan required complex therapy procedures, “to be delivered by the therapist himself/herself (and not an assistant) in order to provide both a safe and effective maintenance program and to ensure patient safety, those reasonable and necessary services would be covered, even if the skills of a therapist were not ordinarily needed to carry out the activities performed as part of the maintenance program.

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Want to see the full document with all the proposals?

July 19, 2010

CMS wants to clarify “accepted practice” and documentation for therapists and assistants

CMS is proposing major changes in therapy qualifications, documentation and “effectiveness” of therapy in the 2011 proposed HHPPS rule. I will cover the main points of the therapy requirements over several posts:

In the 2011 proposed  HHPPS rule, CMS works to clarify  “accepted practice” and “effective treatment” so HHAs know the agency’s expectations regarding PT, SLP, and OT. This section of changes deals with assessment documentation and reassessment requirements for therapists and assistants.

Current language for §409.44 (c)(2)(i) is:

“(i) The services must be considered under accepted standards of medical practice to be a specific, safe, and effective treatment for the beneficiary’s condition.”

The following are the specifics CMS wants added to §409.44 (c)(2)(i):

Functional Reassessment Expectations

To remain eligible for the home health benefit, a patient’s function will be periodically reassessed by a qualified therapist.

To be covered, there must be an objective measurement assessment in accordance with acceptable standards in clinical practice.

“As such,” states the proposed rule, “progress toward therapy goals would be objectively measurable by  comparing measurements obtained at successive functional assessment time points.  The objective measurements obtained from the periodic reassessment of function would reflect progress (or lack of progress) toward therapy goals, or achievement of therapy goals and the measurements would be documented in the clinical record.”

Therapist assessment participation: As part of the functional assessment, a qualified therapist can include objective measurements or observations made by a PTA or OTA within their scope of Practice. The qualified therapist would have to actively and personally participate in the functional assessment, and measure the patient’s progress.

Patients for 13 or 19 visits: For patients requiring 13 or 19 therapy visits, the patient would be functionally re-assessed by a qualified therapist, minimally, on the 13th and the 19th therapy visit (thus requiring reassessment prior to the HH PPS therapy thresholds of 14 and 20 therapy visits), and at least every 30 days.

“No subsequent therapy visits would be covered until the qualified therapist has completed the reassessment, objectively measured progress (or lack of progress) toward goals, determined if goals have been achieved or require updating, and documented the therapy progress in the clinical record.  If the objective measurements of the reassessment do not reveal progress toward goals, the qualified therapist, together with the physician, would determined whether the therapy is still effective or should be discontinued.”

Continued therapy would need a “clinically supportable statement of why there is an expectation that anticipated improvement is attainable in a reasonable and generally predictable period of time.”

CMS states that these reassessments would ensure that the patient receives effective care and that patients were not remaining on the benefit and “continuing to receive therapy services after the therapy goals were met, or after improvement could no longer be expected.”

Documenting “Effective” Therapy Progress

CMS focuses in this document on how PTAs and OTAs can participate in documenting progress.

The agency proposes that assistants can document progress between functional assessments, but that these notes are not functional assessments of progress. Clinical notes from assistants would include:

• The date of the note,  the assistant’s signature and job title, or “for dictated documentation, the identification of the assistant who composed the clinical note, and the date on which it was dictated”;

• Preferrably, the notes will have objective measurements or a description of changes in status relative to each goal currently being addressed in treatment, if applicable in that visit. CMS notes that the descriptions would make “identifiable reference” to the goals in the current plan of care. Assistants would not make clinical judgments but could report the progress objectively.

For therapists and their responsibility in “effective” progress documentation, CMS wants to expand §409.44 (c)(2)(i) to include:

“• Documentation of objective measurement obtained during the functional assessment and extent of progress (or lack thereof) toward each therapy goal.

• Plans for continuing or discontinuing treatment, with reference to evaluation results, and/or treatment plan revisions.

• Changes to goals or an updated plan of care that is sent to the physician for signature or for discharge.

• Documentation of objective evidence or a clinically supportable statement of expectation that: 1) the patient’s condition has the potential to improve or is improving in response to therapy; or 2) maximum improvement is yet to be attained, and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.  Objective evidence would consist of standardized patient assessments, outcome measurement tools, or measurable assessments of functional outcome.  Use of objective measures at the beginning of treatment, and during and/or after treatment would be required to quantify progress and support justifications for continued treatment.”

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Coming soon: More therapy requirements.

What about case-mix? Read about the proposal to take HTN off the case-mix list!

Want to see the full document with all the proposals?

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