Home Health & Hospice Week

Get some clues about home care's future in the proposed physician fee schedule for next year.

Home health agencies that furnish outpatient therapy in the home will have a whole new set of codes to report on claims, if a proposed rule becomes final. But HHAs that furnish therapy only under the home health benefit also will want to keep close tabs on the therapy coding development.

Why? The Centers for Medicare & Medi-caid Services has long indicated its unhappiness with the therapy unit of the home health prospective payment system. Utilization statistics seem to bear out CMS's fears that PPS reimbursement incentives drive therapy provision more than clinical concerns, for at least a portion of HHAs. In an effort to realign or eliminate those incentives, CMS may take a page from its outpatient therapy play book, suggests physical therapist and consultant Cindy Krafft with Fazzi Associates.

And now CMS has revealed the specifics of the new Part B therapy reporting requirements in the proposed Medicare Physician Fee Schedule rule for 2013, published in the July 30 Federal Register.

Biggest Change: Starting Jan. 1, 2013, CMS wants therapy providers to code outpatient rehab patients' functional status and projected goals. This data, which will go on the claim forms, is to help CMS develop a new payment methodology for outpatient rehab.

CMS proposes to create six G-codes that would describe patient function. The agency also proposes a 12-tier severity scale to be denoted with modifiers. CMS wants providers to code patient function at the initial evaluation and discharge, as well as once every 10 treatment days or at least once during each 30 calendar days " whichever comes sooner.

The G-codes are informational only and will not impact claims' reimbursement -- for now. "From a medical review standpoint, however, I think [these codes] could have a really big effect," says Gayle Lee with the American Physical Therapy Association.

Important: According to the proposed rule, if you don't include functional limitation codes on the claim form after July 1, 2013, CMS won't process your claim.

"We have serious concerns about this proposal and how it will impact therapists next calendar year," says Jennifer Hitchon with the American Occupational Therapy Association. "First and foremost," therapists wonder whether six generic G-codes really will be able to capture the information necessary to create a payment reform. CMS needs more detailed information about a patient's condition, function (e.g., cognition, self-care, psychosocial factors, etc.), participation, and therapy interventions. "The proposed data collection plan may be unable to account for this," Hitchon says.

Severity Modifiers 'Off-Scale' For SLPs

Speech-language pathologists already report severity on a 7-point scale via the National Out-comes Measurement System (NOMS), so CMS's proposed 12-point scale poses an even bigger challenge for SLPs.

"NOMS is already validated for inter-rater reliability on the 7-point scale that we currently use," says Lisa Satterfield with the American Speech-Language Hearing Association. Members have received specific training to evaluate patients using this scale, she explains, so a 12-point scale, while applauded for higher specificity, seems a bit premature to fully implement by July 2013.

Biggest concern: Suddenly requiring a 12-point scale without established reliability or validity is worrisome, says Mark Kander with ASHA. "It would be so subjective by each practitioner that it would not be good for data purposes."

Prepare for Extra-Steep Learning Curves

Rehab advocates also worry that six months is too tight a squeeze to ensure the new documentation and claims coding system is in place by next July.

"While I am pleased to see a six-month testing period included in the proposal, I remain concerned about the provider outreach and education necessary to responsibly and accurately collect this data in the two months between the release of the final rule in November 2012 and implementation in January 2013," Hitchon says.

And coding isn't the only concern therapy providers have. Reporting these functional limitations "would require a lot of education and changes in the way therapists document because they need to support the information they put in the G-codes," Lee points out.

Plus: "CMS is also considering a separate set of G codes ranging from 8-25 for 'select' categories," Hitchon points out.

Rest assured, CMS has no plans to change the claim form, Lee confirms. Lee predicts that the new G-codes and modifiers "will probably be reported the same way PQRS measures are placed on the claim form as line-items."

Note: The proposed rule at www.gpo.gov/fdsys/pkg/FR-2012-07-30/pdf/2012-16813.pdf off-ers an aggregate payment increase of 3 percent for Part B physical therapy services. The sustainable growth rate has a projected 31-27 percent cut, which will require congressional action to prevent.

For more information about Part B outpatient therapy, see Eli's Rehab Report at www.elihealthcare.com.