OASIS Alert

Auto-upcoding provides backup to your estimate for payment accuracy.

If your clinicians are still way off in answering M0826, use the following tips to ease their struggles.

Many clinicians are happy with the change to the therapy question on the OASIS assessment. Even though they no longer have the "yes" or "no" answer of M0825 and now have to predict a specific number of visits in M0826, they don't have to worry as much about getting the answer wrong. This is because the prospective payment system now automatically corrects both under- and overestimated therapy predictions.

Not so fast: But that doesn't mean your answer to M0826 doesn't matter. M0826 (Therapy need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits [total of reasonable and necessary physical, occupational, and speech-language pathology visits combined]?) leaves you a three-digit space to enter the number of visits expected and asks you to enter "000" if no therapy visits are indicated.

If you underestimate the number of visits, your agency will have to pay for the extra visits and wait to be reimbursed in the final claim. On the other hand, if you over-estimate the therapy visits, your agency will get more money up front from the request for anticipated payment (RAP) by claiming a higher-paying functional domain category than it actually will deliver.

Red flag: With the auto-upcoding in place under the PPS refinements, authorities may crack down on providers that always report very high predicted therapy utilization, experts warn. "Systematic overestimates that generate a very high up-front payment may attract attention cautions physical therapist Cindy Krafft, Peoria, Ill.-based consultant with Fazzi Associates. "It can look like a way to enhance cash flow."

Remember, though, this is just an estimate, Krafft emphasizes. The industry's accuracy rate when you look at predicted therapy visits and the number actually done is about 24 percent, she reports. Look at your last year of historical data on M0826. How is your accuracy?

How far off are you? "If there aren't wild swings in your adjustments, I would leave it alone," she says. If you are always way off in one direction, you may want to set up a system of having staff automatically add or subtract a few visit to the number the clinicians predict.

Agencies need to be particularly careful about dramatically overstating the number of therapy visits routinely, warns consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tenn. Regulators could see that as a sign of fraud and abuse.

On the other hand: Consider whether enough of your patients are getting access to therapy, Krafft reminds clinicians. "Abt Associates showed just over 50 percent of Medicare home health patients receive at least one therapy visit," she reports. But by definition these patients are homebound. The majority have mobility issues, she says. If you have a large percentage of your patients receiving no therapy visits, be sure to look at access, Krafft suggests.

Accurately answeringM0826 will require careful consultation between the nurse and the therapists, warns consultant Lisa Selman-Holman with Denton, Texas-based Selman-Holman & Associates. Use the five-day OASIS window to schedule the therapy evaluation.

And set up a system to speed up communication between the therapist and nurse for greater M0826 accuracy, experts advise.

"Until the therapy evaluation is done, you don't really know how many visits to put in there," Gaboury says.

Because CMS does not expect the estimated and actual therapy visit numbers to closely correlate, some agencies are trying to make it easier on clinicians by expecting an underpayment, Krafft reports. They have clinicians answer M0826 with one, two, or three visits, based on the initial orders and expect additional therapy payment on many patients at the end of the episode, she says.

Downside: The variety of agency approaches to M0826 has affected the ability of HHAs to compare case mix weights from the request for anticipated payment (RAP), Krafft says. "How your agency decides to handle M0826 has a huge impact on the start of care RAP case mix weight. It's now a much softer number," Krafft says. If an agency leans toward using a higher therapy visit number -- leading to a higher case mix weight, that weight is no longer helpful as a check on OASIS accuracy, Krafft explains. "If a clinician puts down 14 visits for a patient who may only need nine, she could have the diagnosis and many other crucial OASIS answers wrong and still have a good case mix number," Krafft says.

Some providers are struggling significantly with the physical therapist shortage and rely exclusively on contracted therapists for services, says consultant Patricia Jump, president of Acorn's End Training & Consulting in Stewartville, Minn. When this happens, there is often less control regarding when the therapist is able to make the first visit, she says. Sometimes the first visit is after the five-day time limit for completing the OASIS assessment. In that case, the nurse needs to determine how many visits therapy will be making. If a nurse is trying to determine therapy visits, here are a few things to keep in mind, Jump says:

1. Focus on rehab potential. Consider how long the patient has had the deficit; how motivated the patient is to improve; and prior level of function.

2. Emphasize action.Ask the patient to demonstrate activities as you perform the OASIS assessment.

3. Consider the situation. Does the patient plan to re-enter the community? If so, what functional abilities will the patient need? And how much caregiver support is there for follow-through?

4. Stick to the basics. Remember the number of visits should reflect the patient's need for therapy services. And that number should be reflected in the plan of care.

5. Provide tools for clinicians. Work with therapists experienced in home care to help nurses develop an approach to deciding on visit numbers. Formulaic algorithms don't work, though, Kraft warns. CMS tested many variations of basing a M0826 answer on a diagnosis code or combination of OASIS answers, but found the most they could do was indicate a high probability of the need for therapy, but not how much, she tells Eli.

Tip: The best strategy is to go by your organization's last year of answering M0826, Krafft suggests. Look at records of patients with specific diagnoses -- such as heart failure or hip replacement -- and see how many therapy visits those patients got, she says. But remember not to use this data to pressure therapists to change their evaluations of what the patient needs, she warns.

6. Be sure clinicians understand that zeros preceed the number of visits. For example, for eight visits M0826 would read 008.

One last point: Don't just rely on CMS to correct M0826, Jump recommends. You may want to check to be sure the auto-corrections are actually occurring. Most agencies are not finding problems with auto-orrection, though, Krafft tells Eli.