The 2011 PPS Rule introduces significant changes to various aspects of the Home Health benefit. Many of these changes are procedural in nature, but they also contain financial ramifications that will alter numerous current and common homecare practices. Certainly, the net effect of the Rule is greater than the sum of its parts; considerable changes are in store as these latest reforms outline a directional shift for the industry. In addition, proposed changes for 2012 and beyond telegraph further activity in the new direction.
The clinical focus of much of the 2011Rule centers around therapy care as currently managed under PPS. Having been featured prominently in the HHRG-based reimbursement formula since the introduction of the Interim Payment System in 1999, the role of therapy has been integral in the PPS fee schedule. First, this occurred via the High Therapy Threshold, which reimbursed providers a $2300/episode payment bonus for claims including 10 or more combined therapy visits. Then, the 2008 PPS Rule eliminated the 10-visit threshold, replacing it with a graded level of volume-based payments for combined therapy totals. In retrospect, the effectiveness of these models suffered from the lack of a consistent audit mechanism. As a result, therapy costs and quality have long had the attention of reform efforts, and today we will examine the latest attempts to impose clinical and cost controls on the Home Health model, specifically focusing on the rehab component of homecare.
The therapy changes include:
DOCUMENTATION REQUIREMENTS
Coverage criteria for rehab therapy were re-stated, with particular emphasis on evaluations. All evaluations and subsequent care plans must outline a treatment program that rises to professional standards, and has measurable goals that relate directly to the illness or injury at hand. These programs must be based on objective tests and measures, commonly recognized as best practices in the respective professional practice. Individual treatment modalities must be connected to the functional declines being addressed, with goals of functional improvement resulting from the care program.
Routine visit documentation should identify how the program that specifically addresses each of the areas from the evaluation progresses on a per visit basis.
HHSM Protocol
All care plans are reported to the Home Health office at the time of the eval visit (via a clinical telephone hotline) for approval from clinical supervisors. In addition, as part of the weekly rounds of therapy clinicians, we track evals for current requirements and defendability. This tests and measures requirement will just add one more aspect to our review.
Weekly rounds with individual clinicians (OBQI Case Conference; an HHSM protocol) provide a review of random notes on a per-program basis, assuring qualified documentation that rises to the level of the 2011 requirements.
RE-ASSESSMENT REQUIREMENTS
Regular re-assessments of therapy programs must be performed by a qualified therapist, for each therapy provided on the case. These re-evals must occur according to a schedule based on combined rehab visit totals, or, at a minimum, every 30 days. These re-assessments must document the effectiveness of therapy to date, and outline plans for additional visits, if they are to occur. The re-assessment should address goals from the initial eval, employing the same tests that established baselines at that time. MD orders should be obtained prior to continuation if changes to the care plan are made.
The re-assessments are required for all therapy disciplines to perform by the 13th and 19th therapy visit, or every 30 days, if that comes first or more frequently than the counted visit totals (13 or 19). Please note this initially confusing and mis-interpreted fact regarding this aspect of the New Rule: THE VISIT COUNT IS A COMBINED TOTAL OF ALL THERAPY DISCIPLINES ON THE CASE. Visit ranges are identified during which the re-assessments must be performed; 11-13 and 17-19. If an individual discipline fails to re-assess by the 13th or 19th visit, all care delivered after that time will not qualify for Medicare coverage, and the provider will be unable to bill the patient for the services. Rural agencies have extended visit ranges for re-evals (10-13 and 16-19); these also apply if the re-eval is missed through circumstances beyond the control of the clinician. If the 30 day mark is reached prior to the 13th visit, the re-eval must occur at the 30th day (not visit). If the program continues after the 19th re-assessment, the next re-eval must follow 30 days later. If a lack of progress is noted, a supportable statement regarding continuing therapy and how goals will be achieved requires MD approval to continue care. If continuing, treatment effectiveness and expectation of continued progress must be addressed in objective terms.
Sound confusing? You are right, and we haven’t discussed some of the complications that may arise. Factor in missed visits, assistant use, re-hospitalizations, staff tracking and manageability, validation of visits, state practice act supervisory regulations, etc., and the dizziness you are experiencing is indicative of what lies ahead. In addition, most providers can’t speak about their therapy department for more than five minutes without describing either the difficulty in attracting and retaining staff, or the struggle to control contract personnel providing therapy content.
HHSM Protocol
Weekly schedules in advance for all rehab visits, in-office scheduler controlling count and responsible for re-assessment scheduling of licensed rehab therapists, therapists calling in all care plans with frequency/duration orders at time of eval, therapists must keep schedules current in the office at all times. These protocols will be required to control and manage rehab care to the extent required to comply with 2011 PPS Rule mandates.
Some thoughts to keep in mind as you contemplate this aspect of the 2011 PPS Rule and prepare for these changes: 1) only 15 % of therapy cases nationally exceed 13 combined visits, only 5 % exceed 19 combined visits; when you provide programs that exceed these levels, would you expect CMS (and their audit contractors) to agree that the clinical acuity of your patients would rise to these percentiles of all claims they receive?, 2) When similar cost and quality controls were introduced to Skilled Nursing Facility rehab in 1998, a 30% reduction in therapy utilization occurred within 60 days, and management of the requirements became a daily facet of rehab supervision in that care environment, 3) Clinical staff of agencies that employ point-of-care software schedules for payroll have valid and current rehab schedules at all times, and 4) Some of your most experienced and veteran clinicians are sure that these reforms don’t address their care programs.
In addition, future CMS and Med Pac proposals for 2012 and beyond outline further sweeping changes regarding how therapy will be managed and reimbursed. These changes will require providers to gain even more control over the therapy component of their care programs in the future if they expect to succeed in tomorrow’s homecare setting.
G-CODES FOR ASSISTANTS AND MAINTENANCE PROGRAMS
New billing codes that address therapy personnel and the establishment of maintenance programs are outlined:
G0151: Qualified PT – each 15 minutes
G0152: Qualified OT – each 15 minutes
G0153: Qualified SLP – each 15 minutes
G-Code 1: PTA – each 15 minutes
G-Code 2: OTA – each 15 minutes
G-Code 3: Maintenance therapy by qualified PT – each 15 minutes
G-Code 4: Maintenance therapy by qualified OT – each 15 minutes
G-Code 5: Maintenance therapy by qualified SLP – each 15 minutes
G-codes identify types of therapy personnel on a per visit basis as a means of tracking volumes of care provided by therapy assistants. When PPS was introduced, the High Therapy Threshold was based on the belief that approximately 80% of the care would be delivered by qualified therapists. Speculation would expect the tracking of assistant visits would preclude either limits on percentage of assistant care employed in Home Health episodes, or a reduction in therapy reimbursement based on the use of less costly assistant personnel.
G-codes for Maintenance Therapy mark a shift in how CMS will define maintenance programs involving therapy-related areas. The 2011 Rule Maintenance G-codes identify the only areas of Home Health therapy coverage that don’t require a “reasonable expectation of improvement”. Under the new interpretation of the maintenance standard, these codes are used when a qualified therapist designs a program whose intent is to prevent loss of function. The therapist is to create and install a program designed to reduce the expected losses, and alternate personnel are to carry out the program on a non-reimbursable basis. The program developed should include instruction and re-evaluation parameters that may be addressed for results under separate G-coded visits. So, these Maintenance G-codes mark a significant turn in how maintenance therapy is addressed under the Home Health benefit. Many providers who currently provide ongoing maintenance programs supplied by licensed therapy staff (therapists, assistants) will undoubtedly experience a loss of business volume in this area.
HHSM Protocol
Time and Travel logs are monitored for accuracy on a weekly basis, billing protocols are reviewed at weekly case conference, and billers are oriented to 2011 Rule requirements as they prepare for various billing codes from all directions on a daily basis. Therapy staff is required to gain approval from their clinical supervisors prior to use of Maintenance Therapy visits, and the weekly clinical rounds (OBQI Case Conference) are used to reinforce their responsibility to identify visit content on logs. Monthly metrics are created and rounded for accuracy and ongoing problems are addressed routinely.
The billing requirements went into effect 1/1/11, and the rest of the therapy changes begin 4/1/11. We have our work cut out for us as we re-wire how we manage
and deliver therapy services in the future. Staff will require education, support, reinforcement, management. Be prepared to help them adapt their care to the latest changes, and help them realize integration of the new requirements are not optional, but required to remain on the correct care path for their patients and their practice.