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Reimbursement:

Make Your Therapy Claims Audit-Proof

Published on Sun Jun 05, 2005 Print Friendly and PDF PDF

Expect more therapy downcodes - thanks to OIG audit.

Medical review of claims with just over 10 therapy visits are more likely than ever, now that the feds are shining a spotlight on extra payment for therapy. Use these strategies to keep the money you earned.

Your intermediary gets a good return on the time invested when it can deny one or two therapy visits and return more than $2,000 to Medicare for each episode downcoded, experts agree.

After the recent HHS Office of Inspector General therapy audit cost one home health agency $42,000, HHAs may want to go beyond their normal documentation efforts, especially in cases with just above 10 visits, experts suggest.

It's not hard for reviewers to deny therapy visits due to reasonableness and medical necessity, because these requirements have criteria that are "not very specific and can be open to interpretation," says Cindy Krafft, director of rehabilitation services for OSF Home Care based in Peoria, IL.

Making sure every visit is medically necessary and reasonable can be especially difficult for small agencies with only one therapist, says physical therapist Linda Krulish, consultant with Redmond, WA-based OASIS Answers Inc. A single therapist with no one to supervise, question or support her practice runs a greater risk of making medically unnecessary visits or not documenting them in a way that supports their necessity, Krulish explains.
 
Strategy: Use these tips to audit-proof your therapy visits.
 

  • Maintain a clinical focus. Clinical care and patient outcomes should be your focus, and you should "cross the 10-visit line as a by-product of a clinical focus," Krafft advises.
     
  • Expand documentation. Documentation for every visit must reflect the therapy skills required, Krafft reminds clinicians. Document skills you are working on and progress the patient has made, she adds. And each visit must stand alone as medically reasonable and necessary, Krulish says.
     
  • Emphasize quality. The combination of above-average therapy use and below-average outcomes can be a red flag to reviewers. If your agency is increasing therapy use to address problem outcomes, be sure you can show this in the record.
     
  • Divide and conquer. You are more likely to need 10 or more therapy visits if more than one discipline is involved, Krafft says. But be sure you clearly document the difference in the skills they are working on.
     
  • Remember homebound status. As a patient's functional abilities increase, be sure she is still considered homebound, or your therapy visits could be downcoded.

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