Home Health Agency Change in Reimbursement – Medicare Patient’s Therapy Needs Have Not Changed

Ordering physicians should be aware that HHAs may be adjusting, or planning to revise, their therapy services in response to fears about decreased reimbursement under the Patient-Driven Groupings Model.

However, CMS published MLN SE20005 to provide information on the continuing role of therapy under the PDGM, emphasizing that though therapy thresholds were eliminated for case-mix adjustment under the PDGM, “the need for therapy services under the PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction on the types of disciplines provided or the frequency or duration of visits.”

Medicare home health case-mixes under the PDGM were created with past trends of therapy usage. If therapy thresholds unexpectedly change, CMS will revise case mixes that may potentially result in decreased reimbursement. HHAs should not turn away patient referrals or limit therapy services based on reimbursement. This is not a responsible patient care option as long as the individual meets the criteria for home health services as described in the regulations at 42 CFR 409.42. The individual can receive Medicare home health services, including therapy services.

For more information regarding The Role of Therapy under the Home Health PDGM, please review MLN Matters®: SE2005: The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM)

Disclaimer: The A/B Medicare Administrative Contractor Home Health and Hospice Collaboration Team developed this document. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and assists the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.

Posted 12/14/2020