Home Health & Hospice Week

The more of these you have, the more you may catch reviewers' attention.

Medicare often has a strong financial incentive to knock down just a few therapy visits per episode--and will be only too happy to do so.

Get ready to defend your visits if you're waving these therapy red flags to auditors from the HHS Office of Inspector General, regional home health intermediaries or elsewhere:

1. High percentage of marginal episodes. If you have many episodes that barely break the therapy threshold, you may show up on the feds' radar screen, noted physical therapist Cindy Krafft, director of rehabilitation for OSF Home Care based in Peoria, IL, in a recent teleconferrence sponsored by Eli Research.

Reviewers have an easy time recouping $2,000 to $2,500 per episode just by denying a few visits based on medical necessity, reasonableness or technical problems like missing visit notes, Krafft cautioned.

2. Short therapy visits. When the Centers for Medicare & Medicaid Services first drafted the home health prospective payment system, it considered using therapy hours rather than visits to set the high-therapy threshold, Krafft recalled. CMS used a therapy visit length of about 45 minutes to set the 10-visit mark.

While there is no official rule about how long your therapy visits must be, CMS "did not want to see the visits ... systematically become shorter," Krafft said. In other words, you shouldn't be providing 30-minute therapy visits so the therapist can go out more often. OIG auditors asked about therapy length when they gathered information.

3. Low discipline mix. OIG auditors focused on episodes that contained physical therapy visits only to exceed the 10-visit threshold, Krafft explained. Agencies may find it harder to justify 10 to 12 visits from one discipline, as opposed to a handful of visits by PTs, occupational therapists and speech therapists to address different issues.

4. Unvarying visits. Reviewers may raise their eyebrows if all your patients get assigned about the same number of visits. "Is that reasonable when everybody looks the same? Not really," Krafft warned. That's especially true if the usual visit number barely exceeds the threshold.

5. Lots of visits for a limited reason. OIG reviewers hammered some cases where 12 therapy visits were called for to administer a home program. "Why do we need all these visits to accomplish this?" Krafft asked. Auditors judged "that after about six visits, this patient should have the home program information down."

If there are complications in addition to the home program--say, inconsistent caregivers or cognitive issues--you need to document those reasons for furnishing more visits.

6. Independent OASIS scores. When your clinicians score a patient as independent in lots of categories such as ambulation and transferring, it is hard to justify why your therapists are in there working on those issues, Krafft predicted. "If this person can get around by themselves ... why do you go" for up to 12 visits?

7. V57.1 overuse. RHHIs are already cracking down on use of V57.1 (Other physical therapy, therapeutic and remedial exercises, except breathing), Krafft noted. That scrutiny is bound to get tighter now that ICD-9 coding rules mandate providers use this code as a primary diagnosis only (see Eli's HCW, Vol. XIV, No. 45).

8. Technical errors. The OIG's third therapy audit focused on visit denials for reasons ranging from missing or not matching orders, missing visit notes and miscalculated billing codes (see Eli's HCW, Vol. XIV, No. 37).

These are the types of issues agencies are used to seeing in surveys, not audits, Krafft noted. The audit "sheds a new light on what it could cost us to have those technical pieces missing." 

Note: To order a recording of the teleconference, go to http://codinginstitute.com/conference/tapes.cgi?detail=404 or call 1-800-508-2582.