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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