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Following PPS Guidelines for Reassessments in Home Health

Diana L Kornetti, PT, MA, HCS-D, COS-C, Kenneth L. Miller, PT, DPT, GCS, CEEAA

November 29, 2012



Can you please review the required assessment and reassessment dates as well as who can perform them?  


The required reassessments are at therapy visit numbers 13 and 19.  If multiple services are involved, at this point, guidelines state that it should be close to [the 13th and 19th visits]. So in other words, if PT and OT are both in a home, then we are working on the range of 11 - 13 and 17 - 19.  Now, that will be further defined - and clearly defined - for multiple therapies in the upcoming finalization of the PPS 2012 rule.  The 13th and 19th visits are therapy counts (the counted number of total visits for all disciplines together) and are episode specific.  When we start a new episode of care, we start that count again.  

We also have a 30 day reassessment.  The 30 day reassessment means that we should not go greater than 30 days from our last assessment without reassessing the patient.  In other words, if we evaluate the patient on day 1 of the episode and do visit 13 on day 22, we don't have to go back out and do a reassessment by day 30.  Day 22 was the reassessment.  We reset the reassessment clock at that point, and now we have until day 52 to go back out and reassess that patient.  

The 30 day reassessment is not episode specific.  The biggest discrimination between the two is that 13 and 19 are visit count episode specific.  They start over with a new episode or a new 60 day period of care.  The 30 day is a continuing count.  As long as you have that person on your service, you cannot go greater than a 30 day period of time without a reassessment for all of the disciplines that are in.  

Who must do them?  Medicare calls it a qualified therapist. That's doesn't mean assistants are unqualified, it just means that they want an evaluating therapist to do them - a PT, OT or SLP.  Assistants are unable to do the mandatory reassessments.



diana l kornetti

Diana L Kornetti, PT, MA, HCS-D, COS-C

Dee, a physical therapist for 30 years, is a past administrator and co-owner of Integrity Home Health Care, Inc. – a locally owned and operated Medicare-certified home health agency. Dee now provides training and education to home health industry providers through a consulting business, Kornetti & Krafft Health Care Solutions, with her business partners Cindy Krafft and Sherry Teague, where she serves as its Chief Operations Officer.  Dee is nationally recognized as a speaker in the areas of home care, standardized tests and measures in the field of physical therapy, therapy training and staff development in the home health arena. Dee is the immediate past Editor of the Quarterly Report, a publication of the  American Physical Therapy Association’s (APTA) Home Health Section , as well as member of the Home Health Section’s Practice and Education Committees.  She currently serves the Home Health Section as its Program Chair for annual conference educational activities.  She has been an active member in good standing in the APTA since 1986.  She is also the President of the Association of Homecare Coding and Compliance, and a member of the Association of Home Care Coders Advisory Board and Panel of Experts.  Dee is a published researcher. You can find her research on the Berg Balance Scale. She has also co-authored Home Health Section resources related to OASIS, goal writing and defensible documentation for the practicing therapist.Dee received her B.S. in Physical Therapy from Boston University’s Sargent College of Allied Health Professions, and her M.A. from Rider University in Lawrenceville, NJ. Her clinical focus has been in the area of gerontology and neurological disease rehabilitation. 


kenneth l miller

Kenneth L. Miller, PT, DPT, GCS, CEEAA

Dr. Kenneth L. Miller is a board-certified geriatric clinical specialist, advanced credentialed exercise expert for aging adults, and credentialed clinical instructor from the APTA. He has over 26 years of clinical experience with the older adult population.  Dr. Miller is an assistant professor at the University of North Texas Science Center with dual appointments in the Department of Physical Therapy in the School of Health Professions and in the Department of Internal Medicine and Geriatrics in the Texas College of Osteopathic Medicine. 

His clinical focus is on best practices for use with the older adult population.  He has spoken nationally and internationally on topics of gerontology including primary prevention, fragility, outcome measures, and pharmacology. 

He serves on editorial boards related to geriatric care and physical therapy education including Topics in Geriatric Rehabilitation where he was guest editor for a thematic issue dedicated to pharmacology and nutrition.  He also serves the physical therapy profession as director of practice for the Academy of Geriatric Physical Therapy and on several Academy Task Forces.  Most recently, he has helped to develop the best practice guidelines for the Academy that describe best practices for the care of older adults.  Dr. Miller is also a co-editor of the Ciccone's Pharmacology in Rehabilitation 5th edition textbook update.  


Related Courses

Wound Management in the Home
Presented by Kenneth L. Miller, PT, DPT, GCS, CEEAA, Lena Rome, RN, MSN, CWOCN
Recorded Webinar


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This course will enhance the participants' knowledge base regarding treatment plans for wound management In the home. This course is directly related to the practice of physical therapy and therefore appropriate for the PT and PTA.

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  'Good clarification of past misinformation'   Read Reviews
The Medicare Benefit for Home Health under Part A includes both restorative care and maintenance therapy. The Benefit Manual clearly states that coverage determination for maintenance service provided is not dependent on any "improvement standard" but, rather on whether there is a need for skilled care. The purpose of this course is to provide the CMS regulations regarding maintenance therapy in home health define rehabilitation and maintenance level care and provide examples of appropriate maintenance episodes.

Putting the Plan into Action - Understanding Goal Statements and Selecting Interventions for the Home Health PTA
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Sherry Teague, MESS, ATC, PTADiana L Kornetti, PT, MA, HCS-D, COS-C
Course: #3202Level: Intermediate2 Hours
  'immediate applicability to daily work'   Read Reviews
This course will discuss addressing goals and choosing interventions for the home health (HH) physical therapy professionals. Evidence-based practice approaches to care will be highlighted in common home health case scenarios. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Balance Training with Smart Phone Apps and Household Items
Presented by Meg Lowry, BPhty, MHSM, APAM, Kenneth L. Miller, PT, DPT, GCS, CEEAA
Recorded Webinar


Meg Lowry, BPhty, MHSM, APAMKenneth L. Miller, PT, DPT, GCS, CEEAA
Course: #3298Level: Intermediate2 Hours
  'I appreciate the presenters giving specific examples with pictures, and more so the videos, of the exercises/activities to give us more tools for our toolbox in treating patients'   Read Reviews
This course will provide the participant with a framework for treating balance impairments in the home using items available in the home and technology. Use of household items and inexpensive smartphone applications offers clinicians the opportunity to provide effective and progressive home programs without cost-prohibitive barriers that purchasing "treatment" equipment poses. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Home Health PDGM: What Therapists Need to Know Now
Presented by Cindy Krafft, PT, MS, HCS-O, Diana L Kornetti, PT, MA, HCS-D
Recorded Webinar


Cindy Krafft, PT, MS, HCS-ODiana L Kornetti, PT, MA, HCS-D
Course: #3304Level: Intermediate2 Hours
  'Great knowledge from the experts!'   Read Reviews
The most significant payment model change in over 20 years will move from concept to reality January 1, 2020. It may seem like there is plenty of time to prepare for impact but this model will remove the relationship between the number of therapy visits and reimbursement and causing additional anxiety for therapists working in home health. This session will break down the key components of the Patient-Driven Groupings Model (PDGM) and provide strategies for therapists to articulate value beyond the visit.

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