Home Health & Hospice Week

Therapists must learn to document better in many cases.

Don’t let your focus on the face to face encounter requirement keep you from getting into compliance with another big regulatory change that hits April 1 -- therapy reassessments.

In the Nov. 17, 2010 Federal Register, the Centers for Medicare & Medicaid Services finalizes home health agencies’ requirement to have therapists -- not therapy assistants -- conduct reassessment visits on the 13th and 19th visits. In certain cases, therapists may make the visits in the 11 to 13 and 17 to 19 ranges (see related box, p. 44).

CMS instituted these changes in part because of perceived abuse of therapy provision in home care. “Therapy under the Medicare HH benefit, in many cases, was being over-utilized,” the agency concludes in the final rule. The former 10-visit threshold “offered a strong financial incentive to provide therapy visits when a lower amount of therapy was more clinically appropriate.”

The bottom line: “Financial incentives to provide 10 therapy visits overpowered clinical considerations in therapy prescriptions,” CMS says.

Even after CMS implemented the six-, 14-, and 20-visit therapy thresholds in 2008 with payment gradations between those levels, data still indicate therapy overutilization, CMS maintains in the final rule. “Some HHAs may be providing unnecessary therapy,” CMS says, citing Medicare Payment Advisory Commission research as support.

Start Working On Visit Timing Now

The biggest challenge associated with the new requirement will be timing the reassessment visits, experts agree. That’s “what agencies should be gearing up for right now,” urges occupational therapist Karen Vance, consultant with BKD in Springfield, Mo.

“The timing of the assessments, especially when multiple therapies are present at the same time, will be the most difficult coordination activity,” predicts consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. “Many will need to determine new ways to coordinate to be sure the reassessment visits are done timely.”

At least HHAs won some leeway in when the visits must take place -- but only in certain instances (see related box, p. 44). “Allowing a range of visits to complete the reassessments prior to the 14th and 20th visit will be a great help in scheduling the visits,” Adams says. “There is always the possibility of so many things that can cause a scheduled visit to be missed.” The visit ranges may make it possible to get the reassessment done in time “versus having only one visit to work with,” she says.

But don’t expect the visit ranges to make adopting the new requirement a snap. “The flexibility of the range will certainly help to get multiple reassessments into the time frame, but it will still take getting used to,” Vance cautions.

Ruling Out Assistants May Squeeze Therapy Access

CMS reiterated in the final rule that it must be therapists who conduct the reassessment visits,not therapy assistants. “In many areas, the therapists have been doing the admission and discharge visits only with the assistants doing all of the other visits,” Adams tells Eli. “These new requirements will force the therapists to provide more of the treatment visits than in the past.”

The therapist requirement may cause access problems “in many rural areas where there are very limited therapists and the HHAs were relying on the assistants to carry most of the treatment visits,” Adams expects. “For some agencies, it could even mean a reduction in the number of therapy patients they can accept.”

Commenters on the proposed rule criticized the reassessment requirement for being “burdensome and costly” to agencies, “prohibitively expensive,”and possibly limiting beneficiaries’ access to home care therapy.

CMS’s response: “By requiring a qualified therapist, instead of an assistant, to perform the needed therapy service, assess the patient, and measure and document progress toward goals and/or effectiveness of therapy at defined points in the course of treatment, we would lessen the risk that patients continue to receive therapy after the treatment goals have been reached and/or after therapy is no longer effective,” the agency says in the rule.

In fact, “these requirements will ultimately result in more access to effective therapy services,” CMS insists in the final rule. “We do not expect that these coverage clarifications will result in access to care issues.”

And the move is good for patients, the feds add. “More qualified therapist involvement would further enhance patient care for those patients needing these levels of therapy,” CMS argues.

Therapists should already be doing these things anyway, CMS maintains. But the agency does admit that many probably are not. “Many agencies have not been in compliance with the documentation practices and qualified therapist oversight we would expect,” CMS acknowledges in the rule.

Rise To The Documentation Challenge

HHAs’ second-biggest hurdle in complying with the new therapy requirements will be documentation, Adams expects. “In many HHAs, especially those that contract for therapy services, no one has held the therapists accountable for good documentation,” she laments. “In many smaller agencies, the agency nursing supervisors are very intimidated by therapists and reluctant to ever question them or ask for better documentation.”

Part of that documentation includes using “objective measurement of the effectiveness of the therapy,” the new regulations say.

But there are very few objective measures that are standardized for the home health setting, Vance points out. “Therapists will hopefully use more objective, measurable language in their documentation that will still meet the requirements,” she tells Eli.

Some therapists have been using evidencebased tools in their practice and documentation for some time, “so it will be business as usual for them,” Adams notes. “But those who have not been using objective evidence-based measures will need to change their practice.”

The final rule does include some improvements over the proposed rule. CMS clarifies that therapists must conduct a functional reassessment atthe designated timepoint, not an overall comprehensive reassessment.

“The qualified therapist must assess a patient’s function using objective measurement of function,” CMS says in the rule. “In other words, the assessment of function would not be a comprehensive assessment of the patient’s clinical condition.”

CMS also clarifies in the rule that therapy maintenance is not a dependent service requiring a skilled nursing visit.

Note: Sign up for Karen Vance’s Eli-sponsored audioconference, “Home Health 2011 PPS Rule: Therapy Standards Clarification,” at www.audioeducator.com -- click on the “Home Health” link in the “Select Conference” box and scroll down to the March 8 session.

For tips on how to implement the therapy changes, see a future issue of Eli’s Home Care Week.