Encore Keynote - February 2021


Who will be eligible to get a COVID-19 vaccine in nursing homes?

The CDC recommends nursing home residents and staff, including therapists, be among the first to get the vaccine. Staff will often be able to get vaccinated before residents to reduce the risk of exposing residents to COVID-19.

Is the COVID-19 vaccine safe?

  • Both the Pfizer and Moderna COVID-19 vaccines are mRNA vaccines that do not contain the COVID-19 virus.
  • Most adverse responses to the vaccine occur within six (6) weeks of vaccine administration.
  • The FDA requires eight (8) weeks of safety monitoring when testing the COVID-19 vaccines.
  • The FDA advises a minimum of 3,000 participants to assess safety. The current COVID-19 phase 3 trials have 30,000 – 50,000 participants demonstrating how safety is a top priority for the FDA and medical community.
  • Severe adverse reactions were uncommon during the COVID-19 vaccine trials.


Why should I trust the COVID-19 vaccine?

  • The standards for the COVID-19 vaccines are the same FDA standards and protocols used for decades.
  • The vaccines must pass two (2) independent advisory committees that review the safety and efficacy data presented in the trials:
    • The Vaccine and Related Biological Products Advisory Committee (“VRBPAC”) that advises the FDA; and
    • The Advisory Committee on Immunization Practices (“ACIP”) that advises the CDC. 



New Customized Rehab Optima Library, March 1st Roll-out

Encore Rehabilitation is excited to announce the roll out of a new Customized version of Rehab Optima. The team who made this project happen included: Shawn Halcsik, Keely Kent, Kim Hooker, Kathy Claypool, Crista Zern, Kathleen Simenton, Renee Dollar, Erin Camilleri, Jolene Barbutes, and Valerie Leskosky.


The team reviewed external audit findings, requests from our users, and best practices to develop the library enhancements, which include: 

  • PT and OT Pathways
  • Increased standardized test options
  • Enhanced Balance Section
  • Enhanced Coordination Section
  • Enhanced Gait Section
  • Restructuring of PT Mobility flow
  • Restructuring of OT ADL/IADL flow
  • Streamlined goal writing      
  • Streamlined diet area documentation
  • “unhiding” assessment sections to ease use



February is Heart Health Month

Heart disease is the number one cause of deaths, affecting all ages, genders, and ethnicities.

  • Risk Factors: high blood pressure, high cholesterol, smoking, diabetes and excessive alcohol use.
  • Reduce Risk: eat healthy, exercise, manage cholesterol and blood pressure. 
  • Hospital Readmission Rates:
    • 30-Day Readmission Rate (All Diagnoses) – 17%
    • 30-Day Readmission Rate (Cardiac) – 22% 
  • Average 90-Day Episodic Cost Trends:
    • National (All Diagnoses) - $25,752
    • National (Cardiac) - $27,255
    • National with Readmission (All Diagnoses) - $43,500



In an effort to provide the best rehabilitation experience to our patients, Encore has a cardiac program called HeartWorks.  

HeartWorks is a comprehensive, interdisciplinary program designed to provide diagnosis-specific programming for patients with various cardiac diagnoses.  The goal is to improve heart function and overall quality of life.  

The HeartWorks program takes clinicians through the anatomy and physiology of the cardiac system.  It helps clinicians identify signs and symptoms of cardiac disease.  This program identifies anticipated goals of patients undergoing a heart-health program.  It describes rehabilitative management for patients with cardiac disease and helps therapists to analyze and interpret data, formulate goals, and develop a plan of care for patients with active cardiac diagnoses.




Physician Fee Schedule Final Rule

On December 1st, 2020, the Physician Fee Schedule Final Rule was issued with an effective date of January 1st, 2021.  This Final rule implemented a 9% reduction for Med B therapy codes by reducing the conversion factor from $36.09 to $32.40.

On December 27th, 2020, the Consolidated Appropriations Act 2021 modified the Calendar Year 2021 Medicare Physician Fee Schedule by:

  • Suspending the 2% Sequestration thru 3/31/2021 
  • Reinstating the 1.0 floor on the work Geographic Practice Cost index thru 2023
  • Providing a 3.75% increase in Medicare Fee Schedule payments for 2021
  • Delaying implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024

As a result of the Consolidated Appropriations Act, CMS has recalculated the payment rates and conversion factor. The revised MPFS conversion factor for CY 2021 is 34.8931. This did not offer full compensation from the 9% reduction to therapy codes but does provide some relief.
Lobbying efforts will now be focused on the anticipated 15% reductions for assistant-provided care set to go into effect in January 2022.
Click Here for CMS’ fee schedule calculator


Home Health Final Rule 2021 

  •    Emphasizes timely initiation of services and submission of documentation is key.
  •    The national standardized 30-day payment is increased
  •    LUPA per-visit rates are increased
  •    The No Pay RAP goes into effect, with a penalty for RAPs accepted later than five days
  •    Telehealth can be provided but must be included on the Plan of Care
  •    The Home Infusion Benefit is finalized



Targeted probe post-payment reviews have resumed for Medicare Part B Program Integrity. 

  • We received an audit, now what happens?
    • Contact your Encore Appeals Management Specialist (AMS)
    • If it is a denial we do not agree with, Appeals Management completes an appeal to be submitted.
    • If there are denials, follow-up education and training   is provided to the therapy team to review outcomes and improve documentation skills. 

Procedure code 97530 
Procedure code 97530 is Therapeutic Activities and defined as direct (one to one) patient contact by the provider (use of dynamic activities to improve functional performance) every 15 minutes.  Therapeutic Activities are referred to functional activities (such as bending, reaching, lifting, carrying, catching, and overhead activities) intended to improve functional performance in a progressive manner and are usually directed at a loss of or restriction of mobility, strength, balance, or coordination. 

  • Why did we receive an audit for procedure code 97530?
    • To reduce improper payment of Medicare claims, CMS has entrusted Medicare Administrative Contractors (MAC) to prevent inappropriate Medicare claims primarily through Medical Review of claims.  Currently, data analysis is identifying that procedure code 97530 (therapeutic activities) are frequently not billed and/or coded correctly per the Medicare guidelines.
  • Requirements for procedure code 97530
    • The patient has a documented condition for which therapeutic activities can be reasonably expected to restore and/or improve function. 
    • There is a clear correlation between the type of exercise performed and the patients underlying medical condition for which the therapeutic  activities were provided
    • The patients' condition is such that he/she is unable to perform the therapeutic activities without the therapist's skilled intervention.
  • Documentation requirements for procedure code 97530
    • Objective measurements for balance, coordination, strength, mobility, etc.
    • Specific activities performed and amount of assistance required.
    • Documentation supports the skills and expertise of the therapist were needed 
    • Functional limitations are addressed
    • Functional progress reassessment and discharge. If there was no progress; the lack of progress documented and/or alternative treatment strategies



NCCI Edits 
In the new edit set effective January 1st, many of these problematic code pairs have been resolved.
In its announcement, CMS says that some of the positive changes are retroactive to October 1,st 2020, with others retroactive to December 31st, 2019.


Click Here to review the code pairings




       Please email Ryan Jones for additional information: [email protected]