Home Health & Hospice Week

You might have to use therapy assistants much less often starting next year, if the feds get their way. That's because the new home health prospective payment system proposed rule sets out new limits and billing requirements for assistants.

The Centers for Medicare & Medicaid

Services proposes new documentation and assessment requirements for therapy utilization, including many items that must be completed by the therapist herself (see related story, p. 218).

Case in point: Reassessments required every 30 days and on the 13th and 19th visits will have to be personally performed and documented by qualified therapists, according to the PPS proposed rule in the July 23 Federal Register.

Don't expect assistant documentation to save your therapy reimbursement. "Clinical notes written by therapy assistants may supplement the clinical record" only, CMS specifies in the rule. Assistant notes "must include the date written, the signature and job title of the writer, and objective measurements or description of changes in  status (if any) relative to each goal being addressed by treatment," CMS lays out. "Assistants may not make clinical judgments about why progress was or was not made, but must report the progress (or lack thereof) objectively."

In other words: "We are proposing that physical therapist assistants or occupational therapy assistants could objectively document progress between the functional reassessments by a qualifiedtherapist and/or physician," CMS explains in the rule. "Clinical notes written by assistants are not complete functional assessments of progress." CMS also makes clear that in cases where therapy visits for maintenance programs are covered, the visits must be provided by therapists themselves, not assistants.

CMS proposes new billing codes that would keep track of therapist vs. therapy assistant visits. HHAs currently use G0151, G0152, and G0153 to report physical, occupational, and speech therapy visits, respectively, whether furnished by therapists or assistants.

Starting Jan. 1, CMS wants those existing codes to apply to visits furnished by "qualified therapists" only. The agency proposes two new G codes "to report the delivery of therapy services by assistants," the rule says. The as-yet-unnumbered codes would specify a PTA or COTA visit. All therapy codes would be reported in 15-minute units.

Plus: CMS also proposes three new G codes to report therapy visits for maintenance programs. CMS focuses on assistant use throughout the proposed rule, notes PT Cindy Krafft with consulting firm Fazzi Associates. CMS based its initial PPS base payment rate on data indicating 79 percent of therapy visits were furnished by therapists. Now the agency wants to see if that ratio still holds.

"I'm not so sure 79 percent is the average we're at" anymore, Krafft tells Eli. Some states have very strict supervision rules and so HHAs use virtually no PTAs or COTAs, she notes. But in other  states with liberal rules, some agencies will have one full time PT and six PTAs, for example, leading to a much lower percentage of therapist visits.

Some agencies use contract therapists where "the physical therapists do the initial evaluation and then assign the patient to a therapy assistant," adds Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C.

HHAs argue that nothing in their state practice acts require PT supervisory visits, notes physical therapist Sparkle Sparks, consultant with OASIS Answers. Then to save money, agencies try to minimize sending out therapists.

Pitfall: But PTs should remember that their licensure could hinge on seeing the patient every 30 days. "If I don't do it, they can yank my license," Sparks tells Eli.

It may not happen right away, but you can surely expect some reimbursement fallout if the new G code data show assistant utilization is markedly different than it was before PPS began. "We are soliciting comments on possible policy options such as using the new claims data to better account for therapy resource use," CMS says in the rule. "It's going to be interesting to see what that data shows," Krafft says of the G codes.

Watch out: The data probably will "provide CMS with a basis for further reduction in home health episode payment," Adams predicts. CMS likely will "claim that less resources are needed in home health to provide physical therapy services when assistants are used to provide the majority of visits."

Extra burden: Reporting the new G codes for assistants and maintenance will mean extra work for billing staff, Adams adds.

Policy and procedure changes will likely be necessary to capture the information for the G codes, notes the National Association for Home Care & Hospice. And software vendors will require time and effort to incorporate the changes and educate users, the trade group expects.