Eli's Rehab Report

See how a 5-visit denial in the new PPS can cost you $1,116

One sloppy record entry could cost you hundreds of dollars under the prospective payment system changes that hit Jan. 1, so therapists in home health had better kick up their documentation a notch.

Before Jan. 1, a denial of a visit or two only mattered when the patient was right at or above the 10-visit therapy threshold. But under the new PPS refinements, home health agencies will receive extra payment for most therapy visits between six and 20, said consultant Cindy Krafft, MS, PT, COS-C, in a recent Eli-sponsored audioconference about PPS therapy changes in home health. That means a denial almost anywhere in that spectrum will hurt your bottom line.

"Our risk is almost bigger because of the different opportunities for failure," Krafft said. "We have to make sure that medical necessity is correct."

Example: A patient with 14 visits will earn $3,468 under the PPS refinements. But a mere two visit denials, knocking the episode down to 12 total visits, will result in a $419 loss to the episode payment.

Another example: A patient with 23 therapy visits would garner $5,310, but a five-visit denial would bring that down by $1,116, Krafft said in the conference, "Standing on the Threshold: How HHAs' 2008 PPS Rule Impacts Your Therapy Practice."

"The tiered system will make each and every therapy visit note a critical piece in keeping the level of reimbursement earned," said Krafft, who works with Fazzi Associates based in Northampton, MA.

How Good Is Your Charting Tool?

Therapists in home health seeking to bulletproof their therapy documentation should start with the documentation tool. Whether it's electronic or paper-based, the tool should not leave gaps or omit triggers for essential documentation elements.

For instance: If an HHA finds its therapists aren't recording home exercise programs, it should check to see whether its charting document or program has a specific place for them. Saying that your software didn't give you a place to put it won't help when you're audited, Krafft said.

Key elements: Your therapy record should contain these four main components: subjective information, objective measurements and tests, the assessment, and the care plan. "Those all need to be evident in documentation," Krafft said.

And be sure to be extra-thorough with documentation when therapists are doing something rather unexpected.

Example: PTs are generally known for working on ambulation issues. So when a PT works with a patient who is bedbound, it may raise medical reviewers' eyebrows.

The therapist should highlight the need for PT care -- for example, helping with positioning and pressure relief, transferring and caregiver education. "I want to be very, very clear in my documentation why I'm there," Krafft said. Spell out the non-walking-related needs the patient has.

Don't Celebrate Independence Prematurely

A major red flag that leads to therapy visit denials is using the word "independent" incorrectly, Krafft said.

Reviewers look at a note saying a patient is independent and they conclude that the patient needs no further therapy or assistance.

Do this: That means therapists have to be very accurate in the use of this word. They shouldn't use it if the patient needs any more help at all with the skill in question. The patient is only truly independent when he has no need for further improvement in the area.

The word is "being taken very literally on review," Krafft said. Reviewers think it indicates "that this is not an issue for the patient, it's safe for them to do this, there's no need for intervention."

Patient scenario: A therapist may describe a patient as independent in gait and ambulation, then continue to see her for strengthening to avoid a fall. In this case, the therapist shouldn't use the term "independent," because it means the patient doesn't need any more help with the skill, Krafft said.

Note: To order a recording of Krafft's audioconference, go to http://www.audioeducator.com/industry_conference.php?id=252 or call (800) 508-2582.