September 13, 2010 Donald Berwick, M.D, Administrator
Centers for Medicare and Medicaid Services (CMS) Department of Health and Human Services
Attention: CMS-1510-P PO Box 1850
Baltimore, MD 21244-1850
Submitted via electronic submission
RE: File Code CMS-1510-P Medicare Program – Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices; Proposed Rule
Dear Dr. Berwick:
On behalf of our 78,000 member physical therapists, physical therapist assistants, and students of physical therapy, the American Physical Therapy Association (APTA) respectfully submits comments on the Centers for Medicare and Medicaid Services’ (CMS) Proposed Rulemaking regarding the Home Health Prospective Payment System Rate Update for Calendar Year 2011. As you are aware, physical therapy is one of the primary services offered to Medicare
beneficiaries in the home care setting, and therefore APTA is very concerned about any changes made to the Home Health Prospective Payment System (HH PPS) that will ultimately affect the delivery of physical therapy services and the patients we serve.
Physical therapists are primary caregivers in home care and have vast experience in using the Outcome and Assessment Information Set (OASIS) tool in their daily practice. Physical therapists are highly trained professionals who provide therapy and develop an individualized home program to restore each patient to the highest level of function and independence. In the home health setting, physical therapists are responsible for providing physical therapy services to patients through a plan of care. Physical therapists provide an examination that includes the history, systems review, and tests and measures to determine the patient’s
therapeutic, rehabilitative, and functional status and any environmental factors that may impact the patient’s activity and/or participation. Through the evaluative process, the physical therapist will develop a comprehensive plan of care to achieve the goals and outcomes of improved function. The physical therapist also instructs patients and caregivers in areas that will help to address specific impairments, activity limitations, participation restrictions, and environmental factors. This may include instruction in the use and performance of therapeutic exercises,
functional activities and assistive or adaptive devices, including prosthetics and orthotics. Additionally, the physical therapist determines the priority needs, initiates the physical therapy program and communicates with other personnel and caregivers to ensure that there is adherence to the home program.
Our comments address: 1) case-mix measurement, 2) therapy coverage requirements, 3) outlier policies, 4) collection of claims data for future changes to the HH PPS, and 5) home health quality reporting. We ask that CMS carefully consider the following comments and recommendations.
I. Case Mix Measurement
In the proposed rule, CMS discusses new analysis of case-mix data. The Agency states that it found a 17.45 percent nominal increase in case-mix that is attributed to documentation rather than treatment of more resource intensive patients. Additionally, from 2000 to 2007, CMS states that it found a 1 percent per year increase in the total average case-mix, and that increase changed more than 4 percent between 2007 and 2008.
If CMS were to account for the difference in the 17.45 percent increase over CY 2011 and 2012, the Agency estimates that the percentage reduction to the national standardized 60-day episode rates and the non-routine supplies (NRS) conversion factor would be 3.79 percent per year. If CMS were to fully account for the increase in CY 2011 alone, there would a 7.43 percent reduction. Therefore, CMS proposes that because the Affordable Care Act contains other provisions which have an effect on HH PPS payments, to make the percentage decreases in payment over CY 2011 and 2012. CMS proposes to impose a 3.79 percent reduction per year to the national standardized 60-day episode rates and the NRS conversion factor for CY 2011 and 2012. CMS states that if further increases in the nominal case-mix are found, as new data becomes available, those percentage decreases will be accounted for fully in one calendar year instead of spreading decreases over multiple years.
APTA strongly urges CMS to further examine the underlying causes of the nominal case-mix growth. We believe that CMS, in its analysis, has failed to take into consideration significant factors such as the implementation of OASIS, public and private educational initiatives to teach home health providers how to more comprehensively assess the patient’s home care needs, improved documentation and quality of care, the evolving home health patient population, and changes in patient characteristics such as shorter hospital lengths of stay which result in more clinically complex patients with additional functional needs.
We believe that the totality of these factors should be carefully considered when analyzing changes in coding practices and utilization of therapy services under the Medicare home health benefit. Most notably, physical therapists have learned to collaborate with their nursing
colleagues to ensure that their OASIS data collection processes best describe and reflect the condition of the patient. An increasing number of home health agencies have realized the importance of the physical therapist when assessing the patient, and as a result, have invited physical therapists in their agencies to be involved in staff education so that assessment strategies can be shared among all disciplines in home health. Also, outreach efforts by CMS such as guidance on OASIS and educational sessions offered by professional associations and private companies have attributed to the home health community’s increased accuracy in coding and use of the OASIS assessment tool.
The involvement of the physical therapist has enhanced the functional component of the
comprehensive assessment through gathering observational data and considering safety factors in determining patient ability to carry out Activities of Daily Living and Individual Activities of Daily Living (ADL/IADL). As a result of this more collaborative and critical assessment, the Home Health Resource Groups (HHRG) tend to be higher, thus affecting the case-mix weights. We believe that this improved accuracy and educational outreach has, in large part, led to coding behavior changes that CMS has highlighted in its analysis from 2008 up until this 2011 proposed rule. CMS should not assume that the nominal case-mix changes are unwarranted. Rather, these changes may reflect a more accurate assessment of patient acuity. Therefore, APTA strongly recommends that CMS explore alternative ways to account for these nominal case-mix changes rather than imposing further cuts to the home health PPS (please see our additional
recommendations for alternatives in section III of our comments). II. Therapy Coverage Requirements
In the proposed rule, CMS makes extensive changes to the requirements for coverage of therapy under the home health benefit. CMS states that it believes that these requirements will aid in slowing case-mix growth that is unrelated to real changes in patient acuity. In general, APTA applauds the Agency on its efforts to better define medical necessity and document therapy services under the Medicare home health benefit. We strongly believe that complete and thorough documentation is essential to quality care. As an Association, we have created several tools to aid physical therapists and physical therapist assistants with documentation, and we stand ready to serve as a resource to CMS to ensure that any documentation standards that are developed and implemented into the HH PPS for therapy services are clinically appropriate.
In reviewing the proposed documentation requirements, we notice that this language is aligned with the current language in the Medicare Benefits Policy Manual (Pub 100-02) Section 220 and 230 for coverage of outpatient rehabilitation therapy services. APTA supports the standardization of documentation requirements between Medicare Part A and Part B therapy settings, and overall, we believe that Part B documentation can be consistently applied in the Part A setting. However, there are some components of the Part B documentation standards that are not practical for Part A settings, and we believe that CMS has carefully and thoughtfully adjusted these requirements in this proposed rule to conform to the home health setting.
The proposed documentation requirements are much more detailed than what is currently
required under the Medicare home health benefit. Thus, it will take significant time and resources for HHAs to ensure that their therapists and other medical staff are educated and prepared to implement the new requirements into their everyday practices. Therefore, APTA recommends that CMS provide extensive educational outreach to HHAs and other Medicare providers that will fully prepare them for implementation of these new provisions. We suggest that this educational outreach be conducted in a similar fashion to the open door forums and seminars that were provided when introducing OASIS C. APTA is also willing to lend our assistance to CMS to ensure that this information is well disseminated to the physical therapy community. In addition, we urge CMS to give HHAs and therapists additional time to adjust to the new requirements and delay implementation until the spring of 2011.
Accordingly, we offer these additional recommendations that we believe will strengthen the proposed documentation standards.
Medicare requires that in order for PT, SLP, or OT to be covered under the home health benefit, therapy services must relate directly and specifically to a treatment regimen, be established by the physician, and be designed to treat the patient’s illness or injury. To ensure that therapy services meet the criteria, CMS proposes the following clarifying coverage requirements.
42 CFR 409.44(c)(1)
• The patient’s plan of care would include a course of therapy and therapy goals which would be consistent with the patient’s functional assessment, both of which are included in the patient’s clinical record. The patient’s clinical record would document the
necessity for the course of therapy described in the plan of care. Specifically, the clinical record would document how the course of therapy for the beneficiary’s illness or injury is in accordance with accepted standards of clinical practice.
• Therapy treatment goals would be described in the plan of care, and they would be measurable. Specifically, therapy treatment goals would be such that progress toward those goals could be objectively measured. The goals would also pertain directly to the patient’s illness or injury and the patient’s resultant functional impairments.
• The patient’s clinical record would demonstrate that the method used to assess a patient’s function included the objective measurement of function in accordance with accepted standards of clinical practice. As such, successive functional assessments would enable comparison of successive measurements, thus enabling objective measurement of therapy progress.
APTA offers the following recommendations:
• In the first bullet, we recommend that CMS elaborate further on the last phrase of the paragraph, “with accepted standards of clinical practice”. We request that CMS cite references to resources from the professional associations such as the American Physical Therapy Association as well as OASIS resources. We believe that this modification will help HHAs and therapists better identify which standards are acceptable and clinically appropriate.
• In addition, we request that CMS clearly state in this first bullet that the “therapy goals” must be established by the physical therapist, occupational therapist, or speech language pathologist.
• In the third bullet, we request that CMS further define what is meant by “objective measurement of therapy progress”. We would recommend that this determination be made by the qualified therapist with commonly used measurement tests and assessing activities of daily living that include but are not limited to: eating, bathing, dressing, toileting, walking, climbing stairs, or using assistive devices (i.e. wheelchairs, walkers and canes).
42 CFR 409.44(c)(2)(i)
Medicare requires that for PT, SLP, or OT services to be covered in the home health setting, the services must be considered under accepted practices to be a specific, safe, and effective treatment for the beneficiary’s condition. To clarify what is considered “accepted practice” and “effective treatment”, CMS proposes to make the following revisions.
Functional Reassessment Expectations
In order to ensure that a patient receiving home health therapy services appropriately remained eligible for the benefit in accordance with accepted practice, and that the services continued to be effective, the patient’s function would be periodically reassessed by a qualified therapist.
While a qualified therapist could include, as part of the functional assessment or reassessment, objective measurements or observations made by a PTA or OTA within their scope of practice, the qualified therapist would have to actively and personally participate in the functional assessment, and measure the patient’s progress.
● For those patients requiring 13 or 19 therapy visits, the patient would be functionally re-assessed by a qualified therapist, minimally, on the 13th and the 19th therapy visit (thus requiring reassessment prior to the HH PPS therapy thresholds of 14 and 20 therapy visits), and at least every 30 days.
● No subsequent therapy visits would be covered until the qualified therapist has completed the reassessment, objectively measured progress (or lack of progress) toward goals, determined if goals have been achieved or require updating, and documented the therapy progress in the clinical record. If the objective measurements of the reassessment do not reveal progress toward goals, the qualified therapist, together with the physician, would determined whether the therapy is still effective or should be discontinued. If therapy is continued, the clinical record would be documented with a clinically supportable statement of why there is an expectation that
anticipated improvement is attainable in a reasonable and generally predictable period of time. APTA offers the following recommendations:
• When considering the functional reassessment, CMS frequently refers to the “qualified therapist”. APTA would strongly urge CMS to acknowledge multi-therapy cases in which there may be more than one “qualified therapist” (i.e. physical therapist, occupational therapist, and speech language pathologist). This distinction is very important because it is not clinically appropriate for an occupational therapist or speech language pathologist to perform a reassessment for the physical therapy needs of the patient and vice versa. In addition, it violates state licensure laws to allow multiple disciplines to assess patients for needs outside of their scope of practice.
• APTA also recommends that when referring to the dates that the reassessments should be conducted, on the 13th or 19th, prior to the 14th or 20 day therapy thresholds, CMS should insert language that allows for some type of window for completing the reassessment prior to or after the 13th or 19th therapy visits. This adjustment should be made to account for extenuating circumstances that are outside of the control of the qualified therapist. Although these instances should be the exception, CMS should acknowledge that there may be cases in which the reassessment is not completed in the timeframes allotted. In the case of these rare instances, it is the responsibility of the qualified therapist to clearly document the reason why the reassessment was not performed on the 13th or 19th day. Documenting “Effective” Therapy Progress
Assistant’s participation – CMS proposes that physical therapist assistants and occupational therapist assistants could objectively document progress between functional reassessments by a qualified therapist and/or physician. Clinical notes written by the PTA/OTA are not complete functional assessments of progress. Only a qualified therapist would be able to document a patient’s progress towards goals as measured during a functional reassessment, regardless of
whether the assistant wrote other clinical notes. However, notes written by assistants are part of the clinical record and need not be copied into the reassessment documentation.
Clinical notes written by assistants would supplement the functional reassessment documentation of qualified therapist and would include:
• The date that the clinical note was written; the assistant’s signature and job title
• Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occurred. Note that assistants would not make clinical judgments about why progress was or was not made, but could report the progress objectively. Descriptions would make identifiable reference to the goals in the current plan of care.
, or for dictated documentation, the identification of the assistant who composed the clinical note, and the date on which it was dictated;
APTA offers the following clarification:
• In the first bullet, we recommend that CMS replace “job title” with “professional designation”. This term more accurately describes therapists and therapist assistants. • Additionally, we recommend that CMS clarify that written and electronic signatures are
acceptable. 42 CFR 409.44(c)(2)(iii)
Medicare currently requires that for therapy services to be covered in the home health setting, there must be an expectation that the beneficiary’s condition will improve materially in a reasonable period of time based on the physicians assessment of the beneficiary’s restoration potential and unique medical condition, or the services must be necessary to establish a safe and effective maintenance program required in connection with a specific disease , or the skills of a therapist must be necessary to establish a safe and effective maintenance program in connection with a specific disease or the skills of a therapist must be necessary to perform a safe and effective maintenance program.
CMS proposes the following clarifications:
• “Material” improvement requires that the clinical record demonstrate that the patient is making functional improvements that are ongoing and practical value, when measured against his or her condition at the start of treatment.
•
• If an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration of therapy services required to achieve such potential, therapy would not be considered reasonable and necessary, and therefore would not be covered as rehabilitative therapy services.
The concept of rehabilitative therapy includes recovery improvement in function and when possible restoration to a previous level of health and well-being.
• Therapy is covered as rehabilitative therapy •
when the skills of a therapist are necessary to safely and effectively furnish or supervise a recognized therapy service whose goal is improvement of an impairment or functional limitation.
Therapy would not be covered to effect improvement or restoration of function where a patient suffered a transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following surgery)
which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. Therapy furnished in such situations would not be considered reasonable and necessary for the treatment of the individual’s illness or injury, and the services would not be covered.
• The specialized skill, knowledge and judgment of a therapist would be required in
developing a maintenance program, and services would be covered to design or establish the plan, to ensure patient safety, to train the patient, family members and/or unskilled personnel in carrying out the maintenance plan, and to make periodic reevaluations of the plan. When indicated, during the last visit(s) for rehabilitative treatment
•
, the clinician may develop a maintenance program for the patient. The goals of a maintenance
program would be, for example, to maintain functional status or to prevent decline in function.
• When a patient qualifies for Medicare’s home health benefit based on an intermittent skilled nursing need, a qualified therapist may develop a maintenance program to maintain functional status or to prevent decline in function, at any point in the episode. If a maintenance program was initiated after the rehabilitative therapy program had been completed (rather than by a clinician at the last rehabilitative therapy session), development of a maintenance program would not be considered reasonable and necessary for the treatment of the patient’s condition, with one exception.
• If the clinical condition of the patient were such that the services required to maintain function involved the use of complex and sophisticated therapy procedures to be
delivered by the therapist himself/herself (and not an assistant) in order to provide both a safe and effective maintenance program and to ensure patient safety, those reasonable and necessary services would be covered, even if the skills of a therapist were not ordinarily needed to carry out the activities performed as part of the maintenance program.
APTA offers the following recommendations:
• In the current language CMS speaks to the “beneficiary’s restoration potential” but in the proposed documentation requirements, the Agency uses the word “rehabilitative”. We contend that these words are not interchangeable and have different meanings within the context of Medicare regulations. Therefore, we ask that CMS be consistent with its language and use the word “rehabilitative” throughout the documentation requirements when referring to the patient’s potential to improve.
• We believe that the fifth bullet regarding transient and irreversible loss under this section is confusing and should be stricken from the requirements as it is unnecessary. This determination should be made by the qualified therapist on case by case basis.
• The seventh bullet regarding maintenance programs is very confusing and needs further clarification.
• In the ninth and last bullet, we would request that CMS add a sentence that clearly states that the maintenance program must be established by the qualified therapist.
42 CFR 409.44(c)(2)(iv)
In order for therapy to be covered in the home health setting, the amount, frequency and duration of the services must be reasonable. CMS proposes:
• The amount, frequency and duration of therapy services must be reasonable and necessary, as determined by a qualified therapist and/or physician, using •
accepted standards of clinical practice.
• The clinical record documentation would have to include objective measurements that demonstrated that the patient was making progress toward goals. If progress could not be measured, and continued improvement cannot be expected, therapy services would cease to be covered, with two exceptions. First, therapy could still be considered
reasonable and necessary (and thus covered) if therapy progress regressed or plateaued, if the reason(s) for lack of progress were documented, and the justification supporting the expectation that progress would be regained and maintained with continued therapy was also documented. Second, therapy could
The plan of care or the functional assessment would include any variable factors that influence the patient’s condition or affect the patient’s response to treatment, especially those factors that influence the clinician’s decision to provide more services than are typical for the patient’s condition.
be considered reasonable and necessary (and thus covered) under specific circumstances when maintenance therapy is established or provided, as explained previously in this section.
APTA offers the following recommendations:
• As stated earlier, we recommend that CMS elaborate further on the last phrase of the paragraph, “with accepted standards of clinical practice”. We request that CMS cite references to resources from the professional associations such as the American Physical Therapy Association as well as OASIS resources. We believe that this modification will help HHAs and therapists better identify which standards are acceptable and clinically appropriate.
• We recommend that in relation to the second bullet, CMS highlight the importance of education of caregivers to ensure that the patient is receiving the appropriate level of care.
III.
Current therapy weights are calibrated on the assumption that 79 percent of home health therapy is provided by therapists. CMS believes the current mix has changed. Therefore, CMS believes there is a need to collect additional data on the HH claim to distinguish between the therapy visit provided by the therapy assistant and the therapist. There are also issues with what is considered skilled nursing and direct skilled nursing; and therapy and restorative therapy. Therefore, CMS plans to require HHAs to report additional data on the HH claim to distinguish between skilled services and direct care skilled nursing or restorative therapy. In addition, CMS solicits comments on ways to restructure the HH PPS to mitigate overutilization and up-coding risks as well as possible proposals on how to use new claims data to better account for therapy resource use.
Collection of Claims Data for Future Changes to the HH PPS
One alternative to making further reductions to the case-mix is the development of a uniform assessment tool for post-acute care which is already underway via the work of the Post Acute Care Demonstration which involves the use of the CARE tool. APTA encourages CMS to continue its work on developing a post-acute care assessment tool that can be used across all settings (such as home health, inpatient rehabilitation facilities, and skilled nursing facilities). We believe that the use of an assessment tool will allow CMS to better determine what settings are appropriate for post-acute care for patients according to acuity and to understand the changes in
the home health case-mix that are impacted by changes in the type of patients admitted to home health.
CMS specifies that a standardized assessment tool will be used to 1) standardize program information on Medicare beneficiaries’ acuity at discharge from acute hospitals; 2) document medical severity, functional status and other factors related to outcomes and resource utilization at admission, discharge and interim times during post-acute treatment; and 3) understand the relationship between severity of illness, functional status, social support factors and resource utilization. APTA supports the concept of having a uniform assessment tool and agrees that patients should be placed into the appropriate setting to meet their needs based on their individual clinical characteristics/presentation.
Another alternative that we believe should be pursued to improve quality and efficiency of care under the Medicare home health benefit is the continued implementation of home health quality initiatives. CMS, as illustrated in this proposed rule, has spent several years developing quality initiatives in the home health setting by using OASIS as a basis. Of note, CMS recently
announced that Medicare saved more than $15 million in savings from 166 home health agencies (HHAs) based on their performance during the first year of the Medicare Home Health Pay for Performance (HHP4P) demonstration. We believe that the continued implementation of like projects will help to ensure that Medicare beneficiaries are receiving quality care without compromising access to care or unfairly imposing payment cuts on Medicare home health providers.
IV.
As mandated by the Affordable Care Act (ACA), CMS implements a HH outlier policy reducing the standard episode payment by 5 percent and target up to 2.5 percent of total projected
estimated HH PPS payments to be paid as outlier payments. In addition, per the new statute, CMS is required to reduce the standard payment rates by 5 percent, pay no more than 2.5 percent of total estimated payments for outliers, and apply a 10 percent agency aggregate outlier cap. CMS estimates that it would maintain a Federal Dollar Loss ratio of .67 in conjunction with the 10 percent cap on outlier payments at the agency level and would pay no more than 2.5 percent target of outlier payments as a percentage of total HH PPS payments as required by law.
Outlier Policies
Per the ACA, CMS is also required to conduct a study on ways outlier payments might be revised to reflect costs of treating Medicare beneficiaries by March 2014. Therefore, CMS is soliciting comments regarding alternate policies and methodologies to better account for high cost patients, specifically on how to impute costs in the calculation of outlier payments.
APTA supports CMS in its efforts to curb fraud and abuse in the Medicare program, and we are not opposed to the proposed implementation of these changes to the outlier policy. But, we would like to caution CMS to carefully analyze the effect of this outlier policy on home health agencies in rural and underserved areas. Often times, patients who are sicker and more clinically complex may be treated in the home health setting due to lack of access to other post-acute care settings which may cause these HHAs to have higher outlier costs than HHAs that are located in urban and higher socioeconomic areas. Therefore, APTA strongly urges CMS to ensure that these HHAs are not unfairly audited or penalized for the treatment furnished to these patients.
V. Home Health Quality Reporting
CMS proposes to continue to use a HHA’s submission of OASIS data to meet the requirement that HHA submit data appropriate for the measurement of health care quality. For CY 2011, CMS proposes to consider OASIS assessments submitted by HHAs to CMS in compliance with HHA Conditions of Participation for episodes beginning on or after July 1, 2009 and before July 1, 2010 as fulfilling the quality reporting requirement for CY 2011.
HHAs that meet the quality data reporting requirements would be eligible for the full home health market basket percentage increase. HHAs that do not meet the reporting requirements would be subject to a 2 percent reduction to the home health market basket increase. CMS proposes to continue to use OASIS data that is publicly reported on Home Health Compare to measure home health quality.
CMS proposes to continue to use the Home Health Compare website to collect data. The following twelve outcome measures are currently publicly reported:
• Improvement in ambulation/locomotion • Improvement in bathing,
• Improvement in transferring,
• Improvement in management of oral medications, • Improvement in pain interfering with activity, • Acute care hospitalization,
• Emergent care,
• Discharge to community, • Improvement in dyspnea,
• Improvement in urinary incontinence,
• Improvement in status of surgical wounds, and
• Emergent care for wound infections, deteriorating wound status CMS will continue to use these measures and one new measure:
• Increase number of pressure ulcers
CMS proposes to discontinue the public reporting of the following measures : • Discharge to community
• Improvement in Urinary Incontinence
• Emergent Care for Wound Infections, Deteriorating Wound Status
APTA supports the continued submission of OASIS data to meet the quality measurement and reporting requirements under the Medicare home health benefit. We strongly believe that quality measurement and reporting are essential to improving the quality of care to physical therapy patients. Our Association has worked extensively with the National Quality Forum (NQF), Ambulatory Quality Care Alliance (AQA Alliance) and other quality groups on the development of quality measures that reflect best practices within the physical therapy profession and that will aid in improving the quality of care provided to patients. Moving forward, we are committed to continuing these efforts and working with CMS to develop appropriate measures to be reported for physical therapy services provided under the Medicare home health benefit.
As stated in earlier comments to the HH PPS 2010 proposed rule in regards to the treatment of pressure ulcers and wounds, APTA would like to emphasize that physical therapy intervention is
highly effective in wound care treatment. When evaluating patients with chronic wounds, a physical therapist reviews the reason for referral and any relevant medical records. The patient’s medical history is taken, and an examination is performed that includes a systems review and tests and measures that include examination of the wound. The wound examination includes the evaluation of the wound characteristics - location, size, shape, depth, necrotic and viable tissue characteristics, peripheral tissue edema, periwound characteristics (e.g. erythema, edema, and maceration), and pulses. In addition, physical therapists will look for signs of infection or inflammation and examine wound characteristics such as bleeding, drainage, necrosis, undermining, contraction, tunneling and odor. A physical therapist will review activities and postures that may aggravate the wound, or those that relieve trauma/pressure to the wound. Based on the examination and evaluation of the findings, the therapist will develop a plan of care and determine the patient’s prognosis and the anticipated outcomes of treatment. The plan of care considers the clinical implications of the severity, complexity, and acuity of the patient and the wound including any impairment, activity limitation, and/or participation restriction secondary to the wound or any underlying pre-existing or co-morbid conditions. The physical therapist will establish goals, including the expected outcome of treatment and its impact on the patient's function in daily life.
One important aspect of the standard care for chronic wounds is treatment interventions that address restoration of mobility and function. Physical therapists are experts in this area. They address the impairments and functional limitations associated with injury, disease and other causes associated with the integumentary, musculoskeletal, neuromuscular and cardiovascular systems or any combination. Improving the patient's mobility and functional status will have a positive impact on their general health as well as that of the wound.
APTA strongly encourages CMS to provide guidance to home health agencies that physical therapists are and should be permitted to perform all wound care interventions legally mandated by state licensure and defined by the education curriculum of the physical therapist. This would include the coverage of interventions such as: dressings (wound coverings, hydrogels, vacuum-assisted closure), including wet-to-dry dressings, wet-to-moist dressings, wet dressing, enzymes, and physical agents and mechanical modalities; oxygen therapy (topical and supplemental); debridement, both nonselective and selective, including sharp debridement, pulsed lavage, debridement with other agents (e.g. autolysis), and enzymatic debridement; topical agents (e.g. ointments); physical agents and mechanical modalities; electro therapeutic modalities, including electrical stimulation by way of direct current, alternating current, pulsed current, pulsed electromagnetic induction; orthotics, protective and supportive devices; and assistive and adaptive devices.
CMS states that OASIS C process measures will be available to preview September 2010 and will be publicly reported in October 2010. OASIS C outcome measures will be available for preview in May 2011 and will be publicly reported in July 2011. In addition CMS will continue to
incorporate HH Consumer Assessment of Healthcare Providers and Systems (CAHPS) into home health quality measurement.
APTA supports the adoption of OASIS C process measures into the home health compare website and applauds CMS for creating a system that is patient-focused, reflects best practices, and seeks to improve outcomes of care in the home health setting. As these measures are adopted and implemented into the system, we strongly recommend that CMS stress the important role that physical therapists can play in the documentation and reporting of these measures. In addition, we
urge CMS to make these measures public before their finalization, giving the
provider/stakeholder community adequate notice to have comment and to provide input before these measures are implemented within Medicare home health quality measurement and reporting requirements.
Conclusion
APTA thanks CMS for the opportunity to comment on the Home Health Prospective Payment System Rate Update Proposed Rule (CY 2011), and we look forward to working with the agency to craft patient-centered reimbursement policies that reflect quality health care for all Medicare beneficiaries. If you have any questions regarding our comments, please contact Roshunda Drummond-Dye, Regulatory and Payment Counsel at (703) 706-8547 or [email protected].
Sincerely,
R. Scott Ward, PT, PhD President
