OASIS Alert

Why were two-thirds of these claims paid?

You could be handing the $2,000 per episode you earned for M0825 high-therapy use back to your intermediary, if you don't document thoroughly on every visit.

Medical review of episodes with 10 therapy visits billed--nine physical therapy and one occupational therapy--showed that "last quarter there was a 31.4 percent denial rate for claims reviewed for this edit," regional home health intermediary Cahaba GBA announced in its Web site notice. The FI will continue to target these claims.

Watch out: Building on the age-old health care adage that if it wasn't documented, it wasn't done, intermediaries are waging war on claims meeting the high-therapy threshold. And the primary reason for the therapy downcodes Cahaba reported was that documentation did not support the need for the OT evaluation or for one or more of the PT visits, the intermediary said. 

Red flag: Targeting claims with exactly 10 visits is an easy choice, experts say, and it's likely to continue. After all, by denying only one visit, the RHHI avoids paying about $2,000 for each episode--a huge financial incentive.

OTs Are Not The Problem

Holding up the single OT visit pattern for scrutiny is leading many agencies to view OT as the problem. Some are considering policies that require extra steps before allowing an OT evaluation, such as having the evaluation authorized by a PT or checking back with the physician who ordered the evaluation to be sure OT is needed, says PT Cindy Krafft, director of rehabilitation for Peoria, IL-based OSF Home Care.

But "restricting OT evaluations is not the solution," Krafft emphasizes. Instead, make sure all the therapy visits are justified, she says.

Only 20 to 30 percent of home care patients receive OT as it is, Krafft says. Don't cut back even more--just be sure the OASIS answers and the patient's individual needs support the OT services.

Only One OT Visit May Make Sense

Look at the reasons why the OT made only one visit, Krafft suggests. After all, Cahaba did not deny 68 percent of the 9 PT-1 OT claims it edited, she stresses. In many cases the 9-1 pattern was perfectly valid.

Example: Maybe the OT made the visit early in the episode and the patient refused further OT visits because of fatigue. Or perhaps the patient misunderstood what OTs do and refused that therapy, Krafft proposes.

It's certainly worth giving special scrutiny to 9-1 claims.  "Anytime you end up with 10 visits, you have to be especially careful that the documentation on every visit supports the skilled need," Krafft warns. Also be sure the OASIS answers show consistency between the functional questions that generate reimbursement and the other functional questions, she tells Eli.