It has recently come to our attention that Palmetto GBA is issuing ADR denials on home health claims for patients whose therapy care plan does not qualify goals as long term and short term. Palmetto has jurisdiction over AL, AR, FL, GA, IL, IN, KY, LA, MS, NM, NC, OH, OK, SC, TN, and TX. Other Fiscal Intermediaries may be following suit. The December 8th issue of Home Health Line talks about this issue which will make it a concern to the home health agencies therapists and therapy companies are doing business with. To be on the safe side, therapists should be documenting long and short term goals in their care plans to remain in compliance with Medicare regulations.

Palmetto GBA has published Local Coverage Determinations (LCDs) for Physical Therapy and Occupational Therapy. In these LCDs, Palmetto GBA states that evaluations and re-evaluations must contain “Short and long term goals stated in objective measurable terms, and their expected date of accomplishment.”

CGS Administrators also published an LCD for Physical Therapy LCD which states that evaluations and re-evaluations must contain “Short term goals which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment.” and “Long term goals which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment.”

The Medicare Policy Manual – Chapter 15 – page 162 talks about short and long term goals as well stating “Long term treatment goals should be developed for the entire episode of care in the current setting. When the episode is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified. Goals should be measurable and pertain to identified functional impairments. Therapists typically also establish short term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of care. If the expected episode of care is short, for example therapy is expected to be completed in 4 to 6 treatment days, the long term and short term goals may be the same.”

Please review and discuss with your home health and therapy companies if you need any further instruction.

Upcoming release of therapyBOSS will have a feature for clinicians to mark goals as long term/short term with one click. This will guide therapists to think about defining the care plans in terms of long term and short term objectives.

 

Local Coverage Determination for Physical Therapy from Palmetto GBA

Local Coverage Determination for Occupational Therapy from Palmetto GBA

Local Coverage Determination for Physical Therapy from CGS Administrators