OASIS Alert

Affected therapists and agencies will face confusing CPT codes.

You probably thought the controversy surrounding the M0825 high therapy threshold was enough excitement for therapists. And information about potential changes to the current 10-visit hurdle is still undercover. Now home health therapy providers in nearly one-third of the states face a problem-filled new local coverage determination, and intermediaries for other states may adopt a similar one.

Regional home health intermediary Cahaba GBA has issued a final therapy utilization local coverage determination that will affect 16 states beginning April 1. But controversy surrounds this new spotlight on home health therapy coverage.

Issue 1. The LCD contains "utilization guidelines" for each therapy service. Comment-ers on the original draft policy urged the intermediary to leave out specific visit numbers.

Example: Wheelchair management (CPT code 97542), 2-3 visits; gait training (CPT code 97116), 12-18 visits in 4-6 weeks.

But Cahaba defends the inclusion in the comments section of the new policy. "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 physical therapist Cindy Krafft, a consultant with UHSA in Atlanta, GA.

"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 LCD now stresses. "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," the policy says.

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 & Hospice.

Issue 2. The LCD introduces CPT codes into home health therapy. A major point of confusion is that in the LCD policy, visit numbers and documentation recommendations are organized by CPT code--" but home health agencies don't bill therapy using those codes.

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

"Home health agencies 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.

Issue 3. The LCD's list is missing vital ICD-9 codes. Many codes are missing from the LCD's list of ICD-9 codes that support medical necessity for home health therapy, experts argue.

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:

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 used and 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."