Home Health & Hospice Week

In three short months your agency will need to be up to speed on major PPS therapy revisions or risk losing out on your rightful reimbursement.

The Centers for Medicare & Medicaid Services will drastically revise how it pays home health agencies for therapy under the prospective payment system revisions that take effect in 2008.

Experts offer this advice to get off on the right foot when PPS therapy changes hit:

1. Complete OASIS accurately. Your patient assessments need to be accurate from the get-go so the care team can develop an appropriate plan of care, counsels consultant Mark Sharp with BKD in Springfield, MO. That includes an evaluation for therapy need when necessary.

The new OASIS item on therapy, M0826, will now ask for the specific number of therapy visits projected, notes consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN. That will require a big change for many agencies, which currently just check "yes" on M0825's question of whether the patient will meet the 10-visit threshold.

HHAs err on the side of marking "yes" because the system doesn't automatically adjust payment if the agency answers "no" to M0825 but the patient does have at least 10 therapy visits. But under the PPS refinements, the system will auto-correct claims, so agencies need to answer as accurately as possible.

Wait time: That will mean waiting for the therapy evaluation's results before completing OASIS, Gaboury says. "Until the evaluation is done, you don't know how many visits to put in there" she says of M0826.

Agencies need to be particularly careful about overstating the number of therapy visits routinely, Gaboury warns. Regulators could see that as a sign of fraud and abuse, since it nets the agency more cash up front on the RAP.

Pressure's off: On the other hand, the autoadjustment should relieve staffers' anxieties about picking the exact right number of therapy visits initially, offers therapist Cindy Krafft with Fazzi Associates based in Northampton, MA. "A quick win in all this change is that we can let clinicians know that M0826 will be adjusted to  match the actual number of visits provided on the final bill," Krafft tells Eli.

2. Stick to the basics. The change in therapy reimbursement shouldn't change the basic way you operate, Sharp says. The tenets of assessing the patient accurately, developing a plan of care that achieves desired clinical outcomes with the most efficient use of resources, and operating in a fiscally responsible manner should remain the same.

"There should be no change in practice if we were already providing the appropriate number of therapy visits," Krafft reminds providers.

3. Beef up documentation. Experts predict an onslaught of therapy-focused medical review once the PPS revisions hit. "Every visit has to be airtight in showing medical necessity," Krafft urges. "Document, document, document," Sharp stresses to providers.

4. Determine your financial impact. "Agencies need to assess the distribution of therapy visits and see where their cases fit in the 6, 14 and 20 model," Krafft suggests. "If there are gaps or peaks, these need to be investigated further to ensure patient-driven care." Financial analyses you ran under the PPS refinements proposed rule may no longer be valid, Sharp warns. CMS significantly revamped the case mix scoring system between the revised and final rules, so you'll want to re-run your numbers accordingly.

5. Train staff on therapy changes. The way you assess and plan care for your patients shouldn't undergo change due to reimbursement differences. But you still need to train clinicians on the new payment methodology, Sharp advises.

"Staff need to understand that the clinical drives the financial under PPS," Sharp says. That's even more true under the more complicated case mix system in the PPS refinements.

Clinicians need to understand why it is so vitally important to assess the patient accurately, code the OASIS form correctly and document services thoroughly, Sharp says. Staffers need to be motivated to get the rightful reimbursement the agency is owed for the patient.

But don't overemphasize the financial element in therapy training, Krafft cautions. "The focus should be on providing the number of visits the patient needs."

Teach staff about the new distribution of revenue over a wider number of visits, Krafft recommends.