Home health therapy reassessment requirements

Deborah C. Escalante

Entry By: Eileen Bach, PT, M.Ed, DPT

Pasted below is a summary from an update from HCA of NY (www.hcanys.org). The timing of the required therapy reassessments (13th and 19th visits, 30 days) is important and based on the CMS response below, when the re-assessments are late, the visits from due date to actual are not only not covered but need to be reported as non-covered in the submitted claim. Another reason for those of us working in home health to be super-organized about visits!

Happy summertime!  Eileen

The U.S. Centers for Medicare and Medicaid Services (CMS) recently responded to an inquiry from the National Association for Home Care and Hospice (NAHC) about requirements related to the reporting of non-covered billing visits on Medicare claims, specifically in the case of late therapy reassessments. The required re-assessment at the 13th and 19th visits and/or 30 days have prompted questions as to the reporting of covered and non-covered services on the claim. Such questions have specifically centered on billing for late therapy reassessments and other non-covered situations. Providers have asked if it would be acceptable to omit from a claim visits that were made prior to a late therapy reassessment visit, as it has been a longstanding practice to exclude such non-covered visits from home health claims. According to CMS, “Therapy would be covered again for the visit which occurs after the qualified therapist(s) completes all the assessment, objective measurement, and documentation requirements … Asking which visit to omit [from the claim] is asking the wrong question. No visits should be omitted. The visits that are not payable should be reported with non-covered charges and will be assigned provider liability. Reporting non-covered charges is required per the Claims Processing Manual, Chapter 10, Section 40.2.”

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CMS further states that when providers do not meet reassessment requirements by visits 13 and 19, non-coverage will apply to visits starting on 14 and 20 (respectively) and non-coverage will continue up to and including the visit during which required reassessments were conducted. Coverage resumes on the visit following the final reassessment visit for each respective therapy threshold. (A similar policy applies when therapists do not reassess a patient by the 30th day, with resumption of coverage on the visit following the visit on which the required reassessment is conducted.)

CMS pointed out that its intent has been for home health agencies to include all non-covered visits and charges on claims to ensure a better representation of all home health costs. Therefore, the reporting of non-covered charges shouldn’t be limited to missed therapy reassessments. Home health agencies should include all non-covered visits and charges on their claims, such as for nursing assessments, aide supervisory visits, etc.


Can you please review the required assessment and reassessment dates as well as who can perform them?  


The required reassessments are at therapy visit numbers 13 and 19.  If multiple services are involved, at this point, guidelines state that it should be close to [the 13th and 19th visits]. So in other words, if PT and OT are both in a home, then we are working on the range of 11 – 13 and 17 – 19.  Now, that will be further defined – and clearly defined – for multiple therapies in the upcoming finalization of the PPS 2012 rule.  The 13th and 19th visits are therapy counts (the counted number of total visits for all disciplines together) and are episode specific.  When we start a new episode of care, we start that count again.  

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We also have a 30 day reassessment.  The 30 day reassessment means that we should not go greater than 30 days from our last assessment without reassessing the patient.  In other words, if we evaluate the patient on day 1 of the episode and do visit 13 on day 22, we don’t have to go back out and do a reassessment by day 30.  Day 22 was the reassessment.  We reset the reassessment clock at that point, and now we have until day 52 to go back out and reassess that patient.  

The 30 day reassessment is not episode specific.  The biggest discrimination between the two is that 13 and 19 are visit count episode specific.  They start over with a new episode or a new 60 day period of care.  The 30 day is a continuing count.  As long as you have that person on your service, you cannot go greater than a 30 day period of time without a reassessment for all of the disciplines that are in.  

Who must do them?  Medicare calls it a qualified therapist. That’s doesn’t mean assistants are unqualified, it just means that they want an evaluating therapist to do them – a PT, OT or SLP.  Assistants are unable to do the mandatory reassessments.



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