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Medical Review:

RHHI WORD PLAY COULD STIFLE THERAPY WOUND CARE VISITS

Published on Thu Aug 01, 2002

Several regional home health intermediaries have put their heads together and come up with a new local medical review policy that could cost home health agencies thousands of dollars.

At first glance, the finalized version of the home health wound care LMRP Palmetto GBA recently posted on its Web site looks vastly improved over the draft version Palmetto and Cahaba GBA floated early this year.

The new version still stipulates that "the coverage of therapists in the performance of home health wound care will depend on the therapist's specific scope of practice formulated by each state." But it leaves out draft language under the utilization guidelines that would have required the wound care services to be specifically spelled out by that state's PT practice act to count toward the 10-visit therapy threshold.

Instead of the original draft language, the utilization guidelines now say, "Therapy visits for wound care will count toward the therapy threshold item in the case mix methodology."

The substitution of that language makes it appear as though the policy is dropping the stringent requirement for practice act specificity, notes Gene Tischer, executive director of the Associated Home Health Industries of Florida.

"Most practice acts are general and vague," Tischer says. "The specificity floated in the original draft would have seriously curtailed wound care treatments historically provided by therapists for many years."

But looks may be deceiving, and the policy probably will place that insurmountable obstacle in front of agencies.

A Cahaba source says the RHHI will issue a nearly identical wound care LMRP very soon. Despite the deletion of the utilization language, "the state practice act has to say a therapist can do more than just general wound care," the official stresses. "It must specify the wound care components, such as sharp debridement, etc."

"A general wound care clause won't cut it," the source warns.

"That's our interpretation" of Palmetto's revised wound care medical review policy, agrees Mary St. Pierre with the National Association for Home Care. "That's very problematic."

That requirement alone could cost many HHAs as much as $2,000 per patient if they can't reach the therapy threshold; at the very least, it will cost them the labor of sending out a nurse to perform the wound care that a therapist could have furnished, experts say.

The RHHIs are cracking down on this area to try to curb abuse of the therapy upgrade under the prospective payment system, industry observers suspect.

Therapists Receive Unfair Scrutiny

State practice acts for other clinicians, including those for physicians, don't spell out services in as much detail as the policy requires, St. Pierre protests. "They just don't do that."

The other RHHIs are expected to follow suit on this policy, the Cahaba official tells Eli.

Other changes from the draft to the final wound care LMRP from Palmetto:

  • Home health patients now will have 60 days instead of 21 days to show improvement under the wound care regimen before the HHA staff and physician must have a conference reassessing the condition and try a new approach. The draft originally called for a face-to-face physician reassessment of the patient.

    The conference between the nurse or therapist and the physician doesn't have to be face to face, but may be conducted via e-mail, telephone, etc., Palmetto says in its response to comments.

    It's convenient that the conference and new treatment plan will coincide with the recertification period, the Cahaba source points out.

  • The policy no longer describes electrical stimulation of wounds as a "conservative" treatment, but it does still say it will be covered only for "pressure ulcers stage III or IV that have not responded to more conventional forms of treatment."

  • The LMRP does not require the nurse to supervise the therapist, but rather requires the nurse and therapist "to work in conjunction" in traditional nursing areas such as nutrition, positioning the patient, etc., Palmetto says in its response to comments on the draft policy.

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