L31607 HOME-BASED FALL EVALUATIONS AND INTERVENTIONS

 

Region IV J11HH-11-015-L

 

02/02/2012

 

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY

 

• The process of falls evaluation and intervention is a complex task for which there exist evidence-based procedures.

o The translation of these evidence-based procedures into clinical care, however, has been limited by an incomplete understanding of Medicare coverage rules.

o While no Medicare benefit category exists for a specific suite of “falls evaluation and intervention” services, some evidence-based falls evaluation and intervention procedures utilize home-based components that may be covered by Medicare with the appropriate documentation.

o The goal of this policy is to provide the framework for covered skilled nursing, physical therapy, and occupational therapy evaluations and interventions in the population of Medicare beneficiaries with a history of falls.

• The complexity of both the evidence-based fall evaluations and interventions and the applicable Medicare coverage instructions, require that documentation be as patient-centered as possible.

o (i.e., reflect the unique needs and circumstances of the patient and the available therapeutic options).

o The coverage of component, skilled services requires that beneficiaries first be eligible for an existing Medicare defined benefit and then under a physician’s order receive covered services that are “reasonable and necessary” with regard to amount, type, frequency and duration.

 

• Home Health Benefit (Bill types 32X and 33X): Once eligibility for the Medicare Home Health Benefit has been established, physicians may request that Medicare-certified Home Health Agency (HHA) evaluate the circumstances of fall events and establish a plan of care to intervene by identifying and modifying known risk factors for fall events.

o Such plans of care may require the skills of a registered nurse, physical therapist or occupational therapist, according to the beneficiary's needs and health status.

o The documentation of each component service must substantiate the need for the skilled services, be specified in the care plan and not be duplicative.

o Beneficiary-appropriate goals and objectives, with measurable outcomes must be included in the documentation.

 

• Part B Outpatient Therapy Benefit (Bill type 34X): Medicare beneficiaries not meeting the eligibility criteria for the Home Health Benefit, but otherwise in need of Medicare-covered, home-based therapy services for the evaluation and intervention of falls, may be eligible for the component physical and occupational therapy services available through the Part B outpatient Medicare benefit.

o The services must be patient-centered, non-duplicative and be well-documented with regard to the amount, type, frequency, duration and relevancy to evidence-based risk factors for fall events.

o Beneficiary-appropriate goals and objectives, with measurable outcomes must be included in the documentation.

 

• Palmetto GBA recommends use of the concepts contained within the World Health Organization’s (WHO’s) International Classification of Functioning, Disability, and Health (ICF) to organize the necessary data and communicate the patient-centered information describing the unique health status of each beneficiary. Such communication is critical to both documenting and delivering reasonable and necessary home-based Medicare services to the heterogeneous population of Medicare beneficiaries experiencing fall events.

• The component Home Health skilled nursing services (e.g., “observation and assessment”) and the corresponding skilled therapy services must adhere to the coverage criteria outlined in the CMS Manual System, Pub. 100-02 Medicare Benefit Policy Manual, Chapter 7 – Home Health Services, Sections 40.1 and 40.2 respectively.

o The component Outpatient skilled physical and occupational therapy services must adhere to the CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §§220-230.2.

o For unsuccessful interventions the reason(s) why the intervention(s) were unsuccessful should be documented in the record.

 

 

Bill Type Codes:

 

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

032x Home Health - Inpatient (plan of treatment under Part B only)

033x Home Health - Outpatient (plan of treatment under Part A, including DME under Part A)

034x Home Health - Other (for medical and surgical services not under a plan of treatment)

 

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0420  Physical Therapy - General Classification

0430  Occupational Therapy - General Classification

0550  Skilled Nursing - General Classification

 

 

CPT/HCPCS Codes

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

G0154 DIRECT SKILLED NURSING SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

 

 

Diagnoses that Support Medical Necessity

• The ICD-9-CM(s) supporting reasonable and necessary services will vary, but must be reported along with the V15.88 (history of falls).

 

 

Documentations Requirements

• Documentation supporting reasonable and necessary services should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

• Documentation should include:

o The specific fall-related impairment(s), activity limitation(s), participation restriction(s) and environmental factors being addressed by the HHA intervention(s).

o The results of the evidence-based intervention(s).

o For unsuccessful interventions, the reason(s) why the intervention was unsuccessful should be documented in the record.

 

Sources of Information and Basis for Decision

 

World Health Organization (WHO).International Classification of Functioning, Disability and Health. Geneva: World Health Organization, 2001.

 

American Occupational Therapy Association (2010). Analysis of Medicare Policy in Relation to Preventing Falls among Older Adults.

 

American Geriatrics Society & British Geriatrics Society (2010). Prevention of Falls in Older Person: Clinical Practice Guidelines. Retrieved 8/17/10 from http://www.medcats.com/FALLS/frameset.htm

 

West Virginia Medical Institute (2010). Best Practice Intervention Package – Fall Prevention. Retrieved 8/17/10 from www.homehealthquality.org.

 

Gardner MM, Buchner DM, Robertson MC, et al. Practical Implementation of an Exercise-based Falls Prevention Programme. Age and Aging 2001; 30:77-83.

 

Robertson MC, Campbell AJ, Gardner MM et al. Preventing Injuries in Older People by Preventing Falls: A Meta-Analysis of Individual-level Data. J Am Geriatr Soc 2002; 50:905-911.

 

Sherrington C, Whitney JC, Lord et al. Effective Exercise for the Prevention of Falls: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2008; 56(12)2234-43.

 

Local Coverage Determination (LCD) for Home-based Fall Evaluations and Interventions (L31607)