Speech-language pathologists as well as physical and occupational therapists will be particularly affected by a new Medicare home health care rule that changes the frequency with which home health care patients must be assessed (see The ASHA Leader, Oct. 12, 2010). In response to providers' concerns about the final rule, the Centers for Medicare and Medicaid Services (CMS) has delayed implementation of some provisions, including those explained below, until April 1, 2011.

Counting Visits 

One of the most confusing issues is the requirement for a reassessment. The previous policy, which established different payment levels based on the number of expected therapy visits, required no documented reassessment of the patient's progress. The result of that policy, noted by CMS in the final rule published Nov. 17, 2010, in the Federal Register [PDF], was an increase in the number of visits for occupational therapy, physical therapy, and speech-language treatment. The final rule cited a 2010 report stating that criteria for the home health benefit are "ill-defined" and calling for "better guidelines."

In response, CMS introduced the new rule, which requires patients to be reassessed at prescribed intervals—visit 13 and visit 19—to document progress objectively and to determine if further treatment is warranted. If more than one discipline is providing treatment, each provider must conduct a reassessment no later than visits 13 and 19.

This reassessment requirement must be fulfilled in conjunction with another CMS rule that patients must be reassessed at a minimum of every 30 days. After each discipline's reassessment is conducted by the 13th visit and 19th visit, a new 30-day reassessment window begins.

Purpose of Reassessment 

In the assessment of a home health care patient receiving speech-language treatment, the SLP must determine the effectiveness of the plan of care related to the goals, decide which goals were achieved or require updating, and compare current measurement data to baseline data. CMS states that assessments and reassessments must include an objective measure of function such as OASIS (Outcome and Assessment Information Set) items, commercially available outcome measurements, or validated tests and measurements in the professional literature or in accepted standards of clinical practice.

This expectation has caused some consternation among home health care agencies as to whether specific therapy assessment instruments or measures should be "approved" by CMS or by professional organizations. In response to ASHA's request for clarification, CMS confirmed that emphasis should be placed on the concepts of "measurable" and "objective" rather than limiting clinicians to a list of approved tests. Formal assessments may not reflect improvement in functions that are meaningful to individuals in their home, suggesting that other instruments, such as outcome measures, may play an important role.

Coverage and Documentation 

The final rule also clarifies the therapy coverage requirements in the Medicare Conditions of Participation, which describe requirements home care agencies must meet to participate as Medicare service providers and are similar to the concepts outlined in the Medicare Benefit Policy Manual for Part B services. Each visit note may be scrutinized to justify medical necessity for continued intervention. The clinician must document that the improvement is ongoing and of practical value compared to the patient's status at the start of treatment and that the intervention requires the skills of a professional SLP.

If no progress is being made or if the patient has reached a plateau, the SLP must provide a "clinically supported statement of expectation that the patient can continue to progress" or resume progress after plateau or regression. The clinical record should include any variables that may influence the patient's condition and/or affect the patient's response to treatment. If the plan of care needs to be revised, a physician's signature will be required.

CMS is expected to release further guidance on implementation of the therapy rule before the April 1 implementation date.