×          A continuation of the Medicare Part B outpatient Therapy Cap Exceptions Process; and

×          An extension of the “Medicare sustainable growth rate formula” commonly called the SGR and a continuation of the “Medicare work geographic floor”.   This prevents the 27% cut to the Medicare Part B fee schedule which sets the reimbursement for all of the therapy CPT Codes. As you can imagine a 27% cut to Part B reimbursement would be significant for Rehab providers.

So we can breathe a sigh of relief for now… but not for too long! February 29^th will be here before we know it.  Please join in the effort to get congress to permanently fix these issues in a way that will not harm patients or our ability to care for them. I recently saw an example from last year where, if the Therapy Cap Exception Process had not been in place, a patient would have started on PT and SLP treatment on January 23^rd and his combined cap amount would have been exceeded by February 6^th! That’s basically two weeks of therapy which was not enough to address his needs at the time and he would not have any additional resources available for additional therapy until the next calendar year!!

As always, you can easily send a letter to your Federal Congressman by using the CapWiz link available on the Key Rehab website.  Simply go to Key’s website and select the “Links” tool and then select www.capwiz.com/nasl.    This will take you to a website that will walk you through sending in a letter to you Congressman.  It’s easy to do, it helps and it’s necessary!  In the meantime, however, its “business as usual”.  There are no caps (financial limitations) in place, and our residents (the beneficiaries) deserve the services when they are needed!  They paid for their Medicare benefits for years and years, they continue to pay for their Part B coverage, and for the time being, we are allowed to deliver them.

“How will I let my caregivers know who I am? …..AT THE MERCY OF STRANGERS Disability obscures individuality like a mask.  When a doctor speaks to the person pushing the wheelchair rather than to its occupant, utter negation occurs.  “How is she feeling today?”  The one who has been negated can always shout, “I am fine, doctor,” thereby declaring her continued status as a person, but the harm has already been done.  To be overlooked, to be discounted even for a moment, wounds even after apologies have been extracted or hasty recognition has been won.  To have to fight to be seen – that is what causes the damage.”

Please visit Key Rehab’s home page, click on “monthly newsletter”, and then click on “Thoughts on the Meaning of Frailty” for the full article.  I hope it helps you slow down and remember the PERSON we are each caring for.

This year’s Medicare changes make me think there is a lack of trust between the people running the Medicare health care system and the providers that try to operate within it. It’s too bad because I believe that for the most part, providers are trying to do the right things, for the right reasons, and I also believe that Medicare is doing the same. In my career I’ve met many providers. Most of them are fine upstanding people who care about their patients. I also have the opportunity and good fortune to meet and interact with many people from Medicare. I’ve also found them to be good people conscientiously trying to do their jobs to manage the Medicare system and protect the rights of the beneficiaries. There are obviously some providers out there who do their best to scam the system and take advantage of the elderly. And likewise there are obviously some people within Medicare who don’t have a realistic understanding of the day-to-day life and operations of the many honest providers out there. In a society as large and complex as ours it is always impossible to come up with “one size fits all” solutions, but it is equally impossible to come up with viable solutions to address the multitude of contingencies that bombard our health care system on a minute by minute basis. And so we all do our best.

So let me say to you that I truly do wish you Happy Holidays this year regardless of which side of the Medicare fence you’re sitting on, bureaucrat or provider. I know we’ve got challenges to face and obstacles to overcome but I know that if we work together, keep the patients in mind, and strive to understand the complex world we live in that we can all be successful.

Happy Holidays everyone!

 Co-treatment

 For Part A:

When two clinicians, each from a different discipline*, treat one resident at the same time (with different treatments), both disciplines may code the treatment session in full. All policies regarding mode, modalities and student supervision must be followed. The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient. (*We have clarified with CMS that co-treatment by two members of the same discipline is not allowed – asterisk added by Key Rehab)

 For Part B:

Therapists, or therapy assistants, working together as a “team” to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.

 Therapists may utilize this technique when selecting treatment approaches for their Part A patients if it is clinically appropriate and when it is performed according to the definitions listed above.  The treatment provided by each therapist must be directly related their own plan of care and it must be distinct from the other discipline’s treatment. Keep in mind that the documentation must support that the skills of each discipline were required for the entire time the activities are being performed.  Some examples of clinically appropriate uses of co-treatment are as follows:

*Example from CMS: A SLP and an OT do a meal with a patient. The OT is working on feeding skills and fine motor coordination of the utensils and the SLP is working on swallowing skills. Both disciplines may code the full treatment session.

 Other Suggestions from Key Rehab:

Low-functioning patients-

•  Sit to stand transfers up to the sink to perform ADL’s.  (PT and OT)
• Edge of bed activities for sitting balance and dressing tasks. (PT and OT)
• Gait training from bed to bathroom. (PT and OT)
• Static standing activity with UE reaching tasks. (PT and OT)
• Meal time activity with safe swallow techniques and self-feeding instruction. (ST and OT)
• Standing activity with word finding or problem solving activity (ST and PT)

 Cognitively Impaired patients- 

• Problem solving/sequencing tasks during an ADL. (ST and OT)
• Gait training around obstacles while sequencing or problem solving. (PT and OT/ST)
• Gait training to closet for clothing retrieval and dressing task. (PT and OT)

High functioning patients-

• Standing/balance activity on uneven surface while working on “brain games”. (PT and OT/ST)
• Dynamic sitting balance on Swiss ball while performing UE exercise. (PT and OT)
• Obstacle course navigation and problem solving task. (PT and OT/ST)

U.S. Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA), Senator Ben Cardin (D-MD) have introduced the Medicare Access to Rehabilitation Services Act (H.R. 1546/S. 829). This legislation would repeal the cap on therapy services for Medicare beneficiaries. If Congress does not take action by December 31, 2011, therapy caps will be imposed on Medicare-covered physical therapy, occupational therapy, and speech language pathology services.

Congress needs to hear from front-line health care providers within the long-term care community that the therapy cap is bad public policy that would be especially hard on patients in long-term care settings.  With congressional focus on debt reduction and recommendations from the “Super Committee”, we need to ensure that Congress does not lose sight of Medicare extenders that are set to expire at the end of the year. Please contact your member of Congress today on this critical issue – we need to take action NOW to ensure the cap does not go back into place.

Please log onto the NASL (National Support for Long Term Care) website and with just a few clicks, you can send letters to your Legislators today.   http://capwiz.com/nasl/issues/alert/?alertid=42500531&type=CO

(Notes taken from ASHA and NASL websites)

 Later in the day, Tracy visited the exhibitor booths of some of our fellow therapy companies and asked them what changes they’re making in response to the Medicare cuts.  Some said they were making cuts. Others said they were following the same course as Key, taking a measured approach and focusing on productivity.      

 I think some perspective can come from the words of the conference’s general session’s second speaker, Maya Angelou.  When, as a child, she would complain about something – if you’re familiar with her story, you know her young life was tragic – her grandmother would say, “When you whine or complain you let a brute know there is a victim in the neighborhood”. 

 So, to feel inspire and to stay focused…Google Maya Angelou.

“I’ve learned that no matter what happens, or how bad it seems today, life does go on, and it will be better tomorrow.  I’ve learned that you can tell a lot about a person by the way he/she handles these three things: a rainy day, lost luggage, and tangled Christmas tree lights.  I’ve learned that regardless of your relationships with your parents, you’ll miss them when they are gone from your life.  I’ve learned that making a “living” is not the same thing as making a “life”.  I’ve learned that every day you should reach out and touch someone.  People love a warm hug, or just a friendly pat on the back.  I’ve learned that I still have a lot to learn.  I’ve learned that people will forget what you said, people will forget what you did, but people will never forget the way you made them feel”.                                 ~Maya Angelou

It all starts with the plan of care.  We need to consider all of the needs of each of our patients as individuals.  We must clearly document in our plan of care: our patient’s prior level of function, their baseline measurements at the start of care, and the goals we want to achieve.  We also should provide a prediction of the progress we anticipate based on the deficits we find.  Knowing the prior level, the baseline measurement, the goal and the expectations, gives us a clear picture of our patient heading into the course of treatment. 

Each treatment for each patient should include a well thought out plan before it is conducted.  As therapists, we need to consider the deficits and then select appropriate skilled interventions that we know to improve those deficits.  As we carry out our treatment plan, we need to continually assess the patient’s current deficits and think about what we learn from the patient each time we treat them.  Are the interventions working? Is the frequency and duration appropriate? Do other disciplines need to be involved? Am I appropriately involving the family and/or nursing staff? Is what I am doing actually carrying over into my patient’s normal life? As we answer those questions, modifications and adjustments to the original plan of care are necessary in order to provide the best opportunity for our patients to succeed.  As those changes are made, careful consideration has to be given to how we document each step of the process so we continue to provide a clear map that shows our destination and plan of how we anticipate getting there.

I do believe that most of us therapists consider all the questions above each time we treat a patient.  What we do not do well however, is document that thought process.  We struggle to write our thoughts and clinical decisions.  Our documentation is all we have as “proof” of the interventions we provide.  Good documentation helps us connect the dots until we reach our goal destination.  Sometimes we have to change our course along the way.  Sometimes it takes a little longer to get there.  But we eventually reach the end of the course and know we’ve given our best effort to improve the life of our patient.

CMS has reduced the number of days available for setting the ARD of regularly scheduled PPS assessments.  Here’s a chart that shows a comparison of the old schedule and the new schedule:

Old PPS Schedule (prior to 10/1/11)

MDS Days Available for ARD

5 -day                              1-8

14 – day                          11-19

30 – day                         21-34

60 – day                         50-64

90 – day                         80 – 94

New PPS Schedule (10/1/11 and beyond)

MDS Days Available for ARD

5 – day                             1-8

14 – day                           12-18

30 – day                           27 – 33

60 – day                           57 – 63

90 – day                           87 – 93

This may or may not seem like a big change depending upon each facility’s patterns for setting ARDs. The main point is that everyone has to be aware of the changes.  Trying to set an ARD outside of the allowable days could result in payment penalties for facilities. As for Grace days, they still exist under the revised assessment schedule (although slightly reduced in number) and CMS has again stated that there is no penalty for using grace days (please see the follow-up information from CMS’s August 23^rd provider call).

Well I think that’s all the bloggin time I have for today.  Until next time…

End of Therapy OMRA:  The End of Therapy OMRA or “EOT” for short was created with the implementation of MDS 3.0 in October of 2010.  The EOT is required anytime a Part A patient receiving therapy services has a break in skilled services for 3 consecutive calendar days.  When this happens the facility is required to complete the EOT which immediately reclassifies the patient into a non-therapy RUG classification.  Prior to October 1, 2011 if therapy was to resume, all new therapy evaluations were required and the facility had to complete an SOT (Start of Therapy OMRA). As of October 1, 2011 CMS has implemented a component to the EOT OMRA that allows therapy to resume without new evals and without a SOT OMRA.  This new component is called the EOT-R or End of Therapy OMRA reporting of Resumption of therapy.  The EOT-R may be used when the patient will resume at the same therapy level as prior to the discontinuation of therapy. The resumption of therapy must occur no more than five consecutive calendar days after the last day of therapy was provided. The use of the EOT-R became effective for all EOT OMRA assessments with resumption with an ARD on or after October 1, 2011.

Change of Therapy OMRA: The Change of Therapy OMRA or “COT” is a new type of OMRA (Other Medicare Required Assessment) created for and implemented with the MDS changes on October 1, 2011.  The COT OMRA policy will be effective for all assessments with an ARD on or after October 1, 2011. The COT Observation Period is a successive 7-day window beginning the day following the ARD of the resident’s last PPS assessment used for payment.  A COT OMRA must be completed in cases where the intensity of therapy provided during the COT observation period is not reflective of the therapy category into which the patient is currently classified. For example, if a patient classified into Rehabilitation Very High and then receives more than 720 reimbursable therapy minutes during the COT observation period, then a COT OMRA would be necessary to categorize the resident into Ultra High Rehabilitation (assuming all other qualifiers for this category are met.) The COT OMRA applies both in cases where the patient’s RUG classification decreases or increases.  Once it has been determined that a COT OMRA is necessary, the new payment rate will be effective from Day 1 of the COT observation period and will continue until modified by a future scheduled or unscheduled assessment.

There is another significant change that went into effect on October 1^st. It has to do with to the schedule of regularly scheduled PPS assessments.  I’ll talk more about that in my next Blog entry.

In case you’re wondering, LeadingAge is an organization that “offers a strong and distinct voice for our not-for-profit members as we strive to expand the word of possibilities for aging. Working together, we lead in innovative practices that transform how we serve our aging population, cutting-edge initiatives to develop services that meet older adults’ needs and preferences and advocacy to advance the interest of the aging consumer.” (Their words, not mine.)

Jan and Tracy will be fully equipped at Booth #1152 with informational materials and promotional give-aways, so stop in. You never know what you’ll walk away with. . .