OASIS Alert

Published on Sat Jan 20, 2007 PDF

Don't hand the money back if you earned it.

If medical reviewers can deny enough therapy visits to drop the number for that episode to fewer than 10, they can ask you to return the $1,500 to $2,000 extra you collected -- even years later.

It's amazing how a simple yes/no question can cause so much trouble for home health agencies, physical therapy specialist Cindy Krafft told listeners in her Jan. 9 teleconference sponsored by Eli Research. HHAs have to try to predict M0825, monitor it, bill it and defend it, says Krafft, formerly director of rehabilitation for OSF Home Health in Peoria, IL and now a consultant with UHSA.

Position Yourself For The Future

There's not much you can do about the 2001 to 2003 years the HHS Office of Inspector General recently audited, Krafft says, but don't expect the audits to stop. Be prepared to convince the OIG that dollars spent on your patients was not money wasted, she warns.

Krafft suggests that agencies ask these questions to prep for possible therapy visit audits:

• Do all your high therapy episodes include at least eight hours of therapy? There is nothing magical about 10 visits, Krafft advises. This number was chosen as a shortcut for the initial intent -- to provide extra reimbursement when a patient requires more than eight hours of therapy in one episode. An average visit length of 45 to 48 minutes translates into 10 visits, she explains. But 10 half-hour visits will likely raise a red flag. And if all therapy visits last the same amount of time, regardless of which patient you see, reviewers may find that suspicious.

• Can each visit stand on its own? Is the frequency and duration reasonable based on the patient's deficits and functional condition? When there is a single hurdle to jump over -- 10 visits -- and the prize is an extra $1,500 to $2,000, the reviewer's job is to look at each visit to see if it can be knocked off the list.

Your job is to be sure each visit required a skilled therapist and that the orders and documentation support the visit. "If it looks from the chart like a family member or neighbor could have done what the therapist did, don't expect Medicare to pay for it," Krafft says.

• Why are you visiting five times a week? This pattern often occurs at the beginning of an episode, Krafft notes. Five visits in a week may be clinically defensible if the number is based on the individual patient's need and ability to benefit from this number of visits.

On the other hand, five visits a week so you can get 10 visits in before the orthopedist sends them to outpatient therapy looks to be for reimbursement rather than clinical reasons. Clearly document the clinical reasons for this visit pattern.

• Why are you visiting only once a week? A good reason may be to skip a few weeks and then go back for a visit to see how the patient and caregiver are doing with their program. It will be harder to defend a single visit made to repeat material -- when coincidentally you reach the 10-visit threshold. Be sure to have good clinical reasons when you're making single visits toward the end of an episode, Krafft warns.

• What are you documenting? Include expected information for your discipline, such as gait for PT and activities of daily living and functional issues for occupational therapy. The reviewer, who is very likely not a therapist, should be able to determine "reasonable and necessary" from the chart review, Krafft says.

Note: For much more on therapy audits order a tape, CD or transcript of Krafft's teleconference, "2007 Therapy Utilization Update: How To Survive OIG Audits," at http://codinginstitute.com/conference/tapes.cgi or call 1-800-508-2583.