assessment changes in - PDF document

1 P ag e 1 o f 6 – T h e r a p y
P ag e 1 o f 6 – T h e r a p y Q u e sti on s a n d A n s w e rs Ther a p y Q u e s t i o ns a nd A n s w e r s – R e v i s ed February 28 , 2013 Q u e stion 1: D oes the January 1, 2013 e f f e c t i ve d a te f or the th e r a p y re assessment changes in the CY 2013 HH PPS Final Rule m ea n that these changes are e f f ec t i ve f or e pisod e s b e g inn i ng on or a ft e r January 1, 20 1 3 ? Ans w e r 1: Y e s Q u e stion 2: I s the 13 th /19 t h vis i t reassessment r e quir e ment p e r e pisod e ? Ans w e r 2: Y e s Q u e stion 3: How a re t h e r a p y vis i ts counted wh e n t r y i n g to det e rmine w h e n the re qui r e d 13th, 19th, a nd “a t l ea st e v e r y 30 d a y s” t h e r a p y re a s s e ss m e nt v i si t s a r e to be p e r f o r med? How is t he c ount i ng of th e r a p y vis i ts a f f e c ted, w h e n a n y one of those r e quir e d th e r a p y re a s s e ss m e nt vis i ts does not oc c u r ? Ans w e r 3: F or the pu r p ose o f d e te r m i ni n g wh e n ce rt a in r e quir e d th e r a p y re a ssessment visi t s n ee d to oc c u r; on l y M e d i ca r e - c o v e r e d vis i ts a r e counted . N o n - c ov e r e d the ra p y vis i ts a r e not t o b e includ e d in t he c ount i n g of th e r a p y vis i ts for the pur p ose o f d e te r m i ning w h e n c e rt a in re quir e d th e r a p y re a s s e s s ment visi t s ne e d to oc c u r . I f a r e quir e d the ra p y re a ssess m e nt v i sit is not p e r f o rm e d t i me l y ( or does not me e t t he the ra p y re a ssess m e nt vis i t r e quir e ments), that visit and a ll s u bseq ue nt t h e r a p y vis i ts are c onsid e r e d no n - c ov e r e d a nd would not cont r ibu t e t ow a rds t h e c ount i ng o f M e di c a r e - c ov e r e d vis i ts u s e d to det e rmine wh e n c er t ain t h e r a p y re a s s e ss me nt v i si t s a r e to be p e r f o r med. On c e the the ra p y re a s s e ss m e nt v i sit r e quir e ments h a v e b e e n met, the re assessment visit and subsequ e nt t h e r a p y vis i ts are c onsid e red M e dic a r e - c ov e r e d a nd are c o unted f or the pu r po s e of d e te r m i ning w h e n c e rt a in re quir e d th e r a p y re a ssessment visi t s ne e d to oc c u r . W e a lso note t h e f ol l owin g : ( 1 ) the c lass i fic a t i ons of M e di c a r e - c o v e r e d a nd no n - Medi ca r e c ov e r e d vis i ts r e f e r to how t h e vis i ts would be re por t e d on t h e c l a i m ; (2) a g e n c ies a nd the ra pis t s shou l d not ch a n g e the num b e r of th e r a p y vis i ts a p a t i e nt r e ce i v e s bas e d on wh e ther prior vis i ts w e re Medi ca re - c o v e r e d o r not; and (3) p a t i e nts s hould o n l y r e ce ive t h e number of th e r a p y vis i ts c a l l e d for in t he p a t i e nt’s plan of c a r e . We do note that i t is important for HHAs to track M edicare - covered visits on an ongoing basis . Q u e stion 4: I n the ca se o f a patient receiving more than one type of therapy , how is t he c ount h a ndled f or the 13th a nd 19th v i si ts ? Ans w e r 4: The c ount is cumul a t i ve a nd includ e s a ll the rap y disciplines. T h e

2 r e f o r e , if someone w ere , f
r e f o r e , if someone w ere , f or exa mp le , rece iv i ng p hy si ca l t h e r ap y (P T) th re e t i mes a w ee k a nd o cc up a t i on a l t h erap y (O T) on c e a w ee k, the 13th the rap y vis i t would pr e s u mab l y be a t t he b eg inn in g of the fou r th wee k. P ag e 2 o f 6 – T h e r a p y Q u e sti on s a n d A n s w e rs Q u e stion 5: I s the “a t l e a st ev e r y 3 0 - d a y s ” r ea sse s sment r e quir e ment m e a s u re d b y e pisode o r the p a t i e nt’s f ull c ourse o f t rea t m e nt? Ans w e r 5: The p a t i e nt’s full c ourse of t r ea t m e nt ( i . e ., st a rting f r om t he the r a pis t ’s f irst a ssessment/v i sit a nd c ont i nuing unt i l t he p a t i e nt i s dis c h a r g e d f rom home h ea l t h ) . Note that b eca use this r e quir e ment is desi g n e d to ens u re that a t a min i mu m , a home h ea l t h p a t i e nt i s vis i ted b y a th e r a pist ( r a t h e r th a n a n a ss i stant) a t l ea st once e v e r y 30 d a y s, the intent is not for a the ra pist to w a it unt i l t he 30th d a y to v i sit a p a t i e nt, but ins t ea d to ensu r e that a the ra pist r a ther than a the r a p y a ss i stant is ass e ss i ng a home h ea l t h p a t i e nt at le a st on c e during a g iven 30 - d a y p e riod. Q u e stion 6: W h e n do e s the “a t le a st e v e r y 3 0 - d a y s” re a ssessment c lock b e g in? Ans w e r 6: I t b e g ins with t he the ra pis t ’s f irst v i si t . ( N ote: I n c a s e s wh e re m o r e than one t y pe of the ra p y is bei n g pro v i d e d, e a c h the ra p y di s c ip l ine h a s i t s own s e p a r a te c ount or c lock.) Q u e stion 7: How should home h ea l t h a g e n c ies a n d pr o vide r s co u nt t he r a p y vis i ts t o e nsure that th e y a re m e e t i ng t h e “a t l ea st e v e r y 30 d a y s ” vis i t r e quir e ment? Ans w e r 7: F or d e t e rmining w h e n the n e x t t h e r a p y rea ssessment visit b y a q u a l i fi e d the ra pist ( f or e ac h discipline if m u l t ip l e types of the ra pis t s a r e c a ri n g f o r the p a t i e nt) w ould b e re qui r e d a s it r e lat e s to t he “ a t l ea st e v e r y 30 d a y s - r e qui r e ment, the c ount i ng should b e g i n the d a y a ft e r the s e rvi c e is provided. F or ex a mpl e , if a the ra pist c o n du c ted a nd do c u m e nted an a ssessment of a p a tient du r ing a vis i t on Ap r il 1, the c ount would be g in on A p ril 2. I n th i s c a s e , to m ee t t he r e quir e ment of m a king a t le a st one vis i t ev e r y 30 d a y s, the t h e r a pist r a ther t h a n a n a ss i stant would n ee d to r e turn b y M a y 1. The therapist then conducted and documented an assessment of the patient during a visit on M a y 1 , t he c l o c k r e s e ts and the n e x t 30 - d a y c ount would b e g i n M a y 2. W e note th a t t h e in t e nt of the p ol i c y is t o e nsure that a t a m i ni m um, a p a t i e nt se e s a th e r a pist ra t h e r th a n a n a ss i stant a t l ea st once e v er y 30 d a y s. Also, th i s r e quir e ment is in ad d i t ion t o the 1 3 th a nd 19th vis i t r e quir e ments th a t

3 oc c ur f o r e a c h e pisode th
oc c ur f o r e a c h e pisode that a b e n e fi c i a r y r ece i v e s home h e a l t h se r vic e s. Q u e stion 8: I f t h e 13th a nd 19th the ra p y vis i ts oc c ur b e f o re the “a t l ea st e v e r y 3 0 - d a y s ” r e a ssessment, w h e n do e s the 3 0 - d a y c lock r e s e t? Ans w e r 8: The 30 - d a y c lock re s e ts a ft e r e v e r y t h e r a p y re a ssessment visit ( p e r dis c ip l ine ) . Th e r a p y re a ssessment visi t s c a n on l y be p e r f o r med b y qu a l i fi e d t h e r a pis t s. A th e r a p y re a ssessment visit includ e s providing the a c tual the r a p y s e rvi c e (s ) , f u n c t i on a ll y a ssessin g the p a t i e nt, m ea suri n g pr o g r e ss t o d e te r m i ne if the g o a ls have b e e n met, do c umenting m e a sur e m e nt r e sul t s , and c o r r e spon d ing the r a p y e f f e c t i v e n e ss in t he c l i nic a l r e c o r d. Q u e stion 9: I f a the r a pis t ’s rea s s e ss m e nt t h a t sati s fi e s the “a t le a st ev e r y 30 d a y s ” the r a p y r e a ssessment r e quir e me n t oc c u r s be f o re the r e qui r e d 13th t h e r a p y r ea sses s ment visi t , is t he qu a l i fi e d the ra pist st i ll r e quir e d to pe r f o rm the 13th t h e r a p y r ea ssessment v is i t ? P ag e 3 o f 6 – T h e r a p y Q u e sti on s a n d A n s w e rs Ans w e r 9: Y e s, the th e ra pist would n ee d to p e r f o r m t he the ra p y s e rvi ce / r ea ssessment/m e a sur e ment/docum e n t a t i on a t t he 13th vis i t. W e n o te th a t conv e r s e l y , if the the ra pist h a d c omp l e ted a nd do c u m e nted the re a ssessment f or the 13th v is i t wi t hin the 30 d a y s, the “a t le a st ev e r y 30 d a y s ” r e a ssessment re quir e ment would h a ve b e e n met. W e a lso note th a t t h e re is s ome f l e x ib i l i t y for the ti m ing o f the 13th a nd 19th t h e r a p y vis i ts for p a t i e nts l i ving in ru ra l a r e a s and for patients re ce iv i ng mo r e than one t y pe of th e r a p y , or w h e n d o c ument e d e x ce pt i on a l cir c ums t a n c e s th a t p re v e nt e d the t h er a pi s t fr om c ompl e ting the 13th / 19th visit e x is t . Q u e stion 10: I n mu l t i pl e - the ra p y discipline situ a t i ons, which therapist is responsible for reassessing the patient for the 13 th /19 th visit reassessment requirements ? Ans w e r 10: I f a p a t i e nt i s r ece iv i n g more t h a n one t y p e of th e r a p y , a ll the ra pis t s mu s t do their r e sp e c t i ve a ssessm e nts after the 10 th visit, but no later than the 13 th visit to satisfy the 13 th visit reassessment requirement . In instances where the frequency of a particular discipline, as ordered by the physician, does not make it feasible for the reassessment to occur during the specified timeframes without providing an extr a unnecessary visit or delaying a visit, then it is acceptable for the qualified therapist from that discipline to reassess the patient on the visit scheduled to occur closest to, but no l a ter than the 13th Me d ic a r e - c ov e r e d vis i t. Likewise, all the ra pis t s mu s t do their r e sp e c t i ve a ssessm e nts after the 16 th visit, but no later than the 19

4 th visit to satisfy the 19 th visi
th visit to satisfy the 19 th visit reassessment requirement . In instances where the frequency of a particular discipline, as ordered by the physician, does not make it feas ible for the reassessment to occur during the specified timeframes without providing an extra unnecessary visit or delaying a visit, then it is acceptable for the qualified therapist from that discipline to reassess the patient on the visit scheduled to oc cur closest to, but no l a ter than the 19t h Me d ic a r e - c ov e r e d vis i t. I t is important for HHAs to track M edicare - covered visits on an ongoing basis . Question 11: In cases where the patient is receiving one type of therapy, if the therapist misses the required 13th reassessment visit and does not reassess the patient until the 15 th visit, which visits are non - covered? Answer 11: In the example above, the 13th and 14th visits would be non - covered. The 15th visit would be covered and would now be counted as the 13 th covered visit. I t is important for HHAs to track M edicare - covered visits on an ongoing basis . Question 12: Under the following scenario, what v isits would be non - covered ?  The patient is receiving PT and OT.  OT completes the reassessment on visit 12, makes visit 15, makes visit 17, completes the reassessment on visit 18, makes visit 20, and on visit 22 determines that the patient no longer has a need for OT .  PT misses the reassessment on visit 13, makes visit 14, completes the reassessment on visit 16, completes the reassessment on visit 19, makes visit 21, and on visit 23 determines the patient no long er has a need for PT . P ag e 4 o f 6 – T h e r a p y Q u e sti on s a n d A n s w e rs Answer 12:  OT Visit 12 – Medicare - c overed, OT reassessed patient within 11 - 13 timeframe.  PT Visit 13 – Non - covered as the PT missed reassessing the patient between the 11 - 13 visits.  PT Visit 14 – Non - covered as the PT missed reasse ssing the patient between the 11 - 13 visits and did not reassess patient during this visit.  OT Visit 15 – This becomes the Medicare - covered 13th visit.  PT Visit 16 – This becomes the 14th Medicare - covered visit where the PT completed the late reassessment.  OT Visit 17 - This becomes the Medicare - covered 15th visit.  OT Visit 18 - This becomes the Medicare - covered 16th visit. Although the OT reassessed the patient on this visit, because prior visits are non - covered, this becomes visit 16 and does not count towards reassessing the patient between the 17 - 19 visits.  PT visit 19 – This becomes the Medicare - covered 17th visit. The PT still reassessed the patient within the appropriate timeframe for the 19th visit reassessment requirement (17 - 19).  OT Visit 20 – Th is visit is non - covered as the OT did not reassess the patient between the 17 - 19 visits.  PT Visit 21 – This becomes the Medicare - covered 18th visit  OT visit 22 – This visit is non - covered as the patient was not assessed within the 17 - 19 visit timeframe.  PT Visit 23 – This becomes the Medicare - covered 19th visit. Note: F or the pu r p ose o f d e te r m i ni n g wh e n ce rt a in r e quir e d th e r a p y re a ssessment visi t s n ee d to oc c u r; on l y M e d i ca r e - c o v e r e d vis i ts a r e counted. I t is important for HHAs to track M edicare

5 - covered visits on an ongoing basis .
- covered visits on an ongoing basis . Q u e stion 1 3 : R e g a rding the no n - c ov e ra g e o f th e r a p y vis i ts when more than one type of th e r a p y is b e ing pro v id e d, using an e x a mp l e of more than 13 visits t o be pro v ided b y 2 the ra p y t y p e s ( e . g ., OT a nd P T ) , if the OT completes the r e a ssessment vis i t on v i sit 12, b u t the PT do e s not do the rea ss e ss m e nt un t il vis i t 17, would v i si t s 13 (PT), 14 (OT) , 15 (PT) , a nd 16 (OT), poss i b l y be c ov e r e d? Ans w e r 1 3 : All the OT visits in this example would be considered covered visits. The PT visits on the 13 th and 15 th visits are non - covered and the PT visit that occurred on the 17 th visit would be considered a covered visit and would now be counted as the 15 th covered visit. I t is important for HHAs to track M edicare - covered visits on an ongoing basis . Q u e stion 14 : Do e s the non - c ov e ra g e pol i c y a pp l y f or both t he 3 0 - d a y r e q u ir e ment a nd the 13th / 19 t h vis i t reassessment r e quir e men t s ? Ans w e r 14 : Y e s Q u e stion 15 : W h a t t ools ca n the r a pis t s use to do the obj ec t i ve a s s e ss m e nts? P ag e 5 o f 6 – T h e r a p y Q u e sti on s a n d A n s w e rs Ans w e r 15 : CMS do e s not w a nt t o be pr e s c riptive r e g a rdi n g wh i c h too l s shou l d be used a nd ins t ea d r e c om m e nds th a t the ra pis t s look to t h e ir r e spe c t i ve n a t i on a l and sta t e a ssoci a t i ons a nd acc r e di t ing bodies for s u c h r e sou r ce s. Q u e stion 1 6 : W h a t happ e ns if a do c tor d o e s not ord e r multip l e types of therapy a t t he sta r t of c a r e , but i nste a d or de rs a not h e r t y pe o f th e r a p y a f t e r the p a t i e nt has b ee n in ho m e h ea l t h for a f e w w ee ks. F or e x a mp l e , if a p a t i e nt r e c e ives PT f or a c ouple w e e ks a n d then t h e do c tor a dds O T to t he ord e rs; how is the c ount a djus t e d? Ans w e r 16 : The sum of a ll the ra py p r ovid e d, f r om all d i s c i pl i n e s, must be c onsid e r e d wh e n c ou n t i ng vis i ts. I n th i s c a s e , if the 13th or 19th v i sit o cc u r re d b e fo r e t h e OT wa s o rd e re d, only PT was required to perform the service and reassess the patient . If OT was ordered before the 13th/19 th vis i t , the OT a nd P T are required to do t h e ir r e spe c t i v e a ssessments after the 10 th but no later than the 13th visit or after the 16 th , but no later than the 19th vis i t ( c umu l a t i ve c ount). Q u e stion 17 : A r e the r e a n y ins t a n c e s in whi c h the “a t l ea st e v e r y 3 0 - d a y s r ea ssessment c a n be d e l a y e d y e t s t i l l be c ov e r e d if the p a t i e nt i s un a v a i l a ble due to ci r c ums t a n ce s b e y ond the c ontrol of the the r a pis t ? Ans w e r 17 : CMS b e l i e v e s that the pol ic y t h a t r e q uir e s a q ua l i fi e d th e r a pist to pe r fo r m t he n ece ss a r y the r a p y se r vi c e , a ssess the p a t i e nt, m ea s u re , a nd do c u m e nt t he e f f e c t i v e n e ss o f the the ra p y a t le a st once e v e r y 30 d

6 a y s d u ring a c o u rse of th e r
a y s d u ring a c o u rse of th e r a p y tr ea t m e nt i s e ssential to e nsuring t h a t e f f ec t i v e , re a sona b le, a nd n ece s s a r y t h e r a p y s e rvi ce s a re b e ing provid e d to t he p a t i e nt. I n t h e ca s e of a h ome h ea l t h p a t i e nt wh e re the th e r a p y g o a ls i n the plan of c a re h a v e not b ee n met, but t he do c tor h a s in s te a d or d e r e d a tempo ra r y in t e r ruption in the ra p y , we would usu a l l y e x p ec t t h a t t he unique c l i nic a l con d i t ion of the p a t i e nt would e n a ble the home h ea l t h a g e n c y to anticip a te th a t an inte r ruption in the ra p y m a y b e n ee d e d. In su c h ca s e s, t h e H H A should e nsure t h a t t he re qui r e ments a r e met ea rlier t h a n the e nd of t h e “a t le a st ev e r y 30 - d a y s” p e riod to ensu r e the H HA m e e ts t his r e q uir e me n t. W h e re un e x p ec ted sudd e n c h a n g e s in t he p a t i e n t ’s c ondi t ion r e sult in a stop th e r a p y or d e r, w e would e x p ec t t o see do c u ment a t i on a nd e viden c e in t he medi ca l r e c o r d (i n c lud i ng a p h y sici a n o r d e r to stop t h e r a p y ) w h ich w ould suppo r t an un e x p ec ted c h a n g e in the p a t i e nt’s c ondi t ion whi c h pr e c lu d e s delive r y of the the ra p y s e rvi c e . W e will mod if y o u r m a n u a l t o d e s c ribe that in such do c ument e d c a s e s, the 30 - d a y qu a l i fi e d t h e r a pist vis i t / a ssessment/ m ea sur e ment r e quir e ment ca n be d e l a y e d unt i l t he p a t i e nt’s p h y sic i a n or de rs th e r a p y to r e sume. Q u e stion 18 : W hich s ce n a rios do the 11th to 13 t h a nd 17th t o 1 9 th Medi ca r e - c ov e r e d vis i t r a n g e s ap p l y to? Ans w e r 18 : (1) C ases where only one type of therapy is being provided and there is a documented e x ce pt i on a l cir c u m stan ce that pr e v e nt ed t h e the ra pist f rom s e e ing the p a t i e nt ; (2) c ases where only one type of therapy is being provided and the p a t i e nt resides i n a r u r a l a r ea ; and (3 ) c ases where a patient is receiving more than one type of therapy. Question 19: When does a mu l t i pl e - the ra p y case become a single therapy case for the purposes of when the patient should be reassessed for the 13th/19th visit reassessment requirements? P ag e 6 o f 6 – T h e r a p y Q u e sti on s a n d A n s w e rs Answer 19: When the patient’s plan of care has been changed to reflect that only one type of therapy is to be provided. For example, if a patient was receiving PT and OT through the Medicare - covered 16th visit, and it was determined during the 16th visit that the patient no longer has a continuing need for OT, at that point in time, this case would become a sin gle therapy case. The next required therapy assessment for PT must occur on the 19th Medicare - covered visit. W e note th a t t h e re is s ome f l e x ib i l i t y for the ti m ing o f the 13th a nd 19th t h e r a p y vis i ts for p a t i e nts l i ving in ru ra l a r e a s and or w h e n d o c ument e d e x ce pt i on a l cir c ums t a n c e s th a t p re v e nt e d the t h er a pi s t fr om c ompl e ting the 13th / 19th visit e x is t