Eli's Rehab Report

CMS determination to curb revenue maximizing efforts by certain agencies could backfire.

The Centers for Medicare & Medicaid Services’ (CMS’) proposal to move to a 14-day timeline for functional assessments was met with resistance from the home health industry. Many report concerns that a measurable improvement is unlikely to be observed in such a short period.

In the 2015 home health prospective payment system proposed rule, CMS floats a 14-calendar-day functional reassessment requirement. That would replace the current reassessment time points of the 13th and 19th visits. Home health agency commenters roundly reject the 14-day timeline as too short in their comment letters on the rule. But what timeline would work better?

The therapy functional reassessment timing change is arguably the most commented upon provision of the 2015 PPS proposed rule — or at least tied with the face-to-face physician encounter changes. And the vast majority of commenters agree that a 30-day deadline for reassessment is significantly more appropriate than the proposed 14-day deadline.

“Tangible improvement (in a restorative model) or stabilization (in a maintenance model) may not be confirmed in a 14-day time period,” says PT and consultant Cindy Krafft with Kornetti & Krafft Health Care Solutions. 

“In order to ensure that either improvement or stabilization has really occurred, evidence has to be seen over a period of time. A decision made too hastily may not be accurate and only indicate the patient had a single good day as opposed to real change as a result of therapy services,” warns Krafft, president of the Home Health Section of the American Physical Therapy Association (APTA).

Krafft requests replacing “at least every 14 days with at least every 30 days not as a convenience for therapists, but for a more appropriate range to account for the individuality of patient response to treatment,” she says in her comment letter.

“For true physiological change to occur to the extent that it will be measureable … realistically takes 6-8 weeks depending on the patient’s individual goals,” notes physical therapist Bill Anderson, manager of therapy practice for VNA Home Health and Hospice in Portland, Maine. But that long of a timeline doesn’t dovetail with CMS’s “need to require reassessments more frequently to curb revenue maximizing efforts by certain agencies,” Anderson acknowledges in the letter commenting on the July proposed rule.

CMS can at least extend the timeline to 30 days to avoid misconstruing functional status test results, Anderson urges. “The concern is that no changes in functional status with the use of these tests could be misinterpreted as the therapy not being effective and a lack of coverage being determined by CMS financial intermediaries,” he warns. “It also could harm clinical practice with therapists discharging patients early when in fact their intervention could have made a substantial difference in a patient’s functional status and fall risk reduction if therapy was continued.”

Look To States For Timeline Guidance

“Many state practice acts require that a therapist reassess a patient at least once every 30 days,” points out Tammy Dorsett of Texas in her comment letter. “I would suggest that CMS adopt this timeframe for therapy reassessments, considering no major change in practice patterns have occurred since the implementation of the 13th/19th reassessment rule was initially proposed.”

“For most patients it takes around 30 days for their bodies to truly gain strength, coordination, develop increased motor skills, and for it to be a measurable change,” says a rep from Accolade Home Health in Texas.

“We should give the patient time to improve, or not, before using a valuable visit to reassess our standing on patient progression and the viability of the plan of care,” urges Brandon Douglas of Oklahoma in his comment letter. “The original standard set by CMS was to reassess at least every 30 days.”

Thirty days “would conform to Medicare Part B outpatient therapy rules, most state regulations, and the clinical guidelines of professional therapy organizations,” points out national chain Amedisys Inc. in its comment letter.

In fact, “in outpatient they are expected to show progress every 30 days, and that is an overall healthier population,” highlights rehab director Linette Zuchowski in Wisconsin in her comment letter.

“The monthly reassessment is an excellent idea as it forces a review of the plan, goals and status in the middle of the certification period,” reasons a rep for Pathways Home Health in California. The monthly timeline “also does not overwhelm the therapist with a burdensome load of documentation when the focus needs to be on care of the patient,” the Pathways letter says. And “it also does not overly burden an agency by discouraging use of the PTA in the treatment of its patients.”

For patients who do progress more quickly, “a 30-day FA requirement would not prevent agencies from doing [reassessments] earlier, and would be often enough to document legitimate progress,” offers PT assistant Brad Woodcock, regional therapy manager for NMMC Home Health in Tupelo, Miss., in his comment letter.

The 30 days should also include “a small window of flexibility for patient/therapist scheduling,” suggests physical therapist Cynthia Jarrett in Mississippi in her comment letter.

If CMS is worried about high-intensity therapy cases, it could make the deadline every tenth visit or every 30 days, suggests Ed Schulte, executive director of Caregivers Home Health in Kansas. That mirrors the Part B outpatient therapy requirement as well, he notes.

Stay tuned: Agencies will have to wait until CMS issues the final rule — expected in early November — to find out the final therapy reassessment timeline. The change is expected to take effect Jan. 1.