Can you prove your patients who are independently performing activities of daily living really need 10 therapy visits?
If you have a patient with less than 15 points in the functional domain who still needs 10 or more therapy visits, your documentation had better be pristine.
Regional home health intermediary Cahaba GBA's medical review department initiated an edit of claims with a low functional domain - represented by an "E" in the HIPPS code - and a high service domain ("M"), due to "possible aberrant billing practices and vulnerabilities," the RHHI says in an article in its April bulletin to providers.
Basically, reviewers wondered why patients needed so much therapy if they could perform their activities of daily living (M0650, M0660, M0670, M0680, M0690 and M0700) with virtually no problems.
Cahaba denied 36 percent of the claims it reviewed from the edit. The biggest reason for denials: "documentation does not support homebound," Cahaba says. Reviewers shot down 23 percent of the denied claims for lack of homebound documentation.
"The homebound status is to be documented in the medical record frequently enough to reflect the beneficiary's current functional status, and at a minimum, at least once per certification/billing period," Cahaba says.
Second, with 20 percent, was a downcode for the patient having a hospital stay within 14 days of admission - the M0175 issue receiving so much attention from the feds lately (see Eli's HCW, Vol. XIII, No. 14).
Third was a downcode for the therapy visits not being medically necessary (18 percent) and fourth was no orders for the therapy (16 percent). Documenting verbal orders seemed to be a particular area of difficulty, Cahaba notes.
For tips on bringing your therapy documentation up to snuff, see Cahaba's article at
www.iamedicare.com/Provider/newsroom/newslines/040104.pdf. Your patients soon could qualify for a new program to manage their chronic disease, known as the "Voluntary Chronic Care Improvement Program."
The Department of Health and Human Services in the April 23 Federal Register will call for "innovative proposals ... to run large-scale chronic care improvement projects" for 15,000 to 30,000 beneficiaries with complex diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease. Qual-ified organizations "must have demonstrated success in population-based chronic care improvement services," HHS says in a release.
The Centers for Medicare & Medicaid Services will choose about 10 projects to run for three years, and might expand successful projects that improve quality of care, reduce Medicare costs and promote patient satisfaction.
More information on the program and CMS' solicitation for proposals is online at
www.cms.hhs.gov/medicarereform/ccip. A requirement to conduct criminal background checks on your direct-care workers could be coming to your state sooner than you think.
CMS has issued a call to states to submit proposals for the [...]
