Home Health & Hospice Week

Lack of goals may be your claims’ downfall.

If you feel like your claims with therapy are under intense scrutiny these days, you’re not alone.

HHH Medicare Administrative Contractors have been denying and downcoding millions of dollars’ worth of therapy claims from home health agencies (see Eli’s HCW, Vol. XXIV, No. 26).

At Palmetto GBA, a main reason for de-nials and downcodes in a recent review was “Absence of Short and/or Long Term Goals Within the Initial (PT/OT/ST as Appropriate) Therapy Evaluation Documentation,” according to the MAC. “Short and or long term goals were not included in the record submitted for review,” Palmetto explains in an article about the review.

“Palmetto-impacted agencies are reporting increases in therapy denials specific to the short term/long term goal issue,” confirms physical therapist consultant Cindy Krafft with Kornetti & Krafft Health Care Solutions. In fact, in an article about the review, Palmetto spells out the 11 elements its reviewers expect to see in the record to support therapy claims — including goals.

“The #9 element relating to short and long term goals appears to be gaining a higher level of attention among home health therapy providers,” observes PT Chris Chimenti, Director of Therapeutic Services for HCR Home Care in Rochester, N.Y. “This is in large part a result of the denials and downcodes that are popping up.”

HHAs may be frustrated with this requirement, because “there is nothing in actual regulation that clearly defines short term and long term goals or confirms that they are mandatory,” Krafft tells Eli.

“I hate Palmetto’s requirement for short and long term goals when Centers for Medicare & Medicaid Services coverage does not require them,” one industry veteran criticizes.

Keep Tabs On Your MAC’s Local Policies

Instead of national regulations, Palmetto has added the requirement via local policy. “Palmetto has implemented and enforced this expectation through Local Coverage Determination: Home Health-Physical Therapy (L31542),” Chimenti points out.

You’re next: Other MACs haven’t officially added the requirement yet, Chimenti says. “But it is likely a matter of time before intermediaries such National Government Services and others adopt the same expectation for this element,” he explains.

Another problem: A complete lack of goals isn’t the only error that will shoot down your claim. Reviewers are also dinging claims for therapists failing to tie goals to functional improvement, says clinical consultant Dana Eichler with Smart Healthcare Resources in Denver, Co.

For example: Eichler recently read an audit that said “why does patient need to walk 150 feet?” the RN reports.

When PT consultant Karen Vance with BKD reviews claims, “the areas I see where therapists have the most problems is the ‘functional reassessment’ not having ‘functional, objective, and measurable’ goals,” Vance reports.

Goal-related problems are only one of many issues dogging HHA claims that include therapy. Watch out for these other common issues:

• Nursing-therapy contradictions. You can bet reviewers will be happy to deny or downcode your claim if nursing and therapy notes seem to be describing a different patient. “I am seeing more of the disconnect between SN and PT documentation being pointed out with downcode occurring,” Eichler relates.

• OASIS documentation. A big problem with inconsistent documentation is that it contradicts the OASIS. And if the chart doesn’t support OASIS elements that lead to case mix points, you can face a costly downcode or denial.

• Disparity hot spots. Therapists have long complained that nurses are not assessing patients correctly in the functional domain of the Start Of Care OASIS. When nurses score patients too high, they can cause two problems: lower-than-deserved case mix scores and reimbursement, and depressed patient outcomes for Home Health Compare.

Plus: Assessing the patient for pain is one area where reviewers are hitting HHA claims, Eichler tells Eli. In this case, it’s therapists who appear to have trouble assessing patients accurately.

• Homebound status. Your whole claim, not just the therapy portion, will get denied if you fail to prove the patient’s homebound status as required by Medicare. “Evaluation documentation completed by the Physical and Occupational Therapist is an important element of the record,” Chimenti says. “PTs and OTs closely evaluate the current level of functional mobility within the home environment. This documentation should support the patient being confined to the home.”