Frequencies under PDGM

Disappearing therapy thresholds have agencies searching for 'magic formula' under Medicare's new payment model

Frequencies are the holy grail of home health right now, as agencies scramble to put together dedicated physical and occupational care pathways for specific medical conditions to help determine resource use.

There’s good reason inspiring the search. By ending volume-based therapy services with the implementation of a new payment model on Jan. 1, the Centers for Medicare and Medicaid Services (CMS) is forcing home care providers to feel their way through new patient-based variables without the comfort of familiar thesholds.

Everyone agrees that having some guidelines in place for delivery of services under Medicare’s new Patient-Driven Groupings model is probably a good idea, but is there really a magic formula?

The magic formula

The truth is ….complicated.

Having sound guidelines in place to establish frequencies of care depending upon the patient’s specific medical condition will definitely help agencies deploy personnel in a more efficient and effective manner, says Heather Calhoun, Director of Special Projects and Appeals at Home Health Solutions LLC.

That's particularly important in light of fiscal uncertainties for the first quarter of the year, when industry experts warn that transition to the new payment model could bring about cash flow shortages due to shorter billing cycles and other financial issues. Most agencies are trying to curtail costs, streamline resources and pare down where they can. Having clinical pathways in place to guide utilization is an attractive option.

"While it’s a smart idea to develop clinical pathways, there are some problems that agencies will want to watch out for," Heather warns.

Medicare wants patient needs to drive delivery of care and services. Agencies depending too heavily on pre-determined pathways of care in which visit frequencies are not dictated by patient specifics may quickly find themselves in trouble.

"What if you have a patient who improves more rapidly than expected?" Heather says. "What if the patient is doing so well you really need to consider an early discharge?"

Agency policy may indicate that additional visits are generally needed for patients with the patient's particular set of functional limitations — but if your agency is doggedly following the standard protocol and provides those visits, Medicare may look at the patient’s improvement and determine that the last few visits were unnecessary, and therefore not billable. Follow the need ...

"In the case of a patient who improves much more rapidly than anticipated, members of the care team really need to be on top of it," Heather said. "You can't just follow a set of guidelines dictating additional visits. Your COTA or PTA is going to need to call the therapist and say, 'Hey, you probably need to get out here and decide whether we need to keep seeing this patient.' All members of the care team are going to have to be aware that what's actually going on with the patient drives the next visit -- not necessarily what's written in the treatment plan as far as frequencies."

Therapy frequency and intensity must align with patient needs, which are determined by objective, measurable testing, and patient-centered goals for rehabilitation, Heather said. Those elements often change thrughout the episode of care.

"As long as you are responding to the patient's current needs, and providing skilled services that address the current goals, your visits are probably going to be billable," Heather said. "The key is for therapists to tailor those clinical pathways and frequencies to each particular patient."

Effectively documenting what’s going on with the patient will establish the need for therapy services, she said, so focus on making sure your documentation establishes medical necessity for all visits. Therapy webinar recordings for sale Recordings of all three of Heather's recent webinars on "The New Role of Therapy Under PDGM" are now available for purchase in The Solutions Shop, the online store on the Home Health Solutions web site. Two focus on effective documentation under PDGM and the third discusses therapy utilization. Webinars may be purchased individually or in a package of three, which includes our new "Value of Therapy Under PDGM Guide to Therapy Documentation. The guide shows therapists how to make sure every visit is a billable one by documenting ongoing medical necessity. It introduces our "EARNED" acronym, a way of helping therapists review therapy documentation to make certain all bases are covered to avoid claim denials.