OASIS Alert

Start teaching staff how to predict therapy visits more accurately.

The good news is you won't have to worry anymore about getting M0825 right; the bad news is M0826 is even more complicated, and your cash flow is sure to change.

Using post-prospective payment system data that show a clear shift in therapy services, the Centers for Medicare & Medicaid Services has changed the M0825 10-visit therapy threshold in a big way. CMS has expressed concern for some time that the current all-or-nothing threshold leading to a significant increase in episode reimbursement has caused an inappropriate overuse of therapy in home health.

But in addition to a focus on the dollars, agencies have responded to the importance of outcomes and the public reporting of outcomes, says consultant Mark Sharp with Springfield, MO-based BKD. Therapy improves patient outcomes, so why express surprise that therapy use increased, he says.

CMS' data analysis also showed that no other measure was as accurate as therapy in predicting service utilization, that counting visits was as accurate as counting minutes and that payment gradations would more accurately  align payment with service need.

Expect Staff Confusion About M0826

In the proposed rule, the simple "yes" or "no" question in M0825 (Therapy need) will be replaced by M0826, which asks for the number of therapy visits the clinician expects in this episode.

M0826 (Therapy need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits [total of reasonable and necessary physical, occupational, and speech-language pathology visits combined]?) leaves you a three-digit space to enter the number of visits expected and asks you to enter "000" if no therapy visits are indicated (for more about OASIS changes, see OASIS Alert, Vol. 8, No. 6, p. 52).

Answering this question will require careful consultation between the nurse and the therapists, warns consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. Choosing a specific number of visits rather than a range will be a major concern for many nurses, she predicts.

Review Your Cash Flow Predictions

The therapy changes are likely to remain in the final rule, clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen tells Eli. CMS will pay for therapy visits in a way that more closely mirrors the therapy care provided. This will change the cash flow picture for many agencies.

Upside: Episodes with six to nine visits will probably receive higher reimbursement under the proposed rule than under current PPS, Sharp predicts. Also, to get paid for a high number of therapy visits when you weren't able to predict them, you will no longer have to go back and cancel a request for anticipated payment (RAP) and re-bill it with "no" corrected to "yes" in M0825.

Downside: Reimbursement for episodes with from 10 to 13 visits will likely be lower under the proposed therapy rules than under the current plan, Sharp says.