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  • Final Home Health Rule Cements PDGM, Allows PTAs to Perform Maintenance Therapy

    When it comes to its most talked-about provisions, the US Centers for Medicare and Medicaid Services' (CMS) final rule for home health payment under Medicare isn't much of a change from the proposed version released earlier this year, meaning that an entirely new payment system will indeed be rolled out beginning January 1. But other parts of the rule have been tweaked—and in several areas, those tweaks represent wins for the physical therapy profession and the patients it serves in home health settings. [In addition to the lengthy final rule, CMS also offers a fact sheet summary.]

    It's official: PDGM is on for 2020.
    There wasn't much debate about whether this would happen, but the final rule eliminates any doubt: the Patient-Driven Groupings Model (PDGM) will be the system under which CMS pays home health agencies (HHAs). It's a big change, and APTA offers extensive information on the details of the model, but the bottom line is that the PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The system classifies 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. CMS says it will monitor how HHAs are operating under the PDGM, including the provision of therapy services.

    Overall payments will increase by 1.3%.
    CMS projects an annual increase of about $250 million in payments related to home health.

    "Behavioral adjustments" will still be used—but they won't be as large as proposed.
    In anticipation of the possibility that HHAs will alter their practices to maximize payment under the PDGM, CMS had proposed a "behavioral adjustment" that reduced payments by 8.01%. The final rule lowers the negative adjustment to 4.36%.

    PTAs will be able to perform maintenance therapy under the home health benefit.
    The final rule follows through on an APTA-supported proposal to allow physical therapists assistants (PTAs) and occupational therapy assistants (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 PTA or OTA, the qualified therapist still would be responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days.

    A question about pain still will be available to patients.
    In addition to removing a quality-reporting measure on to pain interfering with activity from the Quality Reporting Program, CMS also proposed eliminating a home health consumer survey question about whether the patient and provider had discussed pain in the past 2 months. APTA and other organizations pressed for that question to remain, and CMS relented. The pain interfering with activity quality measure has been removed, however.

    Split payments are going away, and Requests for Anticipated Payment (RAPs) will be gone by 2022—but a modified RAP process will be in place beginning in 2021.
    CMS is phasing out the split percentage payment approach beginning in 2020. The split percentage payment amount, paid in response to a RAP, will shift from an upfront 60%-initial, 50%-subsequent payment for each 60-day period to 20% for both initial and subsequent 30-day periods of care. Then, beginning in 2021, there will be no upfront payment made in response to a RAP; however, all HHAs will be required to submit a "no-pay” RAP every 30 days to alert the claims processing system that the beneficiary is under a home health period of care. HHAs must submit the “no-pay” RAP within 5 calendar days of each 30-day period or be subject to a late penalty. Beginning in 2022, CMS will eliminate RAPs and instead require HHAs to submit a Notice of Admission (NOA) every 30 days; agencies must do so within 5 calendar days of each 30-day period or be subject to a payment penalty. CMS says that because they are removing upfront payment associated with the RAP, the agency is relaxing the information needed to submit the “no-pay” RAP and subsequent NOA.

    Want more on PDGM? Sign up for the November 20 APTA "Insider Intel" phone-in session, where the home health system will be discussed along with the final Medicare physician fee schedule.


    • I am taken back by the PTA'S providing maintenance! It reduces a PTA to a restorative type aide, with maintenance they can't be progressed! This is horrible for PTA'S like myself who have been practicing for 20 plus years. I am very disappointed in how we are being treated as opposed to nurse practitioners and PA'S? I only see one them when I pay regular visit price for office visit? How is that any different?

      Posted by Mary Marbut on 11/5/2019 7:48 AM

    • Replying to Mary Marbut, I work in a small town HH agency and having a PTA be able to do the maintenance program is a huge plus for us. This option opens up rehab avenues for patients that we couldn't take advantage of before due to staffing. Besides, it was up to to the PTs to provide maintenance programs prior to this shift, so did that make the PTs a restorative type aide?

      Posted by Chris Kozlowski on 11/6/2019 6:54 PM

    • does the APTA receive any money from the AOTA?

      Posted by mike spitz on 11/7/2019 7:14 AM

    • I agree with Chris. Allowing a PTA to provide maintanance therapy is a huge big deal. It will be greatly beneficial for the client as well as the PT profession. There are certain diagnoses such as parkinsons that require the on going skills of a physical therapist in order to maintain functional mobility. Without the skilled physical therapy, the client may decline each time they are discharged and decrease their quality of life and increase their risk for falls. The treatment still involves a plan of care with an on going goal which would be above and beyond what a restorative aide could provide.

      Posted by Michele Dart on 11/13/2019 9:13 PM

    • In response to Mary. Mary, I think you are not understanding what has changed. Only PTs and OTs were able to bill for maintenance therapy before, making it difficult for PTs and OTs to perform more of their detailed assessments, evaluating, and discharging when a qualified PTA or OTA/COTA could be performing those treatments. I never understood why that was in place anyway. I am glad this has been changed, and look forward to getting to keep patients that have intense progressive diseases and diagnosis that I would lose as patients before due to them becoming to ill to make progress. This allows PTAs that have been working with a patient to keep them at a certain level, hence maintenance therapy. I hope you understand this will help the world of therapy from my perspective.

      Posted by Dewayne Trobaugh on 11/19/2019 9:45 PM

    • On the same subject any PTAs seeing a pay cut with upcoming changes?

      Posted by Sue rovinsky on 12/6/2019 3:09 PM

    • I am a physical therapist working at at home health setting for the past 5 years. I've been increasingly becoming an evaluation and discharge machine. I'm utilizing a lot of ptas. Recently two of my ptas have had substantial pay cuts of about 40%. What is the APTA doing to address the pay cuts. The cost of education continues to go up, the cost of living continues to go up why are we seeing a reduction in payment? stop trying to get dry needling approved in states and start focusing on increasing reimbursement rates. For God's sakes people are losing their freaking jobs...

      Posted by Stijn on 12/11/2019 7:06 PM

    • Just wondering about the wording, "PTAs will be able to do maintenance programs under PDGM" This means now ONLY PTAs can do maintenance, or PTAs and PTs can do maintenance programs?

      Posted by klaas dewit on 12/15/2019 8:52 PM

    • Just got an 11% pay raise with Amedisys

      Posted by Brian Hutchinson on 12/19/2019 12:33 AM

    • I just got a 45% pay reduction with Choice Home Health!! Basically told that PT was no longer an important service to them and it was about the bottom line. I have been working in HH for 15 years.

      Posted by jstewart on 12/29/2019 4:27 PM

    • Looking for help on supervision requirments for PTA's in home health setting. Can't seem to find a solid answer, but have been scouring the APTA website, etx. Any helpful resources????

      Posted by LAURA CHEVREAUX on 1/20/2020 10:22 PM

    • Per the federal home health regs:G728 (Rev. 182, Issued: 09-28-18, Effective: 09-28-18, Implementation: 09-28-18) §484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. Interpretive Guidelines §484.75(c)(2) An assistant must be supervised by a skilled therapy professional for the assistant’s respective therapy type. For example, only a physical therapist may supervise a physical therapist assistant and only an occupational therapist may supervise an occupational therapy assistant. The applicable therapist should monitor and evaluate the therapy assistant’s performance with regard to provision of treatments, patient education, communication with the therapist, and data collection regarding the patient’s status and health needs (as delegated by the therapist). Only the skilled therapist may perform comprehensive assessments, patient evaluations, care planning and discharge planning. The agency would need to create a policy for the frequency of supervision as well as other pertinent details. (For nursing, the standard is every 30 days for the the RN to supervise an LPN. For CNAs, the federal regs require an onsite supervisory visit (aide present or not) at least every 14 days.) Hope this helps!

      Posted by Carol Eastburg on 1/28/2020 1:54 PM

    • I am a PTA of 15 years and 12 years of home health. I am responsible for 30 hours of continuing education a year and I invest yearly in my education to be a good versatile therapist. I at times have more training than the PTs I work with. I feel like doing maintenance therapy is a slap in the face as I Feel you can teach a restorative aide to do this. I do feel bad for PTs whom have gone to school so long to be a eval/dc machine and not getting to treat. I feel we both learn from each other and we both need to be treated respectfully in our professions. I recently had to take a 5% pay cut, and then expected to start doing nursing duties like breath and bowel sounds and even told to do a PTINR which is out of my s hope. All do to PDGM

      Posted by Shawna on 2/11/2020 1:56 PM

    • I am a P.T. in florida and thanks to PDGM I am out of work. I am a contractor and scrambling to get any kind of patients and at the same time with a major paycut. if i do get them, they are strictly evals and dc's. the irony is ( nothing against the PTA'S) that my pay is marginally higher than the PTA's , they get all the visits, not the excessive paperwork and i am the one providing the work for them and not able to meet ends!!!!!!

      Posted by bari azirovic on 2/14/2020 10:07 AM

    • I'm PT in Illinois and also scrambling to find patient. PTA's had taken most of my patients and just doing eval discharge. Agencies are using PTA's and has better salary than me. What's happening to PT and home health! When are PT going to wake up to what's happening around? A lot of PT are out of work.

      Posted by ABeltran on 2/17/2020 7:30 PM

    • Can someone please inform me if you can begin a maintenance program in home health at the PT 30 day re-eval or is the only time the maintenance program can be initiated is at recert?

      Posted by Bonnie LaFollette -> >NP]=J on 2/26/2020 2:16 PM

    • @Bonnie: Please refer to Medicare Benefit Policy Manual Chapter 7, including Section 40.2.1(d) for CMS guidance regarding maintenance therapy coverage requirements: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf. If you have additional questions, please contact us at advocacy@apta.org.

      Posted by APTA staff on 2/27/2020 6:42 AM

    • PTA of 18 years . Ive worked home health In rural areas outside of Corpus Christi mainly for contract companies , my workload has decreased from 35-40 visits a week to 15-20 visits a week with a pay cut of -10 dollars per visit , they are now paying us what I was earning 10 years ago and with lower overall volume . Patient are being evaluated an DCd post 8 visits regardless of any factors. Many HHA have closed in my area and a lot of my fellow PTAs are out of work right now with few full time jobs , only jobs available are PRN and from what ive heard jobs offered at full time are just to attract employees then they are reduced to part time after one or two weeks, some of my friends have moved long distances and uprooted their families to take these jobs only to be let down and hours cut post 1-2 weeks. PTA was a good living if you worked hard, now I wouldn't recommend any young person to pursue this career as wages are decreasing as cost of living goes up and there is absolutely no advancement possible . Best wishes to all my colleagues.

      Posted by Gerardo Salinas on 3/5/2020 11:01 AM

    • I also work for Amedisys. Yes in theory we got a raise , but if you really look at the time you are putting in for all the extra work , the “ raise “ was really a cut. No matter how you look at it. Your quota you had before is now added 3 more visits to make your “ raise” . Also, nothing has been sent out from GA stating that we as PTAs can do maintenance therapy.

      Posted by Haley Coursey on 3/8/2020 9:19 PM

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