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.”


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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