Eli's Rehab Report

Tip: Communication problems between nurses and therapists could be at the root of the problem claims.

Home Health & Hospice Medicare Administrative Contractor Palmetto GBA is looking at patients with lower clinical scores who have 20 or more therapy visits. Brace yourself for probe reviews targeting five high-therapy codes.

The five HIPPS codes under scrutiny include:

1. 5AHK*: 20+ therapies, Clinical Severity Level 1, Functional Severity Level 3, Service Severity Level 1
2. 5BGK*: 20+ therapies, Clinical Severity Level 2, Functional Severity Level 2, Service Severity Level 1
3. 5AGK*: 20+ therapies, Clinical Severity Level 1, Functional Severity Level 2, Service Severity Level 1
4. 5BFK*: 20+ therapies, Clinical Severity Level 2, Functional Severity Level 1, Service Severity Level 1
5. 5AFK*: 20+ therapies, Clinical Severity Level 1, Functional Severity Level 1, Service Severity Level 1.

The “5” at the beginning of the HIPPS code indicates that 20 or more therapy visits were provided, said Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR—Coding Done Right and Code Pro University in Denton, Texas. The rest of the HIPPS code translates to the following HHRG scores, she pointed out in a blog post at http://selmanholmanblog.com/:

A = C1
B = C2
F = F1
G = F2
H = F3

“This means that Palmetto is looking at patients with lower clinical scores who have 20 or more therapy visits,” Selman-Holman said. “Agencies with lower clinical scores and 20 therapy visits should take the time to review OASIS accuracy as well as coding accuracy. If the agency finds HIPPS codes such as those above you may be chosen for these probe edits.”

Know What You Can Do

Checking the internal data your agency has available will give you an ongoing knowledge of where you stand with this review, says Karen Vance, OTR, supervising consultant with BKD in Colorado Springs, Colo. Be sure to run appropriate reports to determine whether your statistics are high relative to the edits, she advises. Sort the results by staff and add the suspect cases to your audit process to ensure documentation warrants the level of utilization under scrutiny in this review.

Communication problems between nurses and therapists could be at the root of the problem claims, says Julianne Haydel of Haydel Consulting Services in Baton Rouge, La. When therapists and nurses don’t communicate efficiently, it often results in conflicting documentation, she says.

When the therapist says the patient can walk with moderate assistance for 200 feet and the nurse says the patient has difficulty ambulating, the MAC is bound to go with the therapist’s documentation, Haydel says. “Both parties need to talk to get a full picture. Is the patient safe to walk without any assistance? Are there any new medications that may increase the risk of falls regardless of the fact that the patient’s strength is returning? What about environmental factors such as torn carpet?”

Try this: “Nurses should always take advantage of therapists when assessing a patient, if possible,” Haydel says. “The therapist may not complete the OASIS questions but collaboration is acceptable, and I believe part of a more complete assessment.”

For example: “A nurse may not see a problem with the patient’s ambulation but the therapist may note that one foot doesn’t clear the ground or [that] the patient’s hips are not on an even plane,” Haydel says. “These are not things that nurses look at on a regular basis. After the therapist does his assessment, the nurse can ask for his input.” After verifying the therapist’s findings, the clinician completing the OASIS can include this data.

Stay Up-to-Date with OASIS

“Palmetto is also interested in patients who have 20 therapy visits with lower functional scores,” Selman-Holman said. “Obviously, if the patient requires that many therapy visits a lower functional score does not support that number of therapy visits.”

Documentation tip: To support you claims, including details such as the necessity of providing two or more types of therapy could help, Selman-Holman said. And because the functional OASIS items are some of the most difficult to understand, it’s important to make certain your clinicians receive the education they need to answer these OASIS items correctly, she said.

Watch out: “Although Palmetto’s probe review may only look at 100 charts in a lot of states, … if there is a problem with a chart from your agency, that probe edit can turn into a large number of claims being reviewed,” Selman-Holman said.