What Is Proper Visit Length
What Is Proper Visit Length?
Q: According to Medicare guidelines, what are the minimum minutes the therapist should spend on a regular patient visit?
A: Thankfully, Medicare does not specify a minimum or maximum number of minutes for home therapy visits. Instead, the issue of visit length is left to the therapist's discretion on a case-by-case basis.
It is important to note, however, that some agencies establish internal policies and procedures concerning expected visit length, and in these instances, employed therapists should follow the specified parameters. For example, at one agency where I worked, the minimum visit length acceptable for therapy was 30 minutes. Interestingly, in an agency Wendy contracted with, they sought to establish a maximum visit length of 45 minutes that therapists were encouraged not to exceed. In our seminars, home care therapists report an average treatment time of 45 minutes, with a range of 30 to 60+ minutes. However, this is self-reported data of a convenience sample and cannot be confirmed, though our experience in home care does coincide with this anecdotal evidence.
One published study examining home therapy practice patterns1 does provide a detailed breakdown of time spent during various activities, including treatment, non-treatment and administrative tasks. Therapists in agencies seeking to develop or reevaluate visit time policies may refer to this article (be aware that the self-report design and limited sample -- it surveyed therapists in western New York only -- limit generalizability, but provides a starting point for dialogue on examining and quantifying time spent in and out of the field).
There are many reasons why therapists and agencies investigate the existence and practicality of visit time standards in home health care. Some agencies establish minimum visit time standards as a marketing tool--they are able to assure customers (patients, payers, physicians, etc.) that all therapy visits will last at least a certain period of time. Other agencies and therapists support and establish minimum visit time standards, erroneously assuming this produces enhanced quality care--but no research confirms that longer visits generate greater clinical outcomes in home rehabilitation to date.
In some markets, agencies establish maximum visit time standards to increase patient volume and/or compensate for staffing problems, so that fewer staff are required to provide more visits per day. We do not agree with the establishment of maximum therapy visit time standards by agencies and believe that visit time should be determined by therapists based on patient needs, not agency needs. The issue of visit time also arises when we encounter other therapists who seemingly provide relatively short visits, causing us to wonder if this practice is acceptable. Most often, however, we find that home care therapists, working in relative isolation from others, are simply curious about how long others spend in the home. This curiosity was further piqued when Medicare began requiring agencies to report visit time in 15-minute increments. Suddenly we all wondered: "Just what is normal?" and "What will they do with this information?"
While early 15-minute incremental data accuracy is marred by presumed improper data collection and reporting methods, it is expected that as agencies improve accuracy, we will all have access to information such as the average length of therapy visits by agency, region and across the nation.
One immediate and practical use of this information by HCFA will be to more closely examine agencies with suspicious use of therapy services. Because therapy utilization, and specifically a threshold of 10 therapy visits, raises the case mix weight and results in a higher episode payment under Medicare's prospective payment system, therapy is an area vulnerable to both overutilization (i.e., a large proportion of patients in an agency receiving 10 therapy visits in an episode) and underutilization (i.e., a large proportion of rehabilitation patients in an agency receiving only therapy 10 visits in an episode).
While initially, HCFA had hoped to use eight hours of therapy as the therapy threshold, they reverted to a 10-visit threshold, in part because of the inaccurate 15-minute incremental billing data collected. We have a 10-visit threshold because HCFA determined, using resource data from the Abt prospective payment system study, that the average therapy visit lasted 48 minutes. Therefore, eight hours of therapy should occur over the course of 10 visits. Agencies with aberrant use of therapy will be examined, using their 15-minute billing data to see if they are in fact providing eight hours of therapy in those 10 visits, or whether they are providing shorter visits and not meeting the eight-hour threshold.
Why is this important? Because HCFA will adjust the episode payment if, upon investigation, they find the therapy threshold of eight hours was indeed not met, even though 10 therapy visits did occur. Agencies encouraging therapists to provide patients with 10 shorter visits to meet the therapy threshold should be educated about this potential liability.
Until HCFA reverts to an eight-hour threshold, therapists should be on guard for agencies that begin to establish blanket policies concerning not only maximum visit time standards, but the number of therapy visits required and maximum visits "allowed."
1. Collins, J., Beissner, K.L., Krout, J.A. (Feb. 1998). Home health physical therapy: Practice patterns in western New York. Phys Ther 78(2):170-79.
We wish to extend a thank you to all readers—We truly enjoy your questions and correspondence! Happy Holidays and we'll see you again in 2001!
Michelle E. Moffa-Trotter and Wendy K. Anemaet are home care therapists in Florida. They have authored The User Friendly Home Care Handbook and Home Rehabilitation: Guide to Clinical Practice. They lecture nationally with GREAT Seminars on the topics of home care, geriatric assessment tools and geriatric strengthening.