Page 16 - Rehab 2020
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2. PEP: Partial Episode Payment- patient is admitted to Agency A, then elects to transfer to
th
Agency B. Agency A receives a proportional payment based on length of stay (1/30 per
day.)
Relationship between OASIS information and the Plan of Care (POC)
1. OASIS and POC must match exactly
2. Accuracy is critical - prepare ahead of time; know what to assess
Medicare Criteria for Reimbursement
Medicare has specific guidelines for coverage and many payers use these guidelines to determine
payment for services.
Medicare- requires the following 3 criteria to be met EACH visit:
1. Homebound:
a. Patient cannot leave the home at all.
b. Patient leaves the home infrequently with “considerable and taxing” effort.
c. Patient may leave home for religious services.
d. Patient may leave home for adult day care program.
e. Patient may leave home for medical care.
f. Patient may leave home for beautician appointments.
2. Skilled service:
a. CMS definition of Skilled Therapy - “There must be an expectation that the
beneficiary’s condition will improve materially in a reasonable (and generally
predictable) period of time based on the physician’s 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 perform a safe and
effective maintenance program. If the services are for the establishment of a maintenance
program, they may include the design of the program, the instruction of the beneficiary, family, or
home health aides, and the necessary infrequent reevaluations of the beneficiary and the program to
the degree that the specialized knowledge and judgment of a physical therapist, speech-language
pathologist, or occupational therapist is required.”
b. Eligibility criteria for admission to home care under Medicare guidelines must be
determined by the clinician performing the start of care (RN or PT).
c. Once eligibility has been determined the patient should be evaluated to determine if
they qualify for other services such as PT, OT, SLP, Home Health Aides, SW, and
Behavioral Health.
d. Care should be intermittent. To decide whether a patient is eligible for home health
care, Medicare defines part-time or “intermittent” as skilled nursing care that’s
needed or given on fewer than 7 days each week or less than 8 hours each day over a
period of 21 days (or less) with some exceptions in special circumstances.
3. Reasonable and necessary:
a. Applies to overall home health program as well as each individual service provided.
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