New claim codes to hit Home Health starting January 3, 2011

CMS will require Home Health Agencies to report new additional data when submitting health claims to distinguish services provided by a qualified Physical Therapist and a qualified Physical Therapist Assistant. Furthermore, CMS will be adding three new G-codes for skilled nursing services. The first code will report skilled services of a licensed nurse in the management and evaluation of the care plan. The second code for observation and assessment of patient’s conditions when only the specialized skills of a licensed nurse can determine the patient’s status until the treatment regimen is essentially stabilized. Lastly, a code for reporting of the training or education of a patient, a patient’s family, or caregiver.

Summary of Home Health Updates that will take effect come 2011.

Update to the Home Health Prospective Payment System (HH PPS) rates, including: the national standardized 60-day episode rates, the national per-visit rates, the non-routine medical supply (NRS) conversion factors, and the low utilization payment amount (LUPA) add-on payment amounts, under the Medicare prospective payment system for HHAs effective January 1, 2011. This rule also updates the wage index used under the HH PPS and, in accordance with the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), updates the HH PPS outlier policy. In addition, this rule revises the home health agency (HHA) capitalization requirements. This rule further adds clarifying language to the "skilled services" section. The rule finalizes a 3.79 percent reduction to rates for CY 2011 to account for changes in case-mix, which are unrelated to real changes in patient acuity. Finally, this rule incorporates new legislative requirements regarding face-to-face encounters with providers related to home health and hospice care. 1

EFFECTIVE DATE: These regulations are effective on January 1, 2011.

OUTLINE:3.79 case mix adjustment applicable to the 60 day episode rates

Therapy Clarifications1. New coverage guidelines to follow (available CMS-1510-F)
2. For patients needing 13 or 19 visits would require a qualified therapist to assess the effectiveness of therapy.

Capitalization requirements To ensure that the HHA maintains its required level of capitalization during this potentially lengthy period - as well as during the period between when it signs said agreement and the time it is granted Medicare billing privileges (a period which also can last several months) - we proposed at §489.28(a) to require the HHA to “have available sufficient the time of application submission and at all times during the enrollment process to operate the HHA for the 3 month period after Medicare billing privileges are conveyed by the Medicare contractor.” 2

Face to face encounters with providers related to home health and hospice.1. 3 months prior to start of care
2. 30 days after start of care if no face-to-face encounter took place 3 months prior to start of care.


1 CMS-1510-F page 1
2 CMS-1510-F page 243

Medicare Therapy Provisions for Home Health Starting January 2011

A. If more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must perform the assessment and periodic reassessments. The measurement results and corresponding effectiveness of the therapy, or lack thereof, must be documented in the clinical record.

B. At least every 30 days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient in accordance with §409.44(c)(2)(i)(A).

C. If a patient is expected to require 13 therapy visits, a qualified therapist (instead of an assistant) must provide all of the therapy services on the 13th therapy visit and functionally reassess the patient in accordance with §409.44(c)(2)(i)(A).

Exceptions to this requirement are as follows:
1. The qualified therapist’s visit can occur after the 10th therapy visit but no later than the 13th therapy visit when the patient resides in a rural area or when documented circumstances outside the control of the therapist prevent the qualified therapist’s visit at the 13th therapy visit.
2. Where more than one discipline of therapy is being provided, the qualified therapist from each discipline must provide all of the therapy services and functionally reassess the patient in accordance with §409.44(c)(2)(i)(A) during the visit associated with that discipline which is scheduled to occur close to but no later than the 13th therapy visit per the plan of care.

How a Physical Therapy progress note must be done in a home health setting.

A physical progress note should use statements which can be used to assess the patient’s response to therapy such as:
a. “Able to perform exercises as prescribed for 15 reps”
b. “Able to safely transfer from bed to wheelchair with standby assistance”
c. “Can now abduct shoulder 120 degrees”
d. “Can bridge now sufficiently to pull slacks up over hips”

Therapists should avoid terms when writing progress notes such as:
a. Doing well
b. Improving
c. Less pain
d. Increased range of motion
e. Increased strength
f. Tolerated treatment well

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