Medicare covers home health therapy only if a qualified therapist, not an assistant, treats the patient and functionally reassesses them at least every 30 calendar days. The rule is 42 CFR 409.44(c)(2)(i)(B). It applies to physical therapy, occupational therapy and speech-language pathology, separately for each discipline, for the whole time the patient is on service.
Every quotation below is from the Code of Federal Regulations on Cornell LII, chapter 7 of the Medicare Benefit Policy Manual, or the CY 2015 home health final rule (79 FR 66032), which set the current interval. The section is named at each quote.
One framing point. Section 409.44 sits in Part 409, Hospital Insurance Benefits. It is a coverage condition: miss it and visits are not covered. The recertification assessment in 42 CFR 484.55 is a different kind of rule, a Condition of Participation.
The Rule Is Two Paragraphs, Not One
The regulation splits the method from the interval. Cite each one.
(A) is the method.
"The patient's function must be initially assessed and periodically reassessed by a qualified therapist, of the corresponding discipline for the type of therapy being provided, using a method which would include objective measurement as described in § 409.44(c)(1)(iv)." (42 CFR 409.44(c)(2)(i)(A))
(B) is the interval.
"At least every 30 calendar days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient in accordance with § 409.44(c)(2)(i)(A)." (42 CFR 409.44(c)(2)(i)(B))
(B) then requires "a qualified therapist from each of the disciplines" when more than one is provided. A PT reassessment does nothing for OT.
The manual's heading: "Reassessment at least every 30 days (performed in conjunction with an ordered therapy service)." Plan it as one of the ordered visits on the visit frequency.
Who Can Do It
Only the qualified therapist of that discipline. Section 409.44(c)(2)(ii) lists who may furnish skilled therapy at all: "a qualified physical therapist or by a qualified physical therapy assistant under the supervision of a qualified physical therapist, by a qualified speech-language pathologist, or by a qualified occupational therapist or a qualified occupational therapy assistant under the supervision of a qualified occupational therapist (as defined in § 484.115 of this chapter)."
- A PTA or COTA can treat but cannot reassess. (B) says "instead of an assistant." Their visits in between are visits of the parent discipline, as set out in which order an assistant works under.
- SLP has no assistant in this rule. The list names none, and 42 CFR 484.115 defines a physical therapist assistant and an occupational therapy assistant but not one for speech.
- The rule binds a therapist who makes every visit. The manual: "At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, and compare the resultant measurement to prior assessment measurements." No assistant has to be involved.
What the Visit Must Show
The therapist treats on that visit, not only measures. The CY 2015 rule: "A therapy reassessment visit should include providing the actual therapy service(s), functionally assessing the patient, measuring progress to determine if the goals have been met, and documenting measurement results and corresponding therapy effectiveness in the clinical record."
The measures must allow "comparison of successive measurements" (409.44(c)(1)(iv)), and the regulation's examples are activities of daily living: "eating, swallowing, bathing, dressing, toileting, walking, climbing stairs, or using assistive devices, and mental and cognitive factors."
The therapist's note must carry what 409.44(c)(2)(i)(F) lists:
- "The therapist's assessment of the effectiveness of the therapy as it relates to the therapy goals"
- "Plans for continuing or discontinuing treatment"
- "Changes to therapy goals or an updated plan of care"
- "Documentation of objective evidence or a clinically supportable statement of expectation that the patient can continue to progress toward the treatment goals"
The manual names phrases that do not describe skilled care, including "Patient tolerated treatment well" and "Continue with POC." Assistants' notes feed the picture, but under (E) assistants "may not make clinical judgments about why progress was or was not made." That judgment is the therapist's.
How to Count the 30 Days
At least once, not every 30th day. The CY 2015 rule: "The reassessment will not have to be done on exactly the 30th day. For example, the reassessment could be done on the 21st day or the 28th day as clinically appropriate and deemed necessary by the therapist."
Counting starts the day after. The same rule: "if a therapist conducted and documented an assessment of a patient during a visit on April 1, the count would begin on April 2. In this case, in order to fulfill the requirement of reassessing the patient at least once every 30 days, the therapist rather than an assistant, would need to return by May 1."
No grace period after day 30. Commenters asked for one. CMS: "we will not adopt a policy of allowing for a 3 or 5 day window or grace period after the 30th calendar day."
One clock per discipline. The manual: "The 30-day clock begins with the first therapy service (of that discipline) and the clock resets with each therapist's visit/assessment/measurement/documentation (of that discipline)." Read with (B), a resetting visit is one where the therapist treats, measures and documents. The text does not say a visit without the measurement resets it.
| Visit | Resets the PT clock? | Why |
|---|---|---|
| PT treats, measures, compares to prior, documents | Yes | Meets (B) |
| PTA treatment visit | No | (B): "instead of an assistant" |
| OT reassessment, same patient | No | Each discipline has its own clock |
| RN recertification assessment | No | Not a therapist of that discipline |
| PT recertification visit that also treats and measures | Yes | That visit meets (B) as well |
The Clock Runs for the Whole Admission
The CY 2015 rule: "the reassessment clock is not measured by episode but by the patient's full course of treatment. That is, the reassessment clock starts with the therapist's first assessment/visit and continues until the patient is discharged from home health."
Recertification and a new payment period do not restart it. Three similar clocks run side by side.
| Clock | Interval, as written | Source | Kind of rule |
|---|---|---|---|
| Therapy reassessment | "At least every 30 calendar days," per discipline | 42 CFR 409.44(c)(2)(i)(B) | Medicare coverage condition |
| Recertification assessment | "The last 5 days of every 60 days beginning with the start-of-care date" | 42 CFR 484.55(d)(1) | Condition of Participation |
| Payment period | "Each 60-day certification can include two 30-day payment periods" | Benefit Policy Manual ch. 7, 10.3 | Billing unit, not a visit deadline |
If the PT makes the recert visit and also treats and measures on it, one visit can satisfy both rules. Recert timing is in tracking 60-day certification periods.
Hospital stays: nothing in 409.44, section 40.2.1 or the CY 2015 discussion pauses the clock. Practice, not rule: make the first visit back in each discipline a therapist reassessment.
PT, OT and SLP Side by Side
| Physical therapy | Occupational therapy | Speech-language pathology | |
|---|---|---|---|
| Who may treat | PT, or PTA under PT supervision | OT, or OTA under OT supervision | SLP only |
| Who reassesses every 30 days | The PT | The OT | The SLP |
| Manual section | 40.2.2(A) | 40.2.4.1 | 40.2.3 |
- PT. Section 40.2.2(A) lists measures such as "range of motion, strength, balance, coordination, endurance, or functional ability."
- OT. Section 40.2.4.1 uses the PT wording, "(instead of an assistant)" included. Practice, not rule: reuse the evaluation's measures so the comparison is real.
- SLP. Section 40.2.3 reads "the qualified speech-language pathologist must perform the ordered therapy service visit," with no assistant clause. It adds that in restorative therapy "routine reevaluations are considered to be a part of the therapy and cannot be billed as a separate visit."
For aide supervision and the wider supervision rules, see supervisory visit requirements.
When the Reassessment Is Late
Section 409.44(c)(2)(i)(C): "therapy visits for the therapy discipline(s) not in compliance with these policies will not be covered until the following conditions are met":
- "The qualified therapist has completed the reassessment and objective measurement of the effectiveness of the therapy as it relates to the therapy goals."
- "The qualified therapist has determined if goals have been achieved or require updating."
- "The qualified therapist has documented measurement results and corresponding therapy effectiveness in the clinical record"
Then: "therapy coverage resumes with the completed reassessment therapy visit." In CMS's example, a patient assessed April 1 is due by May 1. If the PT is not back by then, PTA visits after May 1 and before the PT's reassessment are not covered. OT visits run on the OT clock.
If the reassessment shows no progress and the maintenance criteria are not met, (D) adds that "the qualified therapist together with the physician or allowed practitioner must determine whether the therapy is still effective or should be discontinued."
Warning
Nothing in the current text excuses a late reassessment. CMS turned down a grace period after day 30, and no exception is written for a hospital stay or a therapist's leave. Plan therapist coverage before an absence.
Where the 13th and 19th Visits Went
Therapists trained before 2015 remember counting visits. The CY 2015 rule: "Effective January 1, 2011, therapy reassessments must be performed on or 'close to' the 13th and 19th therapy visits and at least once every 30 days (75 FR 70372)." It then eliminated the visit-count reassessments. Only the 30-day interval is left. State boards can add their own PTA and COTA supervision terms on top of Medicare's.
Tip
Practice, not rule: book the next therapist visit at the reassessment, well inside the window, so one sick call cannot push it past day 30. CMS's own on-time examples are "the 21st day or the 28th day."
Key Takeaways
- 409.44(c)(2)(i)(A) is the method: objective, comparable measurement by a therapist of that discipline. (B) is the interval: at least every 30 calendar days.
- The therapist, not the PTA or COTA, treats and reassesses on that visit. SLP has no assistant in the rule.
- Count from the day after the visit. April 1 means back by May 1. No grace period after.
- One clock per discipline, running for the full course of treatment until discharge. Recertification and payment periods do not restart it.
- Late means that discipline's visits are not covered until the therapist reassesses, rules on the goals and documents it.
Frequently asked questions
Can a PTA or COTA do the 30-day reassessment?
No. 42 CFR 409.44(c)(2)(i)(B) requires a qualified therapist, instead of an assistant, to provide the needed therapy service and functionally reassess the patient at least every 30 calendar days. The PTA or COTA can keep treating between reassessments. The PT or OT has to make the reassessment visit and treat on it.
Is the 30-day reassessment due on exactly day 30?
No. It is due at least once every 30 days. The CY 2015 final rule says the reassessment will not have to be done on exactly the 30th day and gives the 21st or 28th day as examples. Counting starts the day after the visit, so a reassessment on April 1 means the therapist must return by May 1. There is no grace period after day 30.
Does the 30-day therapy clock restart at recertification?
No. CMS says the reassessment clock is not measured by episode but by the full course of treatment, from the therapist's first visit until the patient is discharged from home health. It resets when a qualified therapist of that discipline treats, reassesses and documents. A recertification by an RN does not reset a therapy clock.
What happens if the 30-day reassessment is late?
Therapy visits for that discipline are not covered until the qualified therapist completes the reassessment and objective measurement, decides whether the goals are met or need updating, and documents the results. Coverage resumes with the completed reassessment visit. Other therapy disciplines are judged on their own clocks.
Does the 30-day reassessment apply if the therapist does every visit?
Yes. The rule is not conditioned on an assistant being involved. The Medicare Benefit Policy Manual applies it to each therapy discipline for which services are provided. A PT, OT or SLP who treats every visit still has to reassess with objective measurement, compare it to the prior measurement and document it at least once every 30 days.
Sources
- 42 CFR 409.44: (c)(1)(iv) objective measurement; (c)(2)(i)(A) the method; (c)(2)(i)(B) the 30-day interval; (c)(2)(i)(C) non-coverage until the reassessment; (c)(2)(i)(D) no progress; (c)(2)(i)(E) assistants' notes; (c)(2)(i)(F) therapist documentation; (c)(2)(ii) who may furnish therapy.
- 42 CFR 484.115: personnel qualifications for the therapist and assistant roles.
- 42 CFR 484.55(d)(1): the recertification assessment window.
- CMS, Medicare Benefit Policy Manual, Chapter 7, Home Health Services: section 40.2.1(b)(i) and (ii) (Rev. 10438), sections 40.2.2(A), 40.2.3 and 40.2.4.1 (discipline restatements), section 40.2.1 clinical notes, section 10.3 (recertification and payment periods). Fetched from cms.gov.
- CMS, CY 2015 Home Health Prospective Payment System Rate Update final rule, 79 FR 66032 (November 6, 2014), section H, "Proposed Change to the Therapy Reassessment Timeframes," 79 FR 66101 to 66105.
- Related on this site: which order an assistant works under, visit frequency guide, supervisory visit requirements, tracking 60-day certification periods.