Home Health & Hospice Week

Intermediary targets single OT visits.

Is your therapy documentation up to snuff? If it's not, you could lose $2,000 per episode that's rightfully yours.

In a widespread claims edit (5 TH87), regional home health intermediary Cahaba GBA has targeted home health claims with nine physical therapy and one occupational therapy visit per episode. "Last quarter there was a 31.4 percent denial rate for claims reviewed for this edit," Cahaba says in Web site posting.

The top denial reason: A therapy downcode, typically because documentation didn't support the single OT visit or one or more of the PT visits, Cahaba explains in the notice.

Your Documentation's Up to the Plate

It's no surprise that Cahaba has picked up on the 9-1 visit pattern for scrutiny, says PT Cindy Krafft, director of rehabilitation for OSF Home Care based in Peoria, IL. "As a PT, nine visits is at least three if not four weeks of therapy," Krafft notes. That utilization level would indicate a significant functional issue. "If that is accurate, how can there be no need for OT beyond the evaluation?"

RHHI edits highlight what could be "suspicious circumstances," notes PT Sparkle Sparks, consultant with Redmond, WA-based OASIS Answers. Agencies must prove the therapy services were medically reasonable and necessary with their documentation. Unfortunately, often "clinicians don't take documentation seriously enough," Sparks laments.

Holding up the single OT visit pattern for scrutiny is similar to Cahaba's edit on single medical social work visits, notes consultant Marian Entin with Simione Consultants in Gaithersburg, MD. "It's the same concept," Entin notes.
 
In this case, one OT visit can put the episode over the lucrative 10-visit therapy threshold. In the earlier edit, one MSW visit can push the episode over the punishing four-visit low utilization payment adjustment (LUPA) threshold (see Eli's HCW, Vol. XV, No. 10).

RHHIs are under great pressure to deny claims and decrease payments to providers, notes PT Fran Fowler, consultant with Fowler Healthcare Af-filiates in Atlanta. "The pressure will only increase," Fowler warns.

Heed these expert tips for avoiding the tightening medical review noose:

1. Beware 10 to 11 therapy visits. When you furnish just enough therapy visits to reach the $2,000 threshold, you'd better be prepared to defend every visit with excellent documentation. Any episodes with 10 or 11 therapy visits are up for increased scrutiny, predicts consultant Betty Gordon with Simione Con-sultants' Westborough, MA office.

2. Individualize care planning. If all your patients receive the same amount of therapy, it will raise red flags at the RHHI, Fowler cautions. "Please ensure that your patients' care plans are individualized to their conditions," Cahaba says in its notice.

That may mean coming up with an internal screening tool to determine which patients receive OT evals, instead of furnishing evals to every therapy patient, Fowler suggests. HHAs can start with the diagnosis to identify which patients should receive an eval, she says.

3. Show why you're there. Although it may seem basic, many clinicians fail to document what they are trying to do in the home, notes OT Karen Vance, consultant with BKD in Springfield, MO. The record must show why the services are reasonable and medically necessary.

And the documentation must show that the services require the unique skills of the PT or OT, Sparks tells Eli.

The most common documentation error Entin sees is failing to show the patient's progress in quantifiable terms. For example, what number of feet a patient can ambulate as the visits progress.

4. Show why you left. Just as important as showing why you went in is showing why you left, Vance advises. If your therapy services break off at the 10- or 11-visit mark for no reason, you're asking for downcodes.

Therapists must start with setting appropriate goals for the patient, Fowler suggests. If they're so hard the patient will never achieve them, you can't prove you should be there at all. If the patient achieves the goals right away, there's no reason for continued therapy.

Showing measured progress toward the goals without reaching the maximum goal before visits end is key, Gordon instructs.

5. Exercise your appeal rights. If all else fails and you get caught up in an unfavorable medical review, don't hesitate to appeal, Fowler recommends.

Tip: But before sending in the appeal letter, contact your intermediary's clinical department directly to find out what kind of documentation it's looking for. They may tell you exactly what information was missing from the record.

Note: Cahaba's notice is at www.iamedicare.com/Provider/newsroom/whatsnew/20060327_mr.htm.