Home Health & Hospice Week

Thousands of claims reviewed in past months.

While you may think any amount of medical review is too much, recently released probe results from one HHH MAC show that the review has become an increasingly crushing burden on home health agencies.

Starting on May 16, HHH Medicare Administrative

Contractor Palmetto GBA released medical review results for probes of claims with these HIPPS codes: 5BGK, 3CHM, 3BPG, 3BGM, 2CHL, 3CHP, 1CHN, 1BGK, 1CHM, 1CHK, and 1BGM. Those HIPPS codes represent episodes along the reimbursement spectrum, from “early” to “late,” high therapy to low therapy, and more.

These probes that ran from November to March resulted in more than 7,000 Additional Development Requests for agencies in Palmetto’s region, according to analysis of the results from M. Aaron Little with BKD in Springfield, Mo. “These probe edits were very problematic for providers” just based on their sheer volume, Little tells Eli.

For example: Palmetto’s data shows that Alabama, which has only about 150 HHA provider numbers, saw nearly 700 ADRs. While the average five ADRs per provider there would seem manageable, “what we saw was agencies were getting considerably more than just an ‘average’ number of ADRs,” Little reports.

And remember, these probes are ongoing, so agencies have been subject to even more ADRs since this time period that ended in March.

The flood of ADRs seems unnecessary when looking at the denial results, Little adds. These claims were chosen as “high risk” areas for review, but overall the denial rate has been about 11 percent.

Don’t expect the scrutiny to level off, says consultant Judy Adams with Adams Home Care Consulting in Durham, N.C. “If the number of denials decrease to below 5 percent, PGBA will cease these edits,” Adams says. “But as long as they continue to see denial rates at 10 percent and higher, they will continue the edits.”

Target On Therapy

While the claims reviewed include both high and low therapy episodes, a large portion of the denial reasons are based on therapy (see sidebar for often cited therapy reasons).

“Therapy denials are attractive to Palmetto GBA because of the dollar amount,” believes Julianne Haydel with Haydel Consulting Services in Baton Rouge, La.

“Palmetto GBA has had focused medical reviews on the HIPPS codes that reflect both low and high therapy use for more than a year now and continue to cite significant denials based on these reviews,” Adams observes.

“I am seeing an uptick in therapy denials,” reports PT and consultant Karen Vance with BKD.

The therapy focus may be particularly appealing to Palmetto because the MAC requires one documentation element that the other contractors don’t — at least not yet: therapy goals. “Palmetto is the only MAC that requires short- and longterm goals in an LCD for therapy,” Vance points out. “Since there is no mention of short- and long-term goals in the CMS Benefit Policy Manual, that can throw an agency off if they are not paying attention to Palmetto’s LCD.” (For more on Palmetto’s LCD goal requirement, see Eli’s HCW, Vol. XXIV, No. 31).

Silver lining: One good thing about therapy based denials, compared to those based on faceto-face requirements or eligibility, is that they often lead to down codes instead of outright denials of the full episodes, experts note. But they still are reimbursement-draining, and if the therapy is supposed to prove the patient’s medical necessity, disallowing the therapy can lead to full episode denials anyway.

Therapy Documentation Falls Short

HHAs’ therapy documentation is often riddled with problems. “Documentation is key, but the problem is that nurses are not therapists,” Haydel laments.

For example, nursing documentation may contradict therapist documentation — nurses often rate patients as better functioning than therapists do.

And nurses who are in charge of reviewing documentation may not understand therapy charting requirements. “Many providers do not have staff educated or experienced in therapy to review the documentation and work with the therapist on improving it or submitting missing data,” says nurse consultant Pam Warmack with Clinic Connections in Ruston, La.

Therapists are often falling short in their documentation duties as well. This is a particular problem with contract therapists, Warmack notes. Many of her small agency clients must use a contract therapist. “Despite numerous efforts to educate these therapists on Palmetto’s documentation requirements, the therapists continue to document poorly,” Warmack relates. “Most of my clients have provided documentation templates for therapists to use, but even then there are errors and omissions on the documentation forms.”

Contract therapists also often turn in their documentation way too late — often 30 days or more, Warmack says. “This is absolutely unacceptable and causes a myriad of problems.”

Trouble spots in therapists’ documentation include the functional reassessment, Vance says. “I don’t see many reassessments that provide a compelling description of therapy effectiveness,” she relates.

Another is the short- and long-term goals. Often, “goals are simply omitted from the paperwork,” Haydel finds.

Making sure goals are measurable is also a problem, Vance adds.

Often therapists do well documenting a measurement such as number of feet a patient can walk, but fail to document other types of measurable goals such as range of motion for an injured shoulder or a pain scale, Haydel offers.

Maintenance therapy, which is supposed to be covered per the Jimmo ruling, also poses problems, Haydel says. It is difficult for therapists to document support for maintenance goals in such a short period of time, she observes.

Note: See the probe results by going to www.palmettogba.com, clicking on “Jurisdiction M Home Health And Hospice” in the “Medicare Resources” blue box, clicking on “Medical Review” in the drop-down “Topics” menu, clicking on “Results,” and scrolling down to the relevant article links. For tips on strengthening your therapy documentation and protecting your claims against therapy denials and downcodes, see a future issue of Eli’s Home Care Week.