OASIS Alert

If efforts to assess patients' likelihood to meet Medicare's 10-visit therapy threshold are leading you to seek mental therapy, you're not alone.

Many clinicians and billers alike quake at MO825, which asks, "Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physician, occupational, or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?"

Agencies must try to figure out whether the patient will require the 10 visits it takes to meet Medicare's threshold, thereby earning the agency significantly more reimbursement as much as $2,000 per patient in some areas.

In theory, it's a simple yes-or-no question, but MO825 continues to be one of the banes of home health agencies' existence. Even though the question itself seems straightforward enough, there is an endless string of variables that can and often will render the agency's initial response incorrect before it's all said and done.

"There's no foolproof way to solve this problem," laments consultant Pat Laff with Laff Associates in Northbrook, IL. But even though changes in a patient's need for therapy are largely beyond agencies' control, there are ways for agencies to increase their chances of answering this question correctly in the first place.

On its face, "MO825 is black and white you either have 10 therapy visits or you don't," notes Laff. And the best way to determine whether the patient will require those visits is to involve a nurse, therapist and physician in the plan of care, says consultant Susanne Justice-Moran with Justice-Moran & Associates in Ft. Lauderdale, FL.

Ideally, a physical therapist should complete MO825, urges Laff. And regardless of whether a nurse or therapist evaluates the patient's need for therapy, that person should base her decision on quantifiable observations, advises consultant Terri Ayer with Ayer Associates in Annandale, VA.

"Whether it's nursing or physical therapy, whoever is doing the initial assessment needs to clearly document a need for 10 visits of therapy," Ayer explains. For example, the clinician should measure how far the patient can walk, how long it takes him to reach the bathroom or the front door and what kinds of assistive devices he's using, she tells Eli. And the clinician should have the patient actually demonstrate these abilities don't just ask him how far he can walk. "Therapists are very good about that," Ayer notes.

Unfortunately, there are no bright-line rules that say, 'If it takes X amount of time for a patient to walk X distance, he'll need 10 therapy visits.' "It's clinical judgment," Ayer says.

If you initially determine that a patient will need 10 visits and therefore mark "yes" on MO825 but he ends up not meeting that threshold, you should document the reason why, Ayer insists. That kind of documentation will show that you weren't trying to game the system by answering "yes" when you had reason to believe the patient wouldn't end up needing 10 visits.