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CMS Weighs in on Therapy Utilization Under the PDGM in New MLN Article

Friday, February 14, 2020   (0 Comments)
Posted by: Kyle Simon

The Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network (MLN) on February 10 released an article entitled The Role of Therapy Under the Home Health Patient-Driven Groupings Model (PDGM), which stresses that the provision of therapy services has not changed under the PDGM so long as the beneficiary meets the requirements in order to receive skilled services in the home.

The article states that “[a]ll services must be furnished in accordance with physician orders and accepted standards of practice. Therefore, the visit patterns of therapists should not be altered without consultation and agreement from the physician responsible for the home health plan of care. Any changes to the frequency or duration of therapy visits must be in accordance with the home health [Conditions of Participation] at 42 CFR 484.60.”

The MLN article continues that “[e]ven though therapy thresholds are no longer a factor in adjusting home health payment, there are two clinical groups under the PDGM where the primary reason for home health services is for therapy (musculoskeletal rehabilitation and neuro/stroke rehabilitation). Furthermore, therapy should be provided regardless of the clinical group when included under the plan of care. While the principal diagnosis helps define the primary reason for home health services, it does not in any way direct what services should be included in the plan of care. Additionally, there is no improvement standard under the Medicare home health benefit and therapy services can be provided for restorative or maintenance purposes. The physician who establishes and periodically reviews the home health plan of care must determine the therapy the patient needs regardless of the patient’s diagnoses or PDGM clinical group.”
All this to say, CMS is fully aware that therapy no longer has an impact on reimbursement. CMS will have a watchful eye on providers to make sure the proverbial industry pendulum does not swing from what they once perceived as an overutilization of therapy services to now an industry in which there is a gross underutilization of therapy services. For additional reading, click here to access a recent Home Health Care News report on CMS' recent actions.

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