As mentioned previously, Medicare has implemented a new Home Health Prospective Payment System case-mix adjustment method, the Patient-Driven Groupings Model (PDGM). Last week, the Centers for Medicare & Medicaid Services (CMS) released a related Medicare Learning Network Matters article on the subject that was aimed at home health agencies (HHAs) but has useful information for physicians, too.
CMS emphasizes that home health eligibility and coverage has not changed under the PDGM. The article also emphasizes that the need for therapy services under PDGM remains unchanged. According to the agency:
Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits. The number of needed visits to achieve the goals outlined on the plan of care is determined through the therapist’s assessment of the patient in collaboration with the physician responsible for the home health plan of care. [Emphasis added]
The article supports physician orders for home health and related therapy in other ways, too. For instance, CMS states, “All 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.” CMS also states:
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. [Emphasis added].
CMS is reminding HHAs that while PDGM may change how they’re paid for their services, it does not change the basics of Medicare home health coverage and payment, nor the central role that physicians play in determining what patients need from home health.
— Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians.
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