Eli's Rehab Report

Published on Wed Sep 08, 2010 PDF

Heed these warning signs before you contract with another agency.

Your therapy assistants may not have as much work starting next year, if the feds get their way.

The new home health prospective payment system rule proposed by the Centers for Medicare & Medicaid Services contains documentation and assessment requirements for home health agencies utilizing therapy -- and the fallout isn't pretty.

Problem: Agencies' proposed documentation requirements must be completed by a therapist, not an assistant.

For instance, reassessments required every 30 days and on the 13th and 19th visits will have to be personally performed and documented by qualified therapists only, according to the PPS proposed rule in the July 23 Federal Register.

PTA Documentation Won't Save The Day

And don't expect assistant documentation to save your therapy reimbursement. "Clinical notes written by therapy assistants may supplement the clinical record" only, CMS specifies in the rule. Assistant notes "must include the date written, the signature and job title of the writer, and objective measurements or description of changes in status (if any) relative to each goal being addressed by treatment," CMS lays out. "Assistants may not make clinical judgments about why progress was or was not made, but must report the progress (or lack thereof) objectively."

In other words: "We are proposing that physical therapist assistants or occupational therapy assistants could objectively document progress between the functional reassessments by a qualified therapist and/or physician," CMS explains in the rule. "Clinical notes written by assistants are not complete functional assessments of progress." CMS also makes clear that in cases where therapy visits for maintenance programs are covered, the visits must be provided by therapists themselves, not assistants.

New Codes Pose A Therapy Ratio Reality Check

CMS has also proposed new billing codes to keep track of agencies' therapist versus therapy assistant visits.

Currently, agencies use G0151, G0152, and G0153 to report physical, occupational, and speech therapy visits, whether furnished by therapists or assistants. But starting on Jan. 1, CMS wants those codes to apply to visits furnished by "qualified therapists" only. Therapy assistant visits will be reported using their own G codes.

Why: CMS based its initial PPS base payment rate on data indicating 79 percent of therapy visits were furnished by therapists. Now the agency wants to see if that ratio still holds. And future reimbursement could hinge on the result.

State Laws & Practice Acts Encourage Fewer Therapist Visits While therapists used to provide 79 percent of therapy visits, "I'm not so sure [that is] the average we're at" anymore, says Cindy Krafft, PT, with consulting firm Fazzi Associates.

Some states have very strict supervision rules and so the HHAs there use virtually no PTAs or COTAs, she notes. But in other states with liberal rules, some agencies will have one full time PT and six PTAs, for example, leading to a much lower percentage of therapist visits.

Some agencies use contract therapists where "the physical therapists do the initial evaluation and then assign the patient to a therapy assistant," adds Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. Many agencies argue that nothing in their state practice acts require PT supervisory visits, notes Sparkle Sparks, PT, consultant with OASIS Answers. To save money, the agencies already try to minimize sending out therapists.

Reality: This heavy reliance on therapy assistants rather than qualified therapists means CMS' payment rate data is skewed -- and that's what CMS is trying to fix. However, it should also be worrisome for therapists.

PT licensure hinges on seeing patients every 30 days. That means a shrinking pool of agency contracts or over-reliance on assistants could jeopardize your therapists' ability to work at all. "If I don't do it, they can yank my license," Sparks warns.