New Medicare Rule: Reporting of Additional Data on HHA claims for Nursing and Therapy Visits
In order for CMS to collect more specific information regarding the types of services provided to home health patients, CMS is has revised the current descriptions for existing G-codes for physical therapists (G0151), occupational therapists (G0152), and speech-language pathologists (G0153), to include in the descriptions that they are intended for the reporting of services provided by a qualified physical or occupational therapist or speech language pathologist.
In addition, CMS has added two new G-codes (G0157 and G0158) for the reporting of physical therapy and occupational therapy services provided by qualified therapy assistants. This new rule went into effect on January 1, 2011 and implementation began January 3, 2011.
| G0151 | – | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes. |
| G0152 | – | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes. |
| G0153 | – | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes. |
| G0157 | – | Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes. |
| G0158 | – | Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes. |
CMS has also added and is requiring three new G-codes for the reporting of the establishment or delivery of therapy maintenance programs by qualified therapists. The following are descriptions for those new G-codes, for the reporting of the establishment or delivery of therapy maintenance programs by therapists:
| G0159 | – | Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes. |
| G0160 | – | Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. |
| G0161 | – | Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes. |
Lastly, CMS has revised the current definition for the existing G-code for skilled nursing services (G0154), and requiring home health agencies (HHAs) to use G0154 only for the reporting of direct skilled nursing care to the patient by a licensed nurse (licensed practical nurse or registered nurse). Additionally, CMS added and is requiring three new G-codes: One for the reporting of the skilled services of a licensed nurse in the management and evaluation of the care plan; another for the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse can determine the patient’s status until the treatment regimen is essentially stabilized; and another for the reporting of the training or education of a patient, a patient’s family, or caregiver:
| G0154 | – | Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. |
| G0162 | – | Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting). |
| G0163 | – | Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting). |
| G0164 | – | Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. |
CMS recognizes that, in the course of a visit, a nurse or qualified therapist could likely provide more than one of the nursing or therapy services reflected in the new and revised codes above. HHAs must not report more than one G-code for the nursing visit regardless of the variety of nursing services provided during the visit. Similarly, the HHA must not report more than one G-code for the therapy visit, regardless of the variety of therapy services provided during the visit. In cases where more than one nursing or therapy service is provided in a visit, the HHA must report the G-code which reflects the service for which the clinician spent most of his/her time. For instance if direct skilled nursing services are provided, and the nurse also provides training/education of a patient or family member during that same visit, CMS expects the HHA to report the G-code which reflects the service for which most of the time was spent during that visit. Similarly, if a qualified therapist is performing a therapy service and also establishes a maintenance program during the same visit, the HHA should report the G-code which reflects the service for which most of the time was spent during that visit.
You may visit the CMS website at https://www.cms.gov/center/hha.asp to learn more about the new rule.
