Home Health & Hospice Week

Want to take a gamble on what qualifies you to use the 11-to-13 and 17-to-19 visit ranges for the newly required therapy reassessments? That's what you'll need to do unless you fit into two specific exceptions.

The prospective payment system final rule for 2011 requires home health agencies to have a therapist (not an assistant) perform a reassessment visit every 30 days and on the 13th and 19th visits in an episode.

When only one therapy discipline is involved in a case, "we would almost all of the time expect that [reassessment visit] to be provided ... on the thirteenth visit," Lori Anderson of the Centers for Medicare & Medicaid Services said in the April 13 Open Door Forum for home care providers. But when providers complained in response to the proposed rule that hitting those visits exactly would be very difficult, CMS provided visit ranges in certain situations.

Exception #1: HHAs and their therapists can use the ranges when "the patient resides in a rural area," CMS explains in an update to the Medicare Benefit Policy Manual issued April 15. CMS issued the manual more than two weeks after the rule took effect, although it did have a "therapy fact sheet" available upon implementation.

Exception #2: Agencies have even more latitude when multiple therapy disciplines are involved in a case. Instead of complying with strict ranges, therapists in those cases must perform the visits "close to but no later than the 13th and 19th therapy visit," CMS says in the manual update issued in Transmittal No. 142 (CR 7374). Remember, "the 13th and 19th therapy visit timepoints relate to the sum total of therapy visits from all therapy disciplines," the agency adds.

"We have provided flexibility associated with the multi-therapy discipline scenarios," Anderson said in the forum. "It doesn't have to be the visit just prior to the 13th and 19th, it just needs to be 'close to' that to facilitate scheduling."

Exception #3: HHAs can also opt for the visit ranges "when documented circumstances outside the control of the therapist prevent the qualified therapist's visit at exactly the 13th visit," the new manual language states. That may make agencies feel they can use visit ranges liberally, but they'll have to be confident their reasons will hold up to scrutiny -- and that they will be documented properly, experts say.

Anderson also addressed these issues related to the new therapy requirements in the forum:

• Billing. The 2011 PPS final rule and new manual guidance make clear that HHAs may not bill for visits after the 13th and/or 19th without the required reassessment visit and documentation. But agencies have a "tremendous amount" of confusion about when they can resume billing, said Mary St. Pierre with the National Association for Home Care & Hospice in the forum.

Agencies may start billing therapy services again the visit after the reassessment visit, Anderson clarified. For example, if the therapist makes the reassessment visit on the 14th visit, agencies can resume billing starting with the 15th visit.

Don't worry if your claim for such an episode doesn't show the therapist's reassessment visit, Anderson told a concerned caller. "We don't have any near term plans to have those sorts of caims processing edits in place," she said about a possible edit to check for a therapist -- versus an assistant -- visit.

Watch out: If you have multiple therapy disciplines involved in a case, none of the therapy visits is billable after the 13th visit if just one of the disciplines hasn't completed its reassessment visit, Anderson said. "No therapy services are covered unless those requirements are met, and all disciplines must meet those requirements," she said.

In other words, if PT and OT are in the case and the PT has completed her reassessment visit but the OT hasn't, the agency may bill no therapy visits at all until after the OT completes her reassessment visit too.

• Counting 30-day units. HHAs have paid a lot of attention to counting the reassessment visits for the 13- and 19-visit thresholds, but they need to count correctly for the 30-day timepoints too. The 30-day deadline can span episodes, Anderson warned in the forum. "The start of the clock is always when the therapy from that discipline is provided," she explained. "So the clock is reset every time the qualified therapist would perform that service." That's different than the 13- and 19-visit timepoints, which reset with the start of each new episode, she noted.