Excerpt from Home Health Line – June 18th 2018|Vol 43, Issue 25
Utilization of maintenance therapy in home health hasn’t significantly changed despite CMS launching a webpage last year to educate providers about it.
Industry experts cite a multitude of reasons for this, including a lack of trust that reviewers will truly understand that maintenance therapy is a covered service. But for those agencies that see an opportunity in taking on these patients, it’s crucial to understand how to ensure documentation can withstand reviewers’ scrutiny, says Chad Whitefield, managing partner of Advance Rehabilitation Management Group in Rome, Ga.
The physical therapy (PT) maintenance code (G0159) was used in 0.72% of home health episodes in 2017, compared to 0.94% in 2016, data from Minneapolis-based ABILITY Network Inc. show. (See benchmark, p. 5.)
The OT maintenance code (G0160) was used in 0.75% of episodes in 2017, compared to 0.58% in 2016. And the ST maintenance code (G0161) was used in 0.48% of episodes in 2017, compared to 0.31% in 2016.
Judith Stein, executive director of the Center for Medicare Advocacy in Willimantic, Conn., wasn’t surprised to see that maintenance therapy utilization hasn’t dramatically changed. But she was “dismayed.” The Center for Medicare Advocacy fought a legal battle with CMS on behalf of Medicare beneficiaries, and as a result, CMS agreed to provide education about maintenance therapy and update the Medicare Benefit Policy Manual about maintenance coverage.
Why isn’t utilization higher?
In August 2017, CMS followed a federal judge’s order to launch a webpage full of resources that reinforce maintenance therapy is covered under the Medicare benefit (HHL 9/4/17). The order sought for CMS to comply with the settlement agreement approved in January 2013 as part of the Jimmo v. Sebelius case (HHL 2/13/17).
The webpage contains a corrective statement, settlement agreement, fact sheet and links to pertinent chapters of the Medicare Benefit Policy Manual. It also includes a set of 15 frequently asked questions (FAQs) that provide details explaining the settlement agreement. (Read the FAQs at http://bit.ly/2vo2BZi.) These items reinforce CMS’ commitment to cover maintenance therapy.
The FAQs haven’t been updated since then. And there hasn’t been significant education from CMS in the past year, Stein notes.
“They came out and they made the clarifications they needed to make, and then that was the end of it,” Whitefield says.
Agencies have remained hesitant to provide maintenance therapy.
For one thing, there’s a belief that taking on patients who don’t improve will negatively impact star ratings and value-based purchasing results, says Kenneth Miller, physical therapist, therapy consultant and clinical educator at Catholic Home Care in Farmingdale, N.Y.
For another, agencies in states where pre-claim reviews were occurring or slated to occur last year were hesitant to bring on maintenance therapy patients, Whitefield says. Agencies nationwide believe that when reviewers examine charts, they won’t look favorably at maintenance therapy, he adds. There’s “fear and trepidation” that cases will be denied and trigger audits.
During CMS’ probe-and-educate review, some agencies received denials due to reviewers’ lack of knowledge about maintenance therapy, Stein contends.
Withstand maintenance therapy scrutiny
- Provide staff with One example of appro- priate maintenance therapy: the patient has Parkinson’s disease and had an episode of aspiration pneumonia. The patient requires skills of a speech-language pathologist to prevent further aspiration; the patient needs help with positioning and feeding techniques, Miller says.In this situation, the agency also would need to document the patient’s deterioration risk — increased risk of developing pneumonia again — and explain that the technical nature of the care requires help from a speech pathologist as opposed to a caregiver, Miller notes.An example of care that wouldn’t qualify for maintenance therapy would be if the physical therapist provides ambulation training for a patient with Parkinson’s who doesn’t want to get up and walk even though the patient is safe to do so with a family member, Miller says.
- Ensure each visit stands For each visit, explain why it takes the therapist’s skills to be able to provide these interventions and why caregivers can’t do it, Whitefield says.
- Create fresh goals should an existing patient shift to needing maintenance therapy. Language for maintenance therapy goals might state: “Patient will maintain strength noted on the 30-second chair stand test to prevent deterioration of transferability,” Miller
- Use details from CMS’ website as supporting During a targeted probe-and-educate review or a claim review during CMS’ review choice demo, print and submit materials that will confirm that maintenance therapy is permissible, Stein recommends. — Josh Poltilove (firstname.lastname@example.org)