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 episodes with 10 to 12 therapy episodes.

The reports carry "the implied need for more medical review" of the industry overall, notes consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas. And agencies can bank on the fact that the feds will paint the entire industry with a therapy over-billing problem, thanks to the handful of HHAs examined in the audit reports, Boyd criticizes.

In the latest report released Jan. 25, the OIG and Cahaba reviewers shot down or reduced payment for 50 percent of the 100 claims reviewed for Oxford Healthcare in Springfield, MO (see Eli's HCW, Vol. XV, No. 4). Some claims had multiple errors. Applied to Oxford's 851 claims with 10 to 12 therapy visits in 2003, the OIG assessed an overpayment of $685,406.

The OIG knocked down therapy visits for medical necessity reasons in 41 of the claims reviewed. In one example, reviewers denied five of 11 therapy visits, while in another example they determined patient goals were met by the ninth therapy visit.

Poor documentation is usually the culprit in medical necessity problems, notes consultant Sparkle Sparks with Redmond, WA-based OASIS Answers Inc. Inadequate documentation can "hang an agency out to dry," Sparks warns.

Paperwork problems: Reviewers found other problems in the sampled claims, including three claims that were billed before the physician signed the plan of care, one claim where the physician didn't authorize the therapy services, and four claims where the physician improperly authorized therapy services.

Usually the lack of strong communication between those performing chart/prebilling audits and those billing the claims leads to these types of technical problems, cautions consultant M. Aaron Little with BKD in Springfield, MO.

And reviewers docked 11 claims for incorrect patient assessment--"the beneficiary's medical records indicated that either the clinical severity or functional status identified in the assessment was wrong," the report explains. For example, one claim was reduced by $779 because reviewers replaced the primary diagnosis of unspecified muscle disorder with general weakness.

Audited HHA Wins Appeals

The OIG originally assessed an overpayment of $771,239, but Oxford brought that figure down to $685,406 by winning appeals on some of its claims already, the provider notes in its response letter included in the report. The agency is appealing the majority of the claims and plans to pursue most of those not already overturned to the Administrative Law Judge, it says.

Oxford will not comment further on the audit until its challenges of the audit's findings are complete, the HHA says in a release. 

Note: The OIG report is at www.oig.hhs.gov/oas/reports/region7/70401010.pdf. The Cahaba medical review notice is at www.iamedicare.com/Provider/newsroom/whatsnew/20060126_probe2.htm.