Question
Can you please review the required assessment and reassessment dates as well as who can perform them?
Answer
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.
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.
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.”
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.
Is home health paperwork really that bad? Until recently, I would have given a resounding “yes.” I’ve made some changes to streamline my workflow, which has made a real difference for me. For me, it now depends on the type of speech therapy (ST) visits I’m doing and how many non-ST situations I have to deal with in any given day.
I think for any of us who work in home health, other important factors include:
- Which electronic medical record (EMR) software our company uses.
- The size of our territory.
- How productivity is calculated.
- Our ability to streamline your work flow.
When all my visits for a day are routine follow-up visits, and there were no incidents I have to report, then paperwork doesn’t take very long. I outline one of these days in my best day as a home health SLP.
On the other hand, when I have other types of visits or there are incidents I have to report (such as a fall or a change in medication), it can add quite a bit of documentation time to my day. Luckily, I’ve found ways to be more efficient (and I plan to write about that in the next month or so). Please share your tips to save time in the comments below.
My goal for this post is to explain the workload so that you can better understand my worst day as a home health SLP. Here is what I’ll cover in this post:
The big picture: every home visit is an assessment
For legal reasons, but also for practical reasons, I can’t be laser-focused on doing speech therapy when I walk into a patient’s home. When I walk into a patient’s home, I have to look at the big picture, including:
- Does the home appear safe today?
- Is the patient in reasonable condition?
- Is the patient getting the support they need?
Does the home appear safe today?
When I walk into a home, I look for tripping hazards or other potentially dangerous situations. I look for signs of neglect, such as old food scattered around, dirty dishes stacked up, or little food in the fridge. I check to see if my patient is wearing clean clothes and appears reasonably well-groomed.
Depending on what I find, I may contact (during the session or later) team members such as the nurse case manager (if there is one), a physical therapist (PT), an occupational therapist (OT), a medical social worker, my supervisor, and/or a family member. I may call the doctor to request an order to add a discipline to the team. I document everything in a communication note in the EMR.
Is the patient in reasonable condition?
I assess the patient, for instance taking vital signs, asking about pain, shortness of breath, and if they are eating and drinking. I check their pill box to see if they are forgetting to take their medications. I ask if they have fallen, or if they have had changes to the medication.
If something is going on, I will contact the nurse case manager (or nurse supervisor), the doctor, my supervisor, a family member, and/or other members of the team. I document everything in a communication note in the EMR.
Is the patient getting the support they need?
As I’m booting up my laptop and taking vital signs, I’m assessing my patient’s physical and mental state. Most of my patients feel comfortable telling me when something is bothering them.
Sometimes a patient will report a new physical problem that may require an OT or PT assessment. Or a patient may show signs of depression or other difficulties coping. A patient may report difficulties obtaining food, picking up prescriptions, or getting to medical appointments. Sometimes a patient may be having trouble with their family, or the family is not supporting them.
I do my best to help them with their concerns, such as educating them about community or government services, searching for an answer online, making quick phone calls for them, reporting their concerns to their doctor, contacting our company or other team members, or making referrals. Of course, everything is documented in the EMR.
If I am treating language or cognitive communication skills in therapy, I do my best to turn the discussion and any problem-solving activity into therapy activities based on my patient’s goals. I view my role as teaching my patients the knowledge and skills to solve their own problems, so that they can better advocate for themselves following discharge.
But the bottom line is that if my patient is not able to pay attention and fully participate in my therapy session, due to mental or physical distress or distraction, then the therapy session may be wasted time for both of us.
“Extra” responsibilities summarized
Just to be clear, at every visit, I:
- Look around for signs of hazard or neglect.
- Look at my patient and listen for signs of distress.
- Take vital signs and ask about pain and other concerns.
- Ask if my patient has fallen since I last was out.
- Ask if there have been any changes to medication.
- Assist patient with any concerns they have, to the extent I’m able.
Types of visits and paperwork involved
I’m going to briefly describe the types of paperwork I have to complete in the EMR for each type of session I do. We have several paper forms that have to be completed at different times. Since they only take a few minutes to fill out, I won’t describe those.
I’m not currently doing the start of care (SOC), which is done to admit a patient to the agency. There are 8 types of sessions I may have:
New evaluation visit
I complete the new evaluation document in the EMR, including a free-text form to report standardized assessments. I write a case communication note to notify my supervisor and the other team members of my plan of care. I document my call to the doctor and write the speech therapy orders for the doctor’s signature. I also document any calls to outside SLPs or other providers who treated my patient in the past.
The time it takes me to do a new evaluation depends on how many skill areas are impaired, how involved the medical history is, and which standardized assessments I completed. A straight-forward swallow assessment is generally pretty quick to write up. It may take 30-45 minutes. A complicated case in which I administered the BDAE or the WAB can easily take 1.5 hours to write up.
Routine visit
A routine visit note is often relatively quick to complete. If there are no issues to report and no change to the plan of care, I can often complete most of the note during the session. Sometimes I can complete the note at the end of the session, but I usually have to complete it outside of the session.
Time to write up: 10-15 minutes.
30-day reassessment visit
A 30-day reassessment is required for Medicare. Some private insurances may require this as well. I write my orders for 30 days, and complete some sort of assessment regardless of insurance. This allows me to step back and see how things are going and to make adjustments.
Depending on the patient, I may re-administer an entire test or just selected sub-tests. Paperwork consists of a routine visit note containing:
- A narrative description of current level of function.
- New assessment results compared to previous.
- A report on progress towards goals.
- Modification of goals.
- Rationale to continue therapy.
In addition, I document the phone call to the doctor and write new ST orders.
The time it takes to write up a 30-day reassessment depends on how many skill areas I’m working on with that patient, how complicated the case is, and which assessments I’ve administered. For me, this can take between 45-90 minutes. To make it easier for the patient, I often start the re-assessment in the previous session. This saves me time, too.
Re-certification visit
Home health episodes are certified for 60 days. If my agency plans to continue to treat a patient in a new certification period, then one of the team members must complete a re-certification.
A re-certification requires:
- A head-to-toe assessment written up in a lengthy OASIS document.
- Completing a fall assessment screening tool.
- Completing my own speech-therapy re-assessment.
- Reconciling medications in the home with what is in the EMR and calling the nurse supervisor.
- Writing up lengthy new therapy orders.
- Documenting several phone calls made during the session.
- Documenting various aspects of the re-certification in several places in the EMR.
A re-certification is the longest type of visit for me. I may be at the patient’s home for more than an hour for the visit itself. If I know the patient well, and I’ve done most of the ST re-assessment in the previous session, I may be able to complete the re-certification documentation in an hour. They often take longer. Luckily, I rarely have more than one or two re-certifications in a month.
Not home not found visit
If a patient is not home for a scheduled visit, I document the not home not found (NHNF) visit in the EMR so that I get paid for mileage. I also document the missed session and my phone call to the doctor (if the visit can’t be made up in the same week). Unfortunately, the missed visit does not count towards my productivity requirement.
Time to write up: 5 minutes.
Refused visit
A refused visit is triggered whenever I lay eyes on a patient, but we can’t do the session. A patient may refuse, or they may be unable to participate. Once, a patient had recently taken pain medication and neither I nor his wife could keep him alert. Another time, I arrived to find an ambulance pulling up to the door. Our nurse was with the patient, so I simply left after finding out what was happening.
As with a NHNF visit, I document the refused visit in the EMR so that I get paid for mileage. I document the missed session and my call to the doctor in a case communication note. A refused visit does count towards my productivity requirement.
Time to write up: 5 minutes.
Therapy discharge visit
A therapy discharge occurs when patient will continue to receive services from my agency after I discharge. I write up a discharge therapy note, including:
- A narrative description of current level of function.
- New assessment results compared to previous.
- A report on whether short and long-term goals were met.
I also complete a fall assessment screening tool and a therapy discharge summary, which are separate from my discharge therapy note. I write a case communication note documenting the ST discharge and my call to the doctor. I also discharge ST in the patient’s EMR profile.
If I’ve stayed organized in documenting progress towards goals, a therapy discharge is relatively quick. Now that we also have to complete a separate therapy discharge summary, it usually takes me around 30 minutes to complete the paperwork.
Agency discharge visit
If I am the last person to discharge a patient, I do an agency discharge. The paperwork consists of:
- My therapy discharge, described above.
- A head-to-toe assessment written up in a discharge OASIS document.
- Completing an agency discharge summary instead of a therapy discharge summary.
- Creating various types of communication notes in the EMR.
- Documenting my call to the doctor.
- Discharging the patient in the EMR profile.
I’ve gotten pretty fast at doing agency discharges, as I do them often. Unless it’s a complicated case, I usually finish the discharge paperwork in about 45-60 minutes.
Other events triggering paperwork
- When a patient is admitted to a facility or Hospice.
- When a patient falls or has a near-fall incident.
- When a patient has a change in medication.
- When a patient misses a dose.
- When a patient has any potentially serious incident.
- When inter-disciplinary team (IDT) communication occurs.
Each of these events triggers the requirement of completing documentation that takes me anywhere from 5 minutes for IDT communication note to perhaps 45 minutes to transfer care to another facility and discharge ST.
Now that you have a sense of what my workload is like, you can better appreciate my best and worst days as a home health SLP (from the standpoint of workload). As you no doubt noticed, this description of my workload doesn’t take into account the work outside of the session that is necessary to actually do speech therapy.
One of the reasons I’m writing this blog is to help me to organize the resources I’ve collected over the years. Another reason is to turn information from continuing education courses, research articles, and other sources of evidence-based practice into easy-to-find and easy-to-use resources.
Share your tips for being more efficient
I’ve written about five strategies to improve work-life balance and how organizing your work bag can free up documentation time during the day.
I’m sure I can learn from you. Please share your tips in the comments below, or contact me. If your experience with home health paperwork is different, please share that as well.
