Vol. 17 Issue 22
Home Health Forum
Why Do I Need To Know the HHRG Score?
Question: My home health agency has recently undergone an initiative to use computers in the field. On one of the first screens, the HHRG score appears. I know that score determines what the agency will be reimbursed during the certification period, but that is about all I know. Why do I, as the physical therapist, ever need to know that?
Answer: You have brought up a very important issue. Most of the clinical field staff who we work with in our consulting business and seminars around the country are unaware of just how significant the HHRG score information is.
The score itself is derived from the answers provided on the admission comprehensive assessment, or OASIS form, completed by the PT, RN or speech therapist.
Medicare has selected questions from the MOs, sometimes referred to as the "money MOs," which earn points toward an increased score. As you state, that score does determine the agency's reimbursement rate for the services it provides for the full 60-day certification period.
As the admitting clinician, you are to answer every question accurately. The score itself is a series of letters and numbers that tells Medicare about the acuity of the patient in three different areas, called domains.
The first domain addresses the clinical ("C") areas. The patient's diagnoses (both primary and secondary) play a role in the points gained if there are qualifying orthopedic, neurological or diabetic issues being addressed by home care.
IV infusions, wounds/ulcers, significant impairments in vision, and respiratory, continence or behavioral status are the other factors which sum for points relating to the patient's clinical severity portion of the HHRG score.
The clinical domain points are totaled and categorized into four groups: C0, C1, C2 and C3, with the C0 score indicating few points and the C3 the maximal points.
The second domain of the HHRG score measures the functional ("F") severity of the patient. The corresponding MO questions from the OASIS comprehensive assessment deal directly with the areas of dressing the upper and lower body (MO650/660), bathing (MO670), toileting (MO680), transferring (MO690) and locomotion (MO700). There are five possible scores: F0, F1, F2, F3, and F4 and, as with the clinical domain, a lower points total gives a lower F value in the HHRG score.
The third and final domain analyzes the service ("S") utilization of the patient. It is based on only two MO answersthe MO175 and MO825.
Accuracy of these has been under recent Medicare scrutiny and must be carefully answered by field staff. MO175 asks where the patient has been in the past 14 dayswith points accumulating if inpatient rehab or skilled nursing facilities are marked. The most points are added if the MO825 answer is a "yes," indicating that the rehab services need is greater than 10 visits. Service domain scores range from S0 to S3.
So with this background on the scoring, what should the field-level clinician take away? A lot! Knowing that the patient with the score of C0F0S0 is only reimbursed by Medicare for around $1,600 for the entire 60-day certification period, you should be aware that a patient with this lower level score appears to Medicare as not so "needy," therefore, requiring much less in terms of services. The patient lacks an acute incident requiring admission to an inpatient facility.
Secondly, the patient was not identified by the admitting clinician as in need of rehab services above the high-therapy threshold mark of 10 visits. Medicare notes that the patient's functional changes are minimal or non-existent.
In order to keep the agency fiscally solvent, extreme caution should be used when formulating the plan for visits. On the other hand, a HHRG score of C3F4S3 will provide an agency with upward of $6,500 per episode. This patient profile indicates that there was a high acuity, significant functional loss for the patient, and a need for greater rehab services.
Medicare is listening, so tell them what is going on with the patient and then efficiently provide the home care services that match what you've presented.
Those in greatest need get more funding. Those with fewer needs are funded at a lower reimbursement level. By keeping watch for your agency's bottom line, you are ensuring that those patients who are genuinely in need get their needs met.
Revisiting Part B Billing
Many of our readers wrote in response to our Aug. 14 column regarding PTA supervision for Part B billing scenarios. A review of ADVANCE Medicare Advisor answers and fiscal intermediary queries, along with the helpful assistance of PTs familiar with the current CMS regulations, have allowed us to revisit (and hopefully clarify) this issue.
Medicare defines many types of supervision levels for PT assistants:
General Supervisionthe supervising PT must be available via telephonic means; e.g., pager, cell phone, landline phone.
Direct Supervisionthe supervising PT must be in the building, but does not have to be in the same room as the PT assistant providing services.
Personal Supervisionthe supervising PT must be in the same room as the treating PT assistant. This is also known as "line of sight" supervision.
Further study of the Part B regulations regarding these levels of supervision reveals that a private practice PT is viewed differently by Medicare. The May 22, 2006, Medicare Advisor column in ADVANCE states, "Services provided by therapists in private practice have always fallen under different regulations from other sites of service with regards to the supervision of assistants."
The Code of Federal Regulations states in 42 CFR 484.4, "The level of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent."
The conclusion of the above regulations is that Part B private practice outpatient patients require direct supervision with a PT on premises. All other Part B patients (e.g., SNF, home health) require general supervision only.
For further clarification regarding this or any related Part B question, contact your fiscal intermediary.
Centers for Medicare and Medicaid Services. (2006). 11 Part B Billing Scenarios for PTs and OTs. Retrieved from the World Wide Web, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp
Franko, P., & Mullins, D. (2006). Clarification on supervising therapists (Medicare Advisor). ADVANCE for Physical Therapists and PT Assistants, 17(12).
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 firstname.lastname@example.org