Home Health & Hospice Week

Denials hinge on documentation.

Your chances of coming under the microscope for therapy services just increased.

The feds have a big incentive to reduce your therapy visit count to under 10, notes Cindy Krafft, director of rehabilitation for OSF Home Care based in Peoria, IL. That's because if reviewers can knock your therapy visit count under the high-therapy threshold, you lose about $1,800 per episode.

The HHS Office of Inspector General has targeted relatively few home health agencies for therapy audits--only four so far. But many more agencies will be seeing therapy visit denials and corresponding payment reductions from their regional home health intermediaries--particularly Cahaba GBA.

From June to August 2005, Cahaba conducted a probe audit of claims with HIPPS code HDGLX, 10 to 15 therapy visits and a length of stay of more than 60 days (in other words, patients were in their second episodes). The RHHI calculated a significant 25 percent error rate in the 80 claims reviewed, and now it's taking the edit into widespread medical review.

Problem 1: "Over one-third of the claims with denials for this edit were paid at a reduced HIPPS code, because the therapy documentation did not support the ongoing medical necessity of 10 or more visits," Cahaba explains in the review announcement on its Web site. "Each visit should be assessed whether the modalities performed require the skills of a therapist, and also if the patient's condition required the skills of that therapist"--in other words, medical necessity and reasonableness.

A common problem Cahaba found was therapists furnishing unnecessary visits after setting up a home exercise program. "Many times an exercise or gait program can be set up in less than 10 visits, and the continued visits may be more repetitive, and do not warrant the skills of the therapist," the RHHI maintains.

HHAs need to be especially careful to examine medical necessity and reasonableness in the second episode, Cahaba urged.

Problem 2: Cahaba reduced payments for another third of claims due to diagnosis coding problems in M0230 and M0245. For example, agencies chose the case mix code 781.2 (Gait abnormality) when the non-case-mix code 719.7 (Difficulty in walking) was more appropriate.

Or HHAs chose the higher-paying case mix code of 436 (CVA) or 332 (Parkinson's disease) when the lower-paying case mix code of 781.2 was really the main reason for treatment, Cahaba explains. "When using a condition such as Parkinson's as a primary diagnosis, there should be documentation of an exacerbation or change in this condition, which is usually reflected by medication or treatment changes, and a holistic approach involving more than one skilled discipline," the RHHI notes. Reviewers Hit Medical Necessity, Billing, Diagnoses Increased medical review comes in the wake of the OIG's four audit reports focusing on HHA [...]