Home Health Blogger

Cerebrovascular Accident (CVA) Home Health Care? Beware Outliers

Posted by Melissa Cott on May 10, 2022

Now that we will have a 30 day billing cycle under Medicare’s Patient Driven Groupings Model (PDGM), there’s no reason not to strive to achieve patient goals within this 30 day window.  Many of your patients, with manageable risk factors, should be able to achieve... desired outcomes within 30 days with no problem.

But what about your more complicated patients? Such as those with multiple problems as a result of a CVA?  The patient recovering from a CVA can have communication, feeding and mental status deficits in addition to expected mobility and self-care limitations.

Oh…Be Careful of Outliers.Cognition-Therapy-Exercises

For that challenging patient with many problems, we’ve come to count on Medicare ‘outlier’ payments to cover services when the usual payment will not cover our expenses. You may have justified scheduling as many visits as possible because of an expected payment via an outlier calculation. Somewhere along the way, Medicare put a cap on outliers. Read this from the April 2019 PDGM Final Rule (page 7 of 233):

“… Section 3131(b)(2) of the Affordable Care Act revised section 1895(b)(5) of the Act so that total outlier payments in a given year would not exceed 2.5 percent of total payments projected or estimated. The provision also made permanent a 10 percent agency-level outlier payment cap. In accordance with the statute, as amended…”

Wow. This means that a maximum of 2.5 percent of your annual Medicare reimbursement can be for outlier payments. If you have a lot of patients with episodes requiring more services – requiring more reimbursement than the usual calculated amount – too bad. Medicare will cap this at a total of 2.5% annually.  Additionally, over the course of your Agency’s business life, outlier payments are capped at a total of 10%.

So BEWARE of scheduling more visits than you’ll get paid for.  While all HHAs have a responsibility to care for their share of patients requiring care over and above what they’ll be paid for, you must be strategic in how you deliver services.

Why this complicated post-CVA requires just a 30-day Certification Period.

Does this patient have a caregiver?

When you admit the patient with multiple problems resulting from a CVA, the most important consideration is whether or not s/he has a competent, teachable caregiver. This caregiver can be taught the rehabilitation exercises prescribed by OT, PT and ST.  Additionally they can be taught symptom monitoring by SN. Unless the patient is unstable and requiring multiple medical careplan changes, symptom stability and demonstration of effective implementation of therapeutic exercises CAN be achieved in 30 days with the AVERAGE number of visits.

2020 Reimbursement for functional deficits resulting from neurological disorder is $1127 to $3196.

Our recommended average 2020 PDGM visit schedule for this patient type is 8 therapy visits and 5 nursing visits. As long as the patient has a competent and teachable caregiver, s/he will not need a home health aide. In many cases, therapy can monitor the patient's medical condition and nursing does not need to be involved. This would increase the number of therapy visits to 13. With an appropriate caregiver, s/he can be taught symptom monitoring and the rehabilitation regimen in those 13 visits.  Goals CAN be achieved in this scenario in 30 days.

Why this complicated post-CVA requires a 60-day Certification Period.

If the patient does NOT have a caregiver home health aide is required. If the patient is teachable, probably two 30-day episodes are needed.

What if the patient is confused and has no caregiver?

We will recommend MAINTENANCE services. Maintenance therapy, home health aide and nursing care is the appropriate careplan for patients who are confused and have no caregiver. As long as the nursing and/or therapy are necessary to maintain the patient’s functioning or to prevent or slow the patient’s decline or deterioration, visits for maintenance care can be made indefinitely. 

Best Practice Assessment of Patients with Cerebrovascular Accident (CVA) 

  • Numbness or weakness of the face.
  • Change in mental status. Decreased oxygen causes the patient to experience confusion.
  • Trouble speaking or understanding speech.
  • Loss of peripheral vision. The patient experiences difficulty seeing at night and is unaware of objects or the borders of objects.
  • Hemiparesis. There is a weakness of the face, arm, and leg on the same side due to a lesion in the opposite hemisphere.
  • Hemiplegia. Paralysis of the face, arm, and leg on the same side due to a lesion in the opposite hemisphere.
  • Ataxia. Staggering, unsteady gait and inability to keep feet together.
  • Dysarthria. Difficulty in forming words.
  • Paresthesia. Numbness and tingling of extremities and difficulty with proprioception.
  • Expressive aphasia. The patient is unable to form words that is understandable yet can speak in single-word responses.
  • Receptive aphasia. The patient is unable to comprehend the spoken word and can speak but may not make any sense.


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