Therapy under PDGM (Part 4)

CMS proposal would allow therapy assistants to provide maintenance therapy

EDITOR’S NOTE: Our summer series of blog posts on the future of therapy under PDGM concludes today, as we examine a new proposal by CMS to allow therapy assistants to provide maintenance therapy. Be sure to check out our previous posts on this topic.

As home care providers look for more cost-effective therapy utilization under the Patient-Driven Groupings Model (PDGM) next year, the Centers for Medicare and Medicaid Services (CMS) is offering one means of potentially reducing costs.

Under the proposed rule for 2020 released by CMS last Thursday, CMS would allow therapy assistants to perform maintenance therapy for patients covered by the home health benefit.

“This may be of value to home health agencies looking at ways to curb the cost of therapy under PDGM,” said J’non Griffin, owner and president of Home Health Solutions. “CMS has said it wants to recognize the value of therapy assistants and help home care providers better utilize resources.”

The change would also bring home health in line with other post-acute sectors, such as skilled nursing facilities, which already allow therapy assistants to perform maintenance therapy, J’non said.

Home health is re-thinking therapy utilization in anticipation of a new Medicare payment methodology which will become effective Jan. 1, 2020. Under the new payment system, therapy volume will no longer drive reimbursement, with pay depending instead upon unique patient characteristics such as principal diagnoses, co-morbidities, admission source and level of functional impairment.

“CMS has said it believes approving the use of therapy assistants for maintenance therapy would allow home health agencies more latitude in their resource utilization,” J’non said.

Specifically, CMS is proposing to modify regulations language at §409.44(c)(2)(iii)(C), which currently states that only a qualified therapist, and not an assistant, can perform maintenance therapy. If the change is approved, the maintenance program the therapy assistant is following would still need to be established by a qualified therapist.

What is maintenance therapy? Regulations at §409.44(c) set out the skilled service requirements for physical therapy, speech-language pathology services, and occupational therapy under the home health benefit.

Two types of therapy are covered: restorative therapy, when the goals of care are geared towards patient improvement, and maintenance therapy, which is designed to prevent or slow further decline/deterioration of the patient’s condition.

Currently, the Medicare home health benefit allows therapist assistants to perform the first type of therapy, restorative therapy, when improvement in the patient’s condition is expected to occur. However, only qualified therapists may provide maintenance therapy, when improvement is not expected to occur.

A 2013 court ruling issued in the case of Jimmo v. Sebelius clarified that Medicare does not require expectations of improvement in a patient’s condition for coverage of skilled therapy services.

“Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition,” J’non said.

“The specific language used in the Medicare program manual is that coverage does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”

Therapy assistant qualifications

Therapy assistants would still need to meet certain Medicare regulations in order to perform maintenance therapy under the proposed change. Regulations at §484.115(g) and (i) state that qualified occupational and physical therapist assistants must meet these requirements:

· Must be licensed as assistants unless they are practicing in states where licensure does not apply. Therapists in states where there is no licensure must still meet certain education and/or proficiency examination requirements.

· Must be registered or certified, if applicable, as assistants by the state in which they are practicing

· Must be graduates of an approved curriculum for therapist assistants

· Must have passed a national examination for therapist assistants

Some details remain fuzzy

Some details about the proposal to allow therapy assistants to practice maintenance therapy have not been determined, according to J’non.

For example, CMS has not specified whether it would require therapists to provide more frequent patient reassessment or maintenance program review when the services are being performed by a therapist assistant.

“There’s also some discussion going on about revising therapy codes,” J’non said. “There are a couple of options.”

One option would be to change the description of therapy codes to indicate whether maintenance services were performed by a physical or occupational therapist assistant (G0151 and G0157) or by a qualified therapist. Another option would be to remove the therapy code indicating the establishment or delivery of the physical therapy maintenance program by a physical therapist (G0159).

Voice your opinion CMS wants to know what you think about the proposal to allow therapy assistants to perform maintenance therapy. Do you like the idea? Do you believe it would affect the quality of care? What do you think about revising therapy codes?

Make your comments electronically here by following the "Submit a Comment" instructions, Be sure to refer to file code CMS-1711-P.

Home Health Solutions can help Does your agency need help preparing for PDGM? The Home Health Solutions staff is friendly, knowledgeable and eager to help. Contact us today to see how we can help you.