Medicare Compliance & Reimbursement

Stay alert: Therapy utilization guidelines to hit agencies.

The feds and payers have had their eyes on home health therapy the last few years as PPS has made its footprint in Medicare Part A coverage. That spotlight continues to heat up with a new local coverage determination that will affect providers in 16 states--and maybe more.

No April Fool's joke: Regional home health intermediary Cahaba GBA proposed the local coverage determination (LCD) for home health therapy last August and has now issued the finalized determination to take effect April 1. Other Regional Home Health Intermediaries soon may follow suit to address the therapy hot topic, industry veterans predict.

Hot button: One of the contested components of the new LCD is the utilization guidelines Cahaba sets down for each therapy service.

Commenters on the original draft policy urged the intermediary to leave out specific visit numbers. But Cahaba defends the inclusion in the new policy's comments section. "We are responding to home health providers' overwhelming requests for guidance in this area," the intermediary maintains.

Cahaba did "back down some" on the visit guidelines, notes Cindy Krafft, MS, PT, COS-C, consultant with Atlanta-based UHSA. The LCD now stresses that "utilization guidelines (i.e. number of visits) mentioned throughout the LCD serve as only a guideline and DO NOT imply coverage or non-coverage of a service therein." The policy adds that "services must be reasonable and necessary for each individual visit, as supported by the plan of treatment and the therapists' documentation, based on an assessment of each beneficiary's individual care needs."

But the visit guidelines "could still cause concern," Krafft cautions. Most of that language was in the draft LCD as well, notes the National Association for Home Care and Hospice.

CPT Codes Cause Confusion

In fact, the finalized LCD looks very much like the proposed one, NAHC says. "No substantive changes were made from the draft document," the trade group tells its members.

A major point of confusion is that in the coverage policy, visit numbers and documentation recommendations are organized by CPT code--but home health agencies don't bill therapy using those codes.

Trap: HHAs may think they have to start using CPT codes under this policy, worries consultant Sharon Litwin with 5 Star Consultants in Ballwin, MO.

"Home health agencies [under Medicare Part A] are not required to document CPT codes in clinical records or on claims," one commenter protested. "The inclusion of CPT codes in this LCD will create confusion on the part of physical therapists and, potentially, medical reviewers, who might expect to find them in clinical documentation."

Justification: Cahaba defends its use of CPT codes. "A significant number of therapists often work across multiple bill types," the intermediary responds. "Organizing by code was geared towards the therapists' ease in transitioning among these bill types."

But in fact, a lot of therapists don't work in other settings, Krafft argues. "Many home health PTs have no idea about CPT codes, and I highly doubt the agencies they work for know more," she tells Eli.

ICD-9 List Missing Vital Codes

The LCD's list of ICD-9 codes that support medical necessity for home health therapy may leave clinicians and coders scratching their heads. Many codes are missing from the list, experts contend.

Limit: The list "is meant to include 'functional' diagnoses," Cahaba maintains. "The functional diagnoses, not necessarily the clinical diagnoses, may support coverage."

But this approach casts the PT in the role of symptom manager rather than manager of the entire patient, Krafft criticizes.

Agencies are already overusing "abnormality of gait" and "weakness" codes and neglecting to document them well, Krafft says. "However, agencies are inclined to use them because they feel they have to in order to support PT."

And using functional instead of clinical codes doesn't always depict the patient's underlying problem, Krafft fears.

Other issues addressed in the new determination include:

• Infrared therapy. Cahaba excludes infrared therapy such as Anodyne from coverage in the LCD. It cites the Centers for Medicare & Medicaid Services' (CMS) October National Coverage Decision excluding the service from Medicare coverage. The therapy "works so wonderfully and outcomes have been fantastic," Litwin laments.

Under the home health prospective payment system, agencies wishing to use infrared therapy can count a therapy visit only when they accompany the infrared therapy with another skilled service the therapist furnished during the visit.

• Additional documentation. Cahaba provides a list of "additional documentation recommendations" for each therapy reviewed. That's scaled back from the proposed determination, where the intermediary labeled them as "requirements," NAHC notes.

Example: For massage (CPT code 97124), Cahaba recommends including in the chart the area(s) treated, technique the therapist used and the patient's response to the treatment/education.

• Respiratory services. The intermediary erred in excluding from coverage HCPCS codes G0237, G0238 and G0239 for therapeutic procedures related to respiratory function, commenters said. "Physical therapists provide these services," one commenter notes. "Excluding them from coverage inappropriately limits the scope of physical therapy practice."

But Cahaba stands firm on the exclusion. "Respiratory care services are billed with a 041X revenue code along with the respective HCPCS code," it responds. "Home health bills do not accept 041X as a valid revenue code."