Home Health & Hospice

New Codes for PPS Claims Signal Changes Are Coming

Homecare Insider, August 23, 2010

In the comments with the proposed rule to update the Prospective Payment System, the Centers for Medicare and Medicaid Services (CMS) notes that it is trying to reduce payment incentives to provide unnecessary service.  One such action involves new codes for reporting physical and occupational therapy assistant visits in 15-minute increments.  CMS will also revise the codes for other therapy services.  Here are the working titles for the new and revised codes:

  • G-Code1, physical therapist assistant
  • G-Code2, occupational therapist assistant
  • G-Code3, physical therapist
  • G-Code4, occupational therapist
  • G-Code5, speech-language pathologist


The current therapy weights are based on the assumption that therapists visit patients 79 percent of the time.  However, CMS believes agencies are using more therapy assistants.  These new codes will provide data to help CMS better understand the delivery of skilled therapy services and more accurately address overutilization vulnerabilities.

The proposed rule includes several other requirements.

  • The patient’s clinical record should include objective measurements of the patient’s function and goals of treatment.
  • Material improvement means the patient demonstrates functional improvement that can be measured. 
  • A qualified therapist must reassess the patient on the 13th and 19th visits.  The patient could not receive additional visits until the therapist objectively measured progress toward goals and reaffirmed the expectation of improvement.
  • Therapy assistant clinical notes would supplement the functional assessment.
  • Successive functional assessments would enable comparison of measurements and support patient progress.


CMS believes that these requirements are nothing more than a prudent agency would impose as a business requirement.  Beacon Health agrees with that.  For years, the Beacon Guide to Medicare Service Delivery (http://www.beaconhealth.org/cgi-bin/ccp51/cp-app.cgi?pg=prod&ref=BGMSD10) has incorporated the concepts of measurable improvement, assessments, and comparisons with the patient’s baseline into the documentation guidance for therapy services.

Download the 72-page proposed rule, which appeared in the Federal Register on Friday, July 23, at — http://edocket.access.gpo.gov/2010/pdf/2010-17753.pdf.  CMS will accept comments on the proposed provisions until September 14, 2010.