Home Health & Hospice Week

Therapist-assistant collaboration will be critical.

In a rule covering sweeping changes from the Patient-Driven Groupings Model to RAP elimination, a therapy-related provision may go relatively unnoticed.

Old way: Currently, Medicare covers maintenance therapy when “the unique clinical condition of a patient requires the specialized skills, knowledge, and judgment of a qualified therapist to design or establish a safe and effective maintenance program required in connection with the patient’s specific illness or injury; or the unique clinical condition of a patient requires the specialized skills of a qualified therapist to perform a safe and effective maintenance program,” (emphasis added), the Centers for Medicare & Medicaid Services explains in the 2020 Home Health Prospective Payment System proposed rule released July 11.

Further, Medicare regulations “state that where the clinical condition of the patient is such that the complexity of the therapy services required to maintain function involves the use of complex and sophisticated therapy procedures to be delivered by the therapist himself/ herself (and not an assistant) or the clinical condition of the patient is such that the complexity of the therapy services required to maintain function must be delivered by the therapist himself/herself (and not an assistant) in order to ensure the patient’s safety and to provide an effective maintenance program, then those reasonable and necessary services shall be covered,” continues the rule published in the July 18 Federal Register.

These requirements are what have kept maintenance therapy restricted to therapists only. But that is inconsistent across post-acute provider types, CMS points out in the rule.

“While Medicare allows for skilled maintenance therapy in a SNF, HH, and other outpatient settings, the type of clinician that can provide the therapy services vary by setting,” according to the rule. “In some settings both the therapist and the therapist assistant can deliver the skilled maintenance therapy services.”

New way: “We believe it would be appropriate to allow therapist assistants to perform maintenance therapy services under a maintenance program established by a qualified therapist under the home health benefit,” CMS says in the rule. “We are proposing to modify the regulations ... to allow therapist assistants (rather than only therapists) to perform maintenance therapy under the Medicare home health benefit.”

Therapists would continue to play the central role in maintenance therapy, CMS assures. “The qualified therapist would still be responsible for the initial assessment; plan of care; maintenance program development and modifications; and reassessment every 30 days, in addition to supervising the services provided by the therapist assistant,” the rule proposes.

Benefit: “We believe this would allow home health agencies more latitude in resource utilization,” CMS notes.

Teamwork Is Key

This provision seems a bit out of left field, notes therapy expert Cindy Krafft with Kornetti & Krafft Health Care Solutions. “Was anyone asking for this?” asks Krafft, a physical therapist.

Nevertheless, the provision can be beneficial if CMS finalizes it as proposed.

The catch: “Patients who qualify for this extensive care have a complex medical condition, or possibly an array of chronic comorbidities that require a sophisticated set of therapy skills to address,” points out PT Chris Chimenti, senior director of clinical innovation with HCR Home Care in Rochester, New York. “To perform ongoing skilled maintenance therapy, the care should be dynamic in nature and likely involve frequent updates to the plan of care in response to changes in a patient’s status over time. These updates, implemented by the supervising PT, would result from consistent case conferences between the PT and PTA,” Chimenti expects.

The complexity of the care that triggers maintenance therapy coverage also will require “ongoing reassessment and close oversight by a PT,” Chimenti judges. “The documentation would need to reflect close collaboration with the supervising PT. Frequent phone calls/meetings, close oversight, and timely reassessment would be the keys to success.”

Otherwise: “If the documentation would fail to demonstrate this, the care may appear repetitive ... and therefore not reimbursable,” Chimenti warns.

Using PTAs for maintenance therapy seems to make sense mainly for “higher-frequency” patients, Krafft tells Eli.

Why? Therapists have to reassess the patient every 30 days anyway, so for patients seen once a month a therapy visit is in order. Adding a PTA visit when an assessment visit must be done anyway isn’t helping streamline utilization.

And not all high-frequency patients are good candidates for PTA use either, Krafft maintains. PTAs are not in charge of modifying care plans, as CMS points out in the rule. That means a therapist will have to make a visit to the patient if the patient needs reassessment for care plan modification anyway.

Under the current system, the therapist is making the visits, so can modify the care plan at any time, Krafft contrasts.

Bottom line: “This change offers home health care agencies additional flexibility,” Chimenti praises. And “this change would enhance satisfaction among patients who wish to retain their PTA throughout the duration of care that may extend into skilled maintenance therapy,” he points out. “Presuming an optimal level of teamwork between the PT and PTA, a high level of success can be achieved for the patient, as well as the home care agency.”

Krafft lauds the change as “great” and notes that it emphasizes therapy’s importance under PDGM. It’s “not going away,” she says.

Give your input: In addition to asking for general comments on the provision and its effect on care quality, CMS specifically asks for comments in three areas for this topic:

1. “whether this proposal would require therapists to provide more frequent patient reassessment or maintenance program review when the services are being performed by a therapist assistant”;

2. “whether we should revise the description of the therapy codes to indicate maintenance services performed by a physical or occupational therapist assistant (G0151 and G0157) versus a qualified therapist, or simply remove the therapy code indicating the establishment or delivery of a safe and effective physical therapy maintenance program, by a physical therapist (G0159)”; and

3. “the importance of tracking whether a visit is for maintenance or restorative therapy or whether it would be appropriate to only identify whether the service is furnished by a ... therapist or an assistant.”

Note: Instructions on commenting are in the rule at www.govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14913.pdf.