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Case Study:

One Agency Learned How To Bill Therapy Right The First Time

Published on Fri Feb 20, 2004

Use these field-tested tips for financial and clinical success.

A Tennessee agency stopped paying a fortune to correct high therapy threshold inaccuracies, and you can too - here's how.

If you underestimate a patient's therapy need on M0825, you can still get the extra money you earned. But to do that you must go back in the system, cancel the first request for anticipated payment, file a corrected RAP and then file the corrected claim. This backtracking delays your final payment and costs you in time and resources.

Since the advent of the prospective payment system, home health agencies have struggled to predict which patients would require 10 or more therapy visits -- earning an extra $1800 to $2200 per episode in the process. But accurately identifying these patients is easier said than done.

St. Mary's Home Care Services in Knoxville, TN decided to improve its financial and clinical performance by improving the percentage of cases that accurately met the anticipated high therapy threshold, says Melissa Evans, director of SMHCS. "We decided to use the reports from [Seattle-based] Outcome Concept Systems to figure out how to catch the inaccuracy on the front end as much as we could," Evans explains.

SMHCS is based at a hospital performing a high percentage of orthopedic procedures, Evans reports, so the agency has many admissions needing physical therapy. Their high therapy threshold cases typically are well over the required 10 visits, she notes.

Where to start: To begin fine-tuning SMHCS' therapy assessment accuracy, Evans assembled a group to look at the process. She included the therapy manager, the nurse manager, and some of the PTs and nurses conducting the OASIS assessments. The group focused on what they could do differently to improve the accuracy of their initial answer to M0825, Evans tells Eli.

The group also chose two outcome measures to track - improvement in ambulation and improvement in transferring -- to ensure quality of care didn't suffer during cost-cutting efforts.

SMHCS found their process improvement project not only lowered M0825 errors to the target levels, but also resulted in outcome levels for the two quality measures consistently higher than the national average, Evans reports. The agency also won a 2003 OCS Vision Award for its results.

How They Got Results

SMHCS revised or improved approaches while refining its therapy assessment process.

Most successful strategy:

  • Assign therapy cases to one therapist. Although the agency had tried to do that before, it's now a primary goal of the improvement plan, Evans says.

    In SMHCS' therapy-only cases, the PT does the assessment and evaluation and then only that PT and a specific physical therapy assistant go into that home, Evans explains. Although that's hard to do, the difference it makes is huge, she tells Eli.

    By having a single therapist manage the case, that PT "knows what the initial plan was and exactly where they are all along," she says. It's then easier for the therapist to determine the patient's progress. Advice to clinicians: Know where you are in the plan of care at all times, Evans stresses. Bonus: The therapists are happier following the patient from beginning to end and the patients are happier as well, Evans reports. And schedules are much easier to manage too.

    More tips from Evans:

  • Improve information sharing. For example, SMHCS requires nurses admitting patients who will need therapy to consult with the therapist to appropriately answer M0825. Therapists and therapy assistants attend weekly team conferences to report on where they are in the patient's plan of care. The therapist monitors the POC and contacts the physician for orders if the plan requires changes.

  • Track the POC. SMHCS staff started carrying calendars. Plans were plotted out on the calendar in the patient's home, based on how many times a week the clinician will see the patient. Field staff keep a copy of the calendar and focus on following the plan.

  • Educate the clinical staff about the billing and financial side of PPS. Both good clinical outcomes and good financial performance are important to the agency's survival, Evans reminds her field staff.

  • Develop written protocols to guide staff. SMHCS worked with physicians and therapists to document care expectations for various patient situations. But the POC is always patient-focused and based on clinical needs, not limited to a specific number of visits, Evans says.

  • Count all therapy visits in the episode. When answering M0825 on resumption of care, staff count visits made in the prior part of the episode as part of the total.

  • Review the record. SMHCS uses patient care coordinators to work on the clinical side of the process. They make sure the plan of care is appropriate, check the OASIS codes and answers (including M0825), review for signatures and documentation and make sure the record is complete and accurate before anything is sent for billing.

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