Home Health & Hospice Week

Intermediary targets single OT visits.

Is your therapy documentation up to snuff? If it's not, you could lose $2,000 per episode that's rightfully yours.

In a widespread claims edit (5 TH87), regional home health intermediary Cahaba GBA has targeted home health claims with nine physical therapy and one occupational therapy visit per episode. "Last quarter there was a 31.4 percent denial rate for claims reviewed for this edit," Cahaba says in Web site posting.

The top denial reason: A therapy downcode, typically because documentation didn't support the single OT visit or one or more of the PT visits, Cahaba explains in the notice. Your Documentation's Up to the Plate It's no surprise that Cahaba has picked up on the 9-1 visit pattern for scrutiny, says PT Cindy Krafft, director of rehabilitation for OSF Home Care based in Peoria, IL. "As a PT, nine visits is at least three if not four weeks of therapy," Krafft notes. That utilization level would indicate a significant functional issue. "If that is accurate, how can there be no need for OT beyond the evaluation?"

RHHI edits highlight what could be "suspicious circumstances," notes PT Sparkle Sparks, consultant with Redmond, WA-based OASIS Answers. Agencies must prove the therapy services were medically reasonable and necessary with their documentation. Unfortunately, often "clinicians don't take documentation seriously enough," Sparks laments.

Holding up the single OT visit pattern for scrutiny is similar to Cahaba's edit on single medical social work visits, notes consultant Marian Entin with Simione Consultants in Gaithersburg, MD. "It's the same concept," Entin notes.
 
In this case, one OT visit can put the episode over the lucrative 10-visit therapy threshold. In the earlier edit, one MSW visit can push the episode over the punishing four-visit low utilization payment adjustment (LUPA) threshold (see Eli's HCW, Vol. XV, No. 10).

RHHIs are under great pressure to deny claims and decrease payments to providers, notes PT Fran Fowler, consultant with Fowler Healthcare Af-filiates in Atlanta. "The pressure will only increase," Fowler warns.

Heed these expert tips for avoiding the tightening medical review noose: 1. Beware 10 to 11 therapy visits. When you furnish just enough therapy visits to reach the $2,000 threshold, you'd better be prepared to defend every visit with excellent documentation. Any episodes with 10 or 11 therapy visits are up for increased scrutiny, predicts consultant Betty Gordon with Simione Con-sultants' Westborough, MA office. 2. Individualize care planning. If all your patients receive the same amount of therapy, it will raise red flags at the RHHI, Fowler cautions. "Please ensure that your patients' care plans are individualized to their conditions," Cahaba says in its notice.

That may mean coming up with an internal screening tool to determine which patients receive OT evals, instead of furnishing evals [...]