Eli's Rehab Report

CMS offers clarification for misses in multi-therapy cases.

Home health agencies will need to get more wary about survey and reimbursement pitfalls when the PPS proposed rule takes effect in 2013. Read on to find out what to look out for in upcoming changes.

Old way: Currently, when beneficiaries receive more than one type of therapy in a home health episode, the therapist's reassessment visit "need only be 'close to' the 13th and 19th visits," the Centers for Medicare & Medicaid Services reiterates in the home health prospective payment system proposed rule for 2013.

New way: CMS proposes "to revise the regulations ... to clarify that in cases where the patient is receiving more than one type of therapy, qualified therapists could complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and the 17th, 18th, or 19th visit for the required 19th visit reassessment," the agency says in the rule published in the July 13 Federal Register. These visit ranges match the ones CMS allows when the patient is in a rural area or has other documented circumstances outside the therapist's control that prevent the reassessment visit from occurring exactly on the 13th or 19th visit.

CMS has proposed this change because it has received repeated questions about what "close to" means under the current requirements. "We recognize the industry's need for additional guidance [and will] provide more precise guidance," the agency says in the rule, which it released July 6.

'Close To' Poses Survey Risks, Some HHAs Believe

Some agencies just find the "close to" standard confusing, observes physical therapist Cindy Krafft, consultant with Fazzi Associates. Others are concerned that an aggressive surveyor might not accept their agency's judgment of what is "close to" the 13th and 19th visit, says Krafft, who is president of the home health section of the American Physical Therapy Association.

The "close to" standard "feels a little too ambiguous" to some providers, Krafft allows. In many agencies' experience, surveyors haven't used common sense before, so why would they start with this requirement?

But giving therapists a specific range in which to conduct the reassessment visit is not a viable solution to this problem, Krafft maintains. That's especially true when the three-visit range is so narrow, particularly in cases where all three different types of therapists must each conduct their reassessment visit in the three-visit window.

"I just don't think that's going to work," Krafft tells Eli. Reassessment visits will inevitably occur outside the allowed visit range, meaning some visits will not be covered by Medicare -- and not counted toward reimbursement.

HHAs need to use the comment period on the rule to combat this proposed change, Krafft urges. Providers must provide constructive comments that illustrate why the proposed visit range will be problematic, including real-world scenarios, she advises. CMS has indicated its willingness to listen to feedback on this topic, saying "We encourage stakeholder comment on these proposed changes" in the visit range section of the rule.

Agencies should push for CMS to just leave the "close to" standard as-is, Krafft believes. Or, at the least, the visit range should be widened to five visits or more, she adds.

Clarification For Misses In Multi-Therapy Cases

In another proposed therapy change, CMS wants to clarify what happens when just one therapy discipline in a multi-therapy episode fails to conduct its reassessment on time.

Old way: Currently, "if a patient receives more than one type of therapy and the required reassessment visit is missed for any one of the therapy disciplines ... therapy visits are not covered for any of the therapy disciplines until the qualified therapist that missed the reassessment visit complies with the reassessment visit requirements," CMS explains in the rule. "Therefore, even if qualified therapists from the other therapy disciplines have completed all their required reassessment visits, therapy visits for these disciplines would not be covered until the qualified therapist who missed the reassessment visit has completed the previously missed reassessment visit."

HHAs have called this policy "unfair," the agency notes. And CMS "had additional concerns that this requirement may be negatively impacting beneficiaries' access to therapy services," it adds. "If an agency anticipates a visit will not be covered because one qualified therapist has not completed the required reassessment, it might be reluctant for any therapy visits to occur until that missed reassessment visit is completed. This is obviously not in the best interest of the beneficiary."

New way: "If the required reassessment visit was missed for any one of the therapy disciplines ... therapy coverage would cease only for that particular therapy discipline," CMS proposes. "As long as the required therapy reassessments were completed timely for the remaining therapy disciplines, therapy services would continue to be covered for those therapy disciplines."

On one hand, it's good that the other therapy disciplines won't be penalized if one type of therapy fails to meet its reassessment visit requirements, Krafft says. But on the other hand, counting some disciplines' visits as covered and not others may create a confusing situation when it comes to counting visits for the next reassessment time point. "That's the piece that's not addressed," she notes.

Add A Visit Back In When You Miss Reassessments

Finally, CMS also proposes to clarify when coverage resumes after a therapist missed a reassessment visit.

Old way: "Currently, when a qualified therapist misses one of the required reassessment visits, once the therapist has completed the required reassessment, coverage resumes after this reassessment visit," CMS reiterates. "Some agencies and therapists believe they are being unfairly penalized by this policy and that the reassessment visit should be covered as therapy was also provided during that visit even though it was not timely," the rule points out.

New way: CMS seems to agree. "If a qualified therapist missed a reassessment visit, therapy coverage would resume with the visit during which the qualified therapist completed the late reassessment, not the visit after the therapist completed late reassessment," the agency proposes. But CMS "will monitor claims for unintended consequences, including possible up-coding associated with therapy-related home health resource groups (HHRGs) pre- and post-implementation," it promises.

Note: CMS will take comments on the rule until Sept. 4. The rule, including instructions for submitting comments online or via paper, will be at www.gpoaccess.gov/fr starting on Friday, July 13.