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Reimbursement :

ONE DENIED THERAPY VISIT CAN COST YOUR AGENCY $600

Published on Sun Mar 08, 2009

These 3 trigger points require special attention.

Good care that is poorly documented can lead the feds to suspect fraud.

The Centers forMedicare & Medicaid Services is concerned that the prospective payment system includes financial incentives to provide more therapy than a patient needs, said physical therapist Cindy Krafft, Peoria, Ill.-based consultant with Fazzi Associates.

To prevent that result, intermediaries focus intensely on the therapy documentation supporting the need for the visits provided, she warned listeners in the Eli-sponsored audio-conference Survive Your Audits: Therapy Documentation Issues for 2009.

If you provided six visits and the intermediary denies just one of them, your agency has lost $600, Krafft emphasized. If the agency has already received the money for that episode,it must now return the overpayment. The most common reason for denial is that the visit was not medically necessary or did not require a therapist's skills, she reported.

The Heat Is On Therapy Documentation

Unlike the 2008 work plan, the HHS Office of Inspector General's 2009 work plan does not specifically include a heading for home health therapy. But therapy services scrutiny is continuing and even expanding, says attorney Lucien Bernard with Pearson & Bernard in Covington, Ky.

If your average number of visits per episode has changed significantly this year, "you'd better be able to defend and justify the variance," Bernard advises.

In looking at claims, the OIG asks if documentation supports services the home health agency is billing. Therapy notes must fit in with the rest of the record, both OASIS items and nurses notes. Inconsistencies will cost agencies because medical reviewers will not give agencies the benefit of the doubt, Krafft stressed. And be aware that a pattern of denials resulting from unintended omissions can look to the government like fraud.

Your Goal Is Revenue Retention

Problem: Good documentation is not just a nice extra to do if you have time. It is integral with the care you are providing, Krafft stressed. "Denials are usually not because a therapist said the wrong thing one time on one note," she explained. There is a pattern: an assessment that doesn't really tell you what's wrong; goals that don't really tell you what the therapist plans to do; visits that don't relate back to the plan of care; and repetitive visits with no clear reason for going.

Protect yourself: Intermediaries put resources into reviewing therapy documentation, and so should you, Krafft advised. In auditing records, Krafft usually finds that on at least 70 percent of the records reviewed, one visit must be removed. Often significantly more than one must be removed, with the average risk of $930 per record if they had been submitted unaudited, she reported.

Take Special CareWith 6 Visits Or Just Over

Three numbers trigger the most audit attention: six visits, 14 visits, and 20 visits. Six visits is the threshold that triggers the first increase in therapy-based reimbursement. So medical reviewers will closely scrutinize episodes with visit numbers just at and above that threshold.

Reason: If you have six visits and the intermediary can deny just one, they save $600 in extra reimbursement.

Episodes with 14 therapy visits or just above that also attract the medical reviewer's spotlight. Historical data from the home health prospective payment system show that most patients don't receive 14 or more therapy visits, Krafft said. So under the latest PPS refinements,14 or more visits combined with certain responses to clinical or functional OASIS questions provide additional reimbursement points.

The next number to increase intermediary scrutiny is 20 visits, which triggers the top therapy reimbursement, Krafft said. "Fiscal intermediaries have already started collecting names of agencies that up until last year always did 10 visits for therapy patients and since 2008 are always doing 20 visits," she noted.

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