OASIS Alert

3 ways to defend therapy need.

Just because you had orders for - and documented that you made - 10 or more therapy visits doesn't mean your intermediary will pay you for them.

Medical review staff at regional home health intermediary Cahaba GBA are denying therapy visits for patients with the primary diagnosis 780.79 (Other malaise and fatigue), the RHHI reports in the Medicare A Newsline for December 2004. Although some physical therapy visits may be appropriate for these patients who have generalized weakness or are in a debilitated condition, agencies should be careful to determine which of the visits actually require a skilled PT, Cahaba instructs.

Patients with the 780.79 diagnosis often are at high risk for falls or may be too fatigued to complete activities of daily living, Cahaba concedes. And therapy may be appropriate to increase the patient's strength.

Snag: "Establishing a safe and effective home exercise program for the weakened beneficiary would be a covered service," Cahaba advises. But repetitive exercises to work on gait, strength or endurance "ordinarily do not require the skills of a physical therapist, it says." These activities are appropriately provided by a non-skilled person, the intermediary warns.

Self-defense: Your documentation must show that the therapist is providing a skilled, medically necessary service on each visit, advises Linda Krulish, president of Redmond, WA-based Home Therapy Services.

What to show: Cahaba defines skilled physical therapy as "therapeutic exercises, which must be performed by or under the supervision of the qualified physical therapist to ensure the safety of the beneficiary and the effectiveness of the treatment, due either to the type of exercise employed or to the condition of the patient."

Use these expert tips to be sure each therapy visit counts for reimbursement:

1. Show why you're in there. Every visit has to stand alone as skilled, says Cindy Krafft, director of rehabilitation at OSF Home Care in Peoria, IL. Documentation is the key to therapy reimbursement, she adds. At each visit document the skills you are working on with the patient, and document the patient's progress from one visit to the next.

2. PT is not the only therapy that counts. Remember that occupational therapists are really the experts on patients' functional abilities, says Krafft. Clearly document the differences in what PT and OT are working on. Generally, PT works on supplying the strength that OT can translate into function, she explains.

3. Document eligibility. Don't stop with documenting homebound status at the beginning of an episode, says consultant Linda Rutman with Charlotte, NC-based LarsonAllen Health-care Group. Continue to provide ongoing evidence, especially as the patient improves with therapy, she reminds clinicians. Include specific information, such as how far the patient can walk, and be sure the information is consistent from one clinician to another. 

Editor's Note: The Dec. 2004 Medicare A Newsline is at www.iamedicare.com/Provider/newsroom/newslines/newslines.htm.