“50 feet”… And other Round-World Realities

The April 2011 APTA Home Health Combined Section publication contained a provocative article from Diane Kornetti, a Physical Therapist and Home Health Agency owner, addressing the reporting of denials seen regarding PT care programs. The title of the article “150 Feet … and Other Flat World Myths” was a back-handed response to the statements this author was making about gait-based denials he was seeing from reviews of homecare therapy claims. Working with multiple agencies of all sizes, recently audited by various CMS Fiscal Intermediaries (FIs), we at HHSM had a front-row seat to the expanding audit reviews appearing across the Home Health landscape at that time. Claims audits performed by FIs and their Program Safeguard Contractors (PSCs) from various states in different parts of the country (NJ, MI, CA, TX, and others) were resulting in denials of Home Health episodes, or therapy components of those episodes based on “not medically necessary” treatment or “lack of skilled content”. At that time, I had reviewed over 300 denials of such claims, and was commenting anecdotally on the fact that I had not seen an audited case where a gait distance greater than 150’ was approved for qualified coverage (because I hadn’t).

The gist of the APTA article was that any education provided around this subject had to be incorrect since the regulations have no specific coverage distance inherent as a care limitation. The opinion of Ms. Kornetti, as asserted in her Combined Section piece, was that I, as a therapy educator, was disseminating false information (an assertion based entirely on hearsay since she had not personally attended any of my presentations or educational events). In reality, no statements were made in our seminars that went beyond the following level; “I have not seen an audited Home Health PT claim that covers a gait training distance greater than 150 feet in 2 years”. I’m not sure if Ms. Kornetti thought I was lying, but, in fact, the statement was the truth.

In addition, my statements were regularly seconded at that time by attendees at multiple presentations in 2011 regarding this specific concept. During a pre-conference seminar for the Oregon Association for Home Care Spring Conference, an attendee (also a Physical Therapist) commented that a representative for the Oregon FI had recently mentioned during an educational webinar that he thought 35 feet of safe ambulation was sufficient. Recounting this to a general session audience a month later at the Illinois Homecare Councils’ Annual Meeting, an attendee raised her hand and stated “I’m a Home Health consultant in California and they are covering 75 feet”.

Regardless of the professional disagreements over this topic, the issue at work reaches well beyond the regulatory coverage that is at the heart of the matter. Rather than reflecting regulatory coverage verbiage, we are discussing the coverage “interpretations“ of those regulations, which is an evolving, ever-changing concept. Changes in the interpretation of specific regulations are not uncommon for Medicare Providers and clinicians (see therapy reassessment regs for the latest example). No one is saying, or said, that the regulations stated anything other than what they state; only the real-world reality that the audits new to homecare (at that time) were resulting in a sea-change from what we had known to that point.

The issue that is the basis of the statements at that time is the skill level inherent in increasing the functional endurance distance of an ambulatory patient, and whether that skill level requires a Physical Therapist to perform this task. The reality relative to Home Health claims is that endurance improvement does not require the specialized training of a Physical Therapy professional, and this could not be truer. Certainly, only a qualified PT can restore safe ambulation to a patient who is compromised in this area, but endurance (typically considered unskilled) can be improved or restored by many types of healthcare practitioners. What is required is keeping the patient safe while approaching the limits of fatigue, resting the patient, and repeating this process. In fact for years, in sub-acute rehab SNF care, unlicensed technicians could perform this very activity in the line-of-sight of the PT and it could be billed under therapy minute totals. In this manner, the patient’s gross motor and balance skills often improve and their endurance increases, but this still fails to rise to the level of specialized Physical Therapy care.

And now, nearly two years later, in 2013, our recent work with Pioneer ACO systems has exposed HHSM to the Care Tool, a new continuum evaluation form mandated by CMS for the Bundling pilots to equalize the assessments for ALL types of Providers. The Care Tool will be performed at admission to the hospital, admission to Inpatient Rehab, admission to SNFs, and admission to Home Health (in addition to the current admission requirements (MDS, OASIS, etc.). CMS seeks to establish uniform data for Post-Acute patients as they dismantle the current care continuum in favor of a more comprehensive, episode-based approach. The Care Tool will be employed in the Bundling pilot programs, including the MS-DRG 469/470 LE Joint Replacement program that is an HHSM/DMC collaboration (see HHSM Newsletter – 11/13/12). The Care Tool we have reviewed has a specific endurance question regarding the functional ambulatory distance of the patient we are about to treat. They ask if the patient’s endurance is greater than…50 FEET. If CMS is willing to state that distance in the new Care Tool that is eventually coming to all of our agencies and patient programs, it seems likely that they won’t be covering therapy claims involving gait distances that are significantly above that level.

Ms. Kornetti’s article went on to state that, to be safe, you should only trust APTA-sanctioned educators for the truth, going on to name specific educators that would qualify to be trusted with accurate information. This approach tends to isolate practitioners and discipline types to groupings of like-minded professionals that may or may not have the most progressive educational materials available. Recent elements of the healthcare reform bill, the Patient Protection and Affordable Care Act (PPACA), outline the dangers of such an approach as we develop the integrated health care systems of the future. In our work with multiple Pioneer ACO systems across the country, HHSM consultants encounter the team-based demands of the healthcare delivery model of the future, and we are discovering the need to integrate our therapy programming into the care models of the future.

Certainly professional organizations are important to our individual professions, and offer a great opportunity to collaborate with other colleagues and broaden our horizons, but to assert that membership in such organizations is required to validate educational material is, in fact, absurd. Therapy clinicians in particular, who have been separated from many other care team members based on their educational requirements and scarcity of qualified licenses, need to integrate into a team approach if they expect to be successful in the new care models required for the Accountable Care Organizations of tomorrow. Perpetuating a navel-gazing, or circle-the-wagons mentality by excluding any education or progressive material not hand-fed to us by the APTA is short-sighted and isolationist at best.

So seek to broaden your horizons with any and all educational material available, particularly when it relates to the wholesale rewiring of the acute and chronic episodes that lie ahead under the ACO model. Understand that the transparency of the Post-Acute Bundling models will invite others to value and affect how you deliver care. Invite others into your care consciousness as a means of improving efficiencies and outcomes, and warm up to the concepts of “50 feet”… And other Round- World Realities.

Arnie Cisneros, P.T., President of Home Health Strategic Management, is the most progressive speaker in homecare today. He provides coaching and consulting services to providers on a national basis (see www.homehealthstrategicmanagement.com) regarding S.U.R.C.H. and other clinical management protocols for quality outcomes.