Vol. 16 Issue 27
Home Health Forum
Length of Home Visits; Preop Preparation
Could you please clarify the following question: Does Medicare state the length of time a home visit must be? I have heard anything from 30 minutes to 60 minutes, and all times between.
Medicare makes no statements regarding time requirements on a per visit basis. In 2000, when Medicare implemented PPS for home health care, it addressed a desired therapy threshold of at least eight hours of combined PT, OT or speech services over the 60-day episode in high therapy cases.
This proposed threshold of eight hours of therapy was based on a clinical assessment of the acuity level that identified a clear need for rehabilitation services and that would result in meaningful treatment with expected results over the course of 60 days. They determined that, on average, a therapy visit lasted approximately 48 minutes.
This implies that an average of eight hours of therapy would be exhausted in 10 visits. This is essentially how the 10-visit therapy utilization threshold came to be.
All other things aside, the emphasis needs to be and remain on service utilization that appropriately addresses the patient's clinical needs. The first visits made to evaluate, assess and establish the initial home program may take longer than later visits. Sessions that include skilled instruction with caregivers (i.e., car transfers, stair management techniques) may also take longer than other routine visits during which modification and progressions of the home program occur.
Medicare continues to urge home health agencies to be diligent in their collection of data so that eventually the therapy threshold can be used as originally determined–in terms of time spent in the home, not number of visits made.
In the Oct. 24 issue of ADVANCE, the Medicare Advisor column addresses the idea of education visits to pre-mastectomy patients. Does this also apply to preop visits for joint replacement patients? Can you make a preop visit to a knee replacement patient prior to surgery to educate the patient regarding exercises to do before surgery that will make postop recovery smoother and faster? The underlying idea here is that patients will then choose your home health agency for recovery after discharge.
The concept and practice of pre-surgical interventions in the home-care setting has increased since the onset of PPS. The emphasis on capitated reimbursement established by the Balanced Budget Act illustrates the importance of early education and patient participation in the postop rehab program.
Not only would this also apply to joint replacement patients, it is predominantly seen in the "joint express" protocols currently in use across the country. We will share some thoughts and concerns regarding these programs.
Both mastectomy and joint replacement clients are examples of patients who will benefit from pre-surgical education and intervention.
Home care patients evaluated before a scheduled surgery are assessed to determine preoperative functional status. Pre-surgical strengthening and ROM exercises can be identified and taught. Postop exercises can also be established to familiarize patients with the direction of treatment prior to their emergence from the recovery phase of the surgery.
Depending on your state's practice act, a doctor's referral would be required prior to the pre-surgical evaluation/education visit. Though the clinical benefits of such a visit may be obvious, it is not reimbursable by Medicare. You may want to check with the specific private insurance carrier for non-Medicare clients.
In most cases, a physician's referral would be required to provide a reimbursable postop home care program after the hospital discharge.
At that time, the Medicare client would receive an admission/evaluation visit to establish the official start of care. Hopefully, the patient would already be performing the exercises you taught during the preop visit. This would certainly lead to the smoother and faster recovery you had noted.
Our concern with these preop programs lies with the idea that the initial visit would result in the individual patient choosing your home health agency. Our experience (and comfort level) with these programs is that the patient and/or physician will have already chosen your agency in initiating the referral for the post-surgical home health program that would include the preop visit.
Though the development and marketing of this programming aspect provided by your agency could lead to an increased referral volume, the choice of a specific agency by an individual patient based on a non-reimbursable visit has obvious ethical concerns. That said, these programs do have benefit for everyone involved by improving the chances of helping patients achieve their goals.
Teri N. Thompson and Arnie Cisneros are both physical therapists in private practices with more than 30 years of home care experience; providing clinical services, management and consulting expertise. They also lecture for Encompass Consulting and Education, LLC, a rehabilitation consulting and education company. You may contact the authors at www.encompassmedicare.com