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  • Proposed Home Health Rule Moves Ahead With New Payment System, Allows Therapist Assistants to Furnish Maintenance Therapy

    The US Centers for Medicare and Medicaid Services (CMS) intends to go full steam ahead with its plans to shift to a new payment system for home health beginning in 2020. The plans are accompanied by other changes that include allowing maintenance therapy to be furnished by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), providing a payment "add on" for rural home health care, and adopting an APTA-supported "notice of admission" requirement to avoid duplicate billing. The new provisions, which include a 1.3% payment increase, are included in CMS’ proposed rule released on July 11.

    The biggest shift has been more than a year in the making: a transition to a new payment system known as the Patient-Driven Groupings Model (PDGM). The PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. Instead, the system classifies 30-day care episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. APTA offers extensive information on the new system and will participate in a live August 5 webinar on the model jointly hosted by APTA, CMS, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. APTA members can participate in this webinar (free to APTA members, login required APTA members can participate in this webinar).

    But that's not all in the proposed rule (.pdf). CMS also plans to allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the therapist assistant, the qualified therapist still would be responsible for the initial assessment; plan of care; maintenance program development and modifications; and reassessment every 30 days. CMS believes the change would bring home health in line with other care settings and give home health agencies (HHAs) more latitude in how they allocate resources.

    The rule also would phase out the split payment approach that requires HHAs to submit a Request for Anticipated Payment (RAP) at the beginning of the initial episode for 60% of the anticipated final claim payment amount. A final bill for the remaining 40% is submitted at the end of the 60-day episode. RAP submissions are operationally significant, as they establish the beneficiary’s primary HHA by alerting the claims processing system that the beneficiary is under a home health plan of care and home health services are subject to consolidated billing, meaning Medicare makes payment for all home health items and services to the single HHA overseeing the plan of care.

    Instead, CMS proposes requiring HHAs to submit a notice of admission to alert the claims processing arm of CMS that a beneficiary is under a home health episode of care. The new system is a direct result of APTA advocacy, which was fueled by members in private practice settings who shared data with the association to help APTA make its case. The change will be phased in next year and fully implemented in 2021.

    APTA and its members successfully argued that the split percentage approach is fraught with logistical inefficiencies that often result in confusion for CMS and therapy providers in outpatient settings. The proposal to replace the RAP with the notice of admission, to be submitted within 5 days of the start of care, would be needed to establish the primary HHA so the claims processing system would be alerted to a home health period of care, helping to eliminate the possibility of any lag time between a beneficiary's admission in home health and the HHA's notice of the admission to CMS. This too-common delay trips up outpatient providers who begin treatment (and billing) before CMS knows that the beneficiary has transitioned to home health. CMS describes the change as "an important step in paying responsibly and appropriately for home health services," according to an agency fact sheet on the proposed rule.

    As for payment, home health would see an overall 1.3% boost—about $250 million. The increase, initially targeted at 1.5% to comply with the Bipartisan Budget Act of 2018, was decreased by .2% to accommodate a rural add-on policy.

    Among other elements of the proposed rule:

    SPADE requirements are expanding. CMS is continuing its efforts to increase the range of standardized patient assessment data (SPADE) reported by HHAs. The use of SPADE in home health was instituted to bring HHAs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care settings. The proposed rule would follow through with the expansions, but it also includes requirements for reporting on cognitive function and mental status, comorbidities, and social determinants of health, among other categories. HHAs would be required to report these additional elements beginning in 2022 for admissions and discharges that occur between January 1 and June 30, 2021.

    A pain measure would be discontinued. Partially in response to concerns about the potential for overprescription of opioids, CMS is proposing to remove the Improvement in Pain Interfering with Activity Measure (NQF #0177) from the Home Health Quality Reporting Program (HH QRP) beginning in 2022. Under this proposal, HHAs would no longer be required to submit OASIS Item M1242, "Frequency of Pain Interfering with Patient’s Activity or Movement" for quality reporting purposes beginning in 2021.

    A pain-related question would be deleted from patient surveys. CMS proposes to remove a patient survey question that asks whether the patient and provider talked about pain in the past 2 months. The question, currently in the "Special Care Issues" composite measure, would be dropped beginning July 1, 2020. Similar to the pain measure being proposed for deletion, the survey question is being eliminated due to concerns about the ways it might influence unnecessary drug prescriptions. The changes are consistent with an earlier CMS decision to eliminate pain-related items from hospital patient surveys.

    APTA continues to review the proposed rule and will provide comments to CMS by the September 9 deadline. In the coming weeks, APTA also will post a unique template letter on its Regulatory Take Action webpage for individuals to use to submit their own comments on the proposed rule.

    Comments

    • How will these changes improve patient care? Already too much time is spent on assessments and evaluation and not enough on treatment.

      Posted by Janw Way on 7/14/2019 10:14 AM

    • If a HHA does not currently employ PTAs, would the PT be able to manage a maintenance program for appropriate patients?

      Posted by Traci Reindle -> ?NYZ=K on 7/14/2019 1:22 PM

    • @Traci: right now PTs are permitted to furnish maintenance therapy in home health but PTAs are not. The rule is proposing to also allow PTAs to furnish maintenance therapy under a maintenance program established by a PT.

      Posted by APTA Staff on 7/15/2019 7:30 AM

    • Very helpful thanks, also thanks for the hard work , representing our interests .

      Posted by Ed bunn on 7/16/2019 10:04 AM

    • Does this apply exclusively to home care provided by agencies and Medicare Part A services?

      Posted by Stacey on 7/17/2019 4:22 PM

    • Just want to thank the APTA and the PT Associations of each state for continuing to fight for our profession and for our patients.

      Posted by Carlo on 7/17/2019 5:05 PM

    • PDGM will decrease the utilization of therapy. It’s great that the laws will try to protect this from happening, but companies will cut back due to it no longer driving revenue. Couple this with the continued use of PTAs to save money and the amount of PT schools opening(flooding the market). The market for home health PTs will never be the same. :(

      Posted by Chris on 7/17/2019 5:07 PM

    • How will this work for supervision of PTAs under PART B if the patient is seen in the home setting. Basically, will PT have to be “onsite” or can they be seen on PART B by the PTA without “onsite supervision”? Thank you.

      Posted by Brent Cox on 7/17/2019 5:30 PM

    • The Federal Govt’s “bureaucratizing” & micromanagement of healthcare is causing a decline in quality of care — not any lack of compliance or efficiency of reporting/billing/statistics/payments. Medicare would “do better” (ie, save money & improve quality of care) by going back to a flat rate per visit with “certifications” that the patient was continuing to need service(s).

      Posted by K Daly-McEver on 7/17/2019 9:32 PM

    • As a PT trying to support all the patients appropriate for maintenance PT , this rule change is very needed and appreciated . I supervise at least 6 PTA's who have the heart and skills to maintain my patients' functional status -- thank you !

      Posted by Lorraine Gohr on 7/17/2019 9:46 PM

    • Can you tell me more about maintenance therapy? Or maybe provide a link on info about it? I had the impression that once the patient reaches a plateau we have to dc but some of the patients have difficulty following through after dc Increasing the likelihood of a regression. Thanks.

      Posted by Roselyn Ursua on 7/17/2019 9:51 PM

    • Wondering, how WILL we be able to document improvement in function from improvement in pain, if deleting the pain questions? Frankly, I often show progress from pain "all the time' or "daily" to less often. Because we fear over prescribing does not make the fact of pain disappear. Ignoring its existence does not alleviate the problem. Solutions? Or am I missing a component somewhere else that addresses the issue of pain?

      Posted by Pauline Navarro on 7/18/2019 9:14 AM

    • Thank you a PTA for trying to improve the quality of home Care and reduce the amount of fraud and over-utilization. just last night I was reviewing a patient chart to prepare to see next week as the current PTA is on vacation. I am not the supervising PT of this patient or PTA. This patient has been seen since January 5th and has received 79 PT visits. This is insane! I am counting on PDGM to never allow this to happen again. I fight this and other ethical battles currently everyday to the point where I feel I can no longer practice in the home Care setting. I have always been proud to work with patients in their home and consider it a privelege. But the rampant HHA poor management, fraud, incompetence and lack of oversight is pushing me out of the setting. I plan to pursue other sources of income for the rest of the year and then see how 2020 shakes out. If I see drastic necessary improvements then I will get back to doing what I love to do. But I fear HHA will find the loopholes.

      Posted by Betsy Brooks on 7/18/2019 12:00 PM

    • @Roselyn: APTA has a number of resources on skilled maintenance therapy that describe when skilled maintenance is covered by Medicare. See: https://www.apta.org/Payment/Medicare/CoverageIssues/SkilledMaintenance/

      Posted by APTA Staff on 7/18/2019 1:38 PM

    • @Stacey: Yes, this proposal is exclusively related to therapy being furnished by the HHA under the home health benefit (Part A). CMS is proposing to modify regulation 42 CFR 409.44.

      Posted by APTA Staff on 7/18/2019 1:39 PM

    • @Brent: CMS is proposing to allow PTAs to deliver maintenance therapy under the home health benefit, which is Medicare Part A. CMS is proposing to modify regulation 42 CFR 409.44. CMS is not proposing to change the rules under Part B.

      Posted by APTA Staff on 7/18/2019 1:40 PM

    • @Pauline: I agree with you whole-heartedly, that the pain question should not be removed from the OASIS. Physical therapists are already being called upon to help alleviate pain in the face of the opioid crisis, and we are doing an excellent job of it. If we don't have a pain measure to show the role we are playing in combating pain, we will lose another way proving the effectiveness of and justifying our much-needed services.

      Posted by Matthew Agen -> BJQaEJ on 7/18/2019 7:46 PM

    • @Pauline: Pain remains a concern for many patients and removal of this item would leave the OASIS without a pain assessment. Pain interference speaks to how pain may limit a patient’s function and provides important information to the provider to ensure that they work to assist the patient with pain management strategies that can limit the pain they have with functional activities. We encourage you to share your feedback with CMS through formal comments. APTA will be making available a unique template letter that addresses this issue, among others, within the coming weeks, so please be on the lookout.

      Posted by APTA Staff on 7/19/2019 6:32 AM

    • So with the maintenance therapy, how long will patients be allowed to be on therapy? One year? I work in NY and we have to see PTA patients every 6th visit- I wonder if that will eliminated with this.

      Posted by Melissa PT on 7/20/2019 10:12 AM

    • @Melissa: The coverage requirements for therapy are not changing unless CMS modifies the regulations to require more frequent PT visits when a patient is receiving maintenance therapy furnished by a PTA. Currently, Medicare regulations require the therapist reassessment to occur at least once every 30 days (in the proposed rule, CMS is actually asking for comments on whether they should require more frequent therapist visits when maintenance is being delivered by the therapist assistant). If your state requires more frequent visits than Medicare, then you would need to continue to follow the more stringent regulations put forth by your state.

      Posted by APTA Staff on 7/22/2019 9:45 AM

    • I am a PTA working PRN at the age of 71. I can not understand how anyone would think that removing a question about pain would change the fact that the patient has pain which limits functional activities. Not asking a question to give us a better idea on the limiting factors will not be a good indicator on patient progress. Adding questions concerning the amount of pain killers needed to control their pain would be more helpful.

      Posted by Linda Hedrick on 7/22/2019 1:29 PM

    • Are PTs being reimbursed for their services higher than PTAs? Is this still being proposed or already in effect?

      Posted by Allan on 7/25/2019 9:55 PM

    • This issue serves well to drive home a point about the arbitrary, at best, and possible lobbyist role, in Medicare regs. Why does outpatient part B require onsite supervisions, a setting where clients are typically healthier and interventions are not drastically different, require “onsite” PT supervision of PTA, while often more critically ill pts in homehealth and hospital settings allow for “readily available for consultation” supervision? Is there a logical explanation for this, or did deeper pockets prevail in the establishment of these rules/regulations?

      Posted by Bill on 7/27/2019 9:11 AM

    • It is insulting that we are being deceived to believe there is an ongoing effort to reduce administrative burden when you examine the details of PDPM for SNF. The administrative burden for this payment model will be untenable. MDS coordinators are going to spend hours scouring hospital records to support primary/principle dx, SLP comorbidities, determining “active” dx status, conducting physician queries (we all know how easy it is to obtain timely feedback from physicians), insuring section GG reporting is consistent (I would be willing to bet ZERO inter/intra-rated reliability studies have been done for this measure, yet we will be in jeopardy of payment denial if reporting discrepancies exist), or MDS coordinator will spend additional time “creatively” rectifying discrepancies which arise from overlap in GG measures reported by nursing and PT/OT), MDS will have to compare ICD-10 coding to mapping file to insure it is not a “return to provider” code, minutes will still be tracked and compared to insure we don’t “cheat” even though the incentive for the new model is to move away from “volume of service” payment model to a “pt’s needs” payment model; we are threatened that if minutes drop we will be punished! How does this make sense when CMS is acknowledging their payment model incentivized a high volume of care? Why is CMS allowed to divise policy around finacial realities, but providers that do so are immoral and fraudsters? This whole paradigm of the healthcare system is hypocritical, and unacceptable. We need a level playing field, and trying to implement social policies into a free market world guarantees frustration and poor quality healthcare. Free market principles is the best avenue available to guide high quality, cost effective healthcare in the USA.

      Posted by Bill on 7/27/2019 9:47 AM

    • Think of the irony. PTA's Have an H.S. diploma and two years of certificate level training. PT's have 8 years of brutally intense University level education. A PTA in a home does not possess the medical safety required, of any kind to assess a medical crisis, none at all, except maybe seeing their patient dead on the floor. Medicare to save 20% is endangering hundreds of thousands of innocent people lives.

      Posted by Dr. John Dempsey on 7/27/2019 11:57 AM

    • @dr John Dempsey Your comment is pretty harsh and generalized. I know plenty of Pt’s with only a certificate in Pt so are they not qualified? Some Pta’s Have bachelors or even masters degrees. Here in nj it’s not a certificate it’s an associates degree just FYI. A degree does not automatically correlate to competence. Are you even familiar with the Pta curriculum to make such statements that an assistant is in no way qualified unless their patient is dead in the floor?!?!? Come on man i get what you are saying about the money and cost factor but sheesh that’s harsh.

      Posted by Brian meyers on 7/29/2019 11:45 AM

    • Is CMS excluding patients coded as skilled maintenance from Home Health Compare statistics? Since these patients are not expected to improve in ambulation, bed transfers, etc, agencies may be hesitant to market a skilled maintenance rehab program for fear of worsening their HHCompare "report card". But there are patients who qualify & need the skilled maintenance therapy that can help them remain at home longer and reduce adverse event- and institutionalization-related health care costs...

      Posted by Cindy Moore -> >GSbB on 7/30/2019 11:55 AM

    • @ "Dr" John Dempsey, paint with broad strokes much? (not to mention a bit dramatic). As a so-called doctor you should probably do a little more research regarding any disciplines that you decide to publicly bash...As a PTA in NJ for 20 years I'd be glad to educate you on your ignorance.

      Posted by Jason Filoon on 8/10/2019 11:18 PM

    • I know the pain question is being removed from the OASIS, but that doesnt necessarily mean we cant address pain in our plan of care. I know I will address it, even though Medicare will not use it as a measurable component.

      Posted by C Henderson, PT, DPT on 8/30/2019 11:08 PM

    • Regulatory oversight will not be enough to police HHAs into proper utilization of therapy services for it’s patients, and in many cases it’s not their fault. There is simply not enough reimbursement for the HHA to survive when providing therapy to patients with a functional decline and with what ranks as a low index Dx(which directly drives payment). Simple truth, this effectively moves therapy back to the Stone Age in terms of intervention in HH. Putting the purse strings in full control of the agency, with no specific component for therapy reimbursement, and expecting outcomes relative to what should be proper utilization of therapy to proliferate the optimal function of each patient is a pipe dream. It will never happen... speaking from 23 years in the field.

      Posted by Clay Lanford on 8/31/2019 6:08 AM

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