Home Health & Hospice Week

Denials from Palmetto just keep on coming.

One HHH Medicare Administrative Contractor has released results from medical review of thousands of more claims, and therapy continues to feature as a major denial reason.

Review: From May 16 through 18, Palmetto GBA released results for more than 7,000 claims that underwent review in 13 states from November to March, revealing a goodly number of claims denied for therapy-based reasons (see Eli’s HCW, Vol. XXVI, No. 20).

On May 30, Palmetto released results for about 4,800 more claims reviewed during that time period with a variety of HIPPS codes. Like the first batch of claims, these results focused on therapy based denials under the following codes: 5F080/ 5T080: Absence of Short and/or Long Term Goals within the Initial (PT/OT/ST as appropriate) Therapy Evaluation Documentation; 5F301/5A301: Information Provided Does Not Support the Medical Necessity for Therapy; 5FTDR/5TTDR: Assessment, Measurement and Documentation of Therapy Effectiveness Not Submitted in the Medical Record; 5CHG3: Medical Review HIPPS Code Change Due to Partial Denial of Therapy; 5F070/5T070: Visits/Supplies/DME Billed Not Documented/Not Documented As Used (often used for therapy visits); and 5F072/5T072: No Physician’s Order for Services or More than Ordered. (See Eli’s HCW, Vol. XXVI, No. 20 for more detailed “granular” findings under the reason codes.)

To prevent these common denials, industry veterans offer this advice about documentation:

1. Know the rules. It’s not enough to just know the overarching Medicare policies about therapy coverage. You need to get into Palmetto’s requirements. “Clearly, PGBA has specific expectations related to documentation to support therapy services,” observes Judy Adams with Adams Home Care Consulting in Durham, N.C. Particularly the short- and long-term goals that other MACs have not yet started requiring.

“Therapy Local Coverage Decisions offer specific guidance,” Adams offers. “And the last couple of years of PGBA workshops and several articles … have given concrete examples of therapy documentation as well as appropriate short- and longterm therapy goals.” Explore all these resources via Palmetto’s website at www.palmettogba.com. (See the elements Palmetto expects to see in documentation, according to its therapy LCD, p. 163).

2. Describe the problem. Focusing only on treatment is a common mistake. Documentation must accurately describe the patient’s problem to start with, so improvement can be assessed. For example, for walking, “the therapists need to describe any and all problems such as balance, shortness of breath, and pain incurred due to walking,” recommends Julianne Haydel with Haydel Consulting Services in Baton Rouge, La. “Therapists should also take before and after vitals to determine the cardiovascular burden of walking or exercises.”

3. Go beyond the goal. It’s not enough to just say the patient’s goal is to ambulate x number of feet. You have to consider the goal’s functionality, advises physical therapist and consultant Karen Vance with BKD in Springfield, Mo. “Documenting strength, for example, is a component” of the goalsetting, Vance says. “But the goal should be stated in terms of what will the patient be able to do with the improved strength? Walk further? Come to a standing position independently? Reach higher to get something out of the closet?” Spell it out in the record.

4. Don’t ignore “measurable” part. Both when setting goals and measuring the patient’s baseline data, don’t just go for the low-hanging fruit such as x number of feet walked, Haydel recommends. “When other injuries are being addressed, it is less common” to see objective measurements included.

For example, “What is the range of motion of a shoulder? How is the patient’s pain both during the visit and throughout the episode? In a number we can all recognize, how close is the patient to reaching goals?” Haydel asks.

Documenting these “measurable” items with counting can make a difference in the patient’s OASIS assessment and HIPPS score (and thus reimbursement level), Vance points out. For example, simply documenting “Improvement in dressing” does not tell how much is improved and whether it matters, Vance says. “How much less assistance? From minimal assistance to occasional verbal cueing? That can matter in the difference between a 2 to a 1 in M1810 or M1820.”

5. Be sure to include timeframes. Leaving out a timeframe is a common problem, observes Pam Warmack with Clinic Connections in Ruston, La. For Warmack’s clients, “the therapists have gotten better about establishing goals that are measurable, but they are reluctant to assign timeframes,” Warmack finds.

Therapists may be afraid of denials if their patients don’t make the timeframes they target, but Palmetto indicates that documentation should avert the problem. “If measurement results do not reveal progress toward goals, but therapy continues, documentation must indicate why the physician and the therapist have determined therapy is still medically necessary,” Palmetto says in its medical review results articles.

6. Don’t set the therapy plan in stone. While the home health agency PT Chris Chimenti works for in Rochester, N.Y., HCR Home Care, is served by MAC National Government Services, there are some documentation problems that affect claims with therapy for all MACs.

For example: “Documentation that reflects a static and repetitive approach to intervention, such as the same exercise plan for three consecutive weeks without variation in sets/repetitions, is likely to result in denial and downcode upon review,” Chimenti tells Eli. Instead, “throughout the duration of the episode, the therapist should vary the interventions as the patient responds to treatment over time. It’s important the therapy documentation be dynamic and changing throughout the episode.”

7. Support maintenance therapy with specifics. The long-term nature of maintenance therapy doesn’t jibe well with Palmetto’s goal-setting expectations. But careful documentation can combat that problem.

Palmetto says in its medical review articles that therapy must be “provided with the expectation, based on the assessment of the patient’s rehabilitation potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time; or the services are necessary to the establishment of a safe and effective maintenance program.” In other words, show how the therapy is maintaining the patient’s functionality, or slowing its deterioration.

“To substantiate the need for restorative home health therapy services, it is important the therapist document the change in functional status the patient has experienced as a result of recent illness or exacerbation of condition,” Chimenti offers.

“Examples would include an increase in required assistance to perform bathing tasks safely or the development of festination and postural instability in a patient with advancing Parkinson’s disease. Once this is established, the sophisticated skills of a trained therapist are warranted to assist the patient in regaining his/her functional baseline status.”

8. Educate your therapists. “Home health agencies need to provide focused education to therapy staff related to documentation required and necessary to support therapy services,” Adams urges.

Note: See the probe results of the nearly 11,900 claims reviewed by going to www.palmetto

gba.com, clicking on “Jurisdiction M Home Health And Hospice” in the “Medicare Resources” blue box, clicking on “Medical Review” in the dropdown “Topics” menu, clicking on “Results,” and scrolling down to the relevant article links. For tips on refining your operational processes to protect your claims against therapy denials and downcodes, see a future issue of Eli’s Home Care Week.