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Error in CMS Regulation Anouncement


Why Read the Regulations?


In light of the Jimmo v. Sebelius decision, Medicare has made updates to the regulations to clarify that the “improvement standard” is not the criteria for covering skilled care. Transmittal 175 was issued on December 6, 2013 with an effective date of January 7, 2014. This will impact inpatient rehabilitation, skilled nursing facilities, outpatient therapy and home health agencies and applies to nursing and therapy services. As home health providers, this is incredibly important information that includes specific examples and documentation expectations.


The real question is – did you read it??


If you did, you probably noticed the wording in red that indicate new or revised language. That color grabs attention and we are inclined to pay more attention to new concepts. Starting on page 35, there wasn't much red lettering as it referenced the functional reassessments so maybe it was easy to miss. HOWEVER, in reading it, the information about single and multiple therapy cases with respect to visit 13 and 19 was outdated and no longer correct. It appears it came from an older version of the regulation and did not reflect the changes made that went into effect on January 1, 2013. Here is the portion of the document as written:


iii. Reassessment prior to the 14th and 20th therapy visit


  1. .           If a patient’s course of therapy treatment reaches 13 therapy visits, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered 13th therapy service, functionally reassess the patient, and compare the resultant measurement to prior measurements. The therapist must document in the clinical record the measurement results along with the therapist’s determination of the effectiveness of therapy, or lack thereof.
  2. .           Similarly, if a patient’s course of therapy treatment reaches 19 therapy visits, a qualified therapist (instead of an assistant) must provide the ordered 19th therapy service, functionally reassess, measure and document the effectiveness of therapy, or lack thereof.
  3. .           When the patient resides in a rural area or when documented circumstances outside the control of the therapist prevent the qualified therapist’s visit at exactly the 13th visit, the qualified therapist’s visit can occur after the 10th therapy visit but no later than the 13th visit. Similarly, in rural areas or if documented exceptional circumstances exist, the qualified therapist’s visit can occur after the 16th therapy visit but no later than the 19th therapy visit.
  4. .           Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the ordered therapy service and functionally reassess, measure, and document the effectiveness of therapy or lack thereof close to but no later than the 13th and 19th therapy visit. The 13th and 19th therapy visit timepoints relate to the sum total of therapy visits from all therapy disciplines. In multi-discipline therapy cases, the qualified therapist would reassess functional items and measure those which correspond to the therapist’s discipline and care plan goals.


The error has been reported to CMS and we expect an updated document to be issued but it raises an interesting question – how many people noticed it??


Reading regulations and other information from CMS may not be your idea of light reading or a fun way to spend time, HOWEVER it is mission critical that each and every person working in any area of health care reads the rules for themselves. It empowers us to communicate with CMS more effectively and timely when we have concerns as well as ensures that we are staying connected to the most current information. Kornetti & Krafft Health Care Solutions is committed to providing you with the links and connections to this type of important information.


Cindy Krafft, 12/20/2013

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