Home Health & Hospice Week

Do your therapy evals contain these 11 items?

It’s not only high-therapy claims that will cost you big if they don’t pass reviewers’ therapy-focused scrutiny.

Case in point: HHH Medicare Administrative Contractor Palmetto GBA reviewed nearly 2,500 claims with HIPPS code 1BGP* in the Feb. 1-to-April 30 time period in the MidWest and South-east regions, the MAC says on its website. The 1BGP* code indicates 11 to 13 therapy visits, a midclinical score (2) and mid-functional score (2).

Palmetto denied 27 percent of the charges in the MidWest and 24 percent in the Southeast, totaling more than $2 million in denied reimbursement.

“MR HIPPS Code Change Due to Partial Denial of Therapy” accounted for a big chunk of the denials — 36 percent of charges in the MidWest and 30 percent in the Southeast, according to Palmetto. “Based on medical review of the records submitted, some of the therapy visits were not allowed, thus, reimbursement was adjusted due to a partial denial and the original HIPPS code was changed,” Palmet-to explains.

The other big denial reason was “Absence of Short and/or Long Term Goals Within the Initial Therapy Evaluation Documentation”— 30 percent in the Southeast and 19 percent in the Midwest. “Short and or long term goals were not included in the record submitted for review” in those cases, the MAC explains.

Palmetto lists 11 items that should be in the therapy evaluation, and notes that the eval “must be completed prior to beginning therapy.” (For a free link to the Palmetto article, email editor Rebecca Johnson at rebeccaj@eliresearch.com with “therapy review” in the topic line.)

Palmetto also posted the results of medical review of claims from March 1 to May 31 with a variety of high-therapy HIPPS codes (those beginning with a “5”). The much smaller reviews saw denial rates ranging from 0 percent to 72 percent.

While the probes focused on high therapy claims, the denials were usually caused by problems with the plan of care/certification (either missing or insufficient); supporting documentation; missing or wrong OASIS; or lack of a response to the medical record request.