OASIS Alert

Published on Fri Feb 20, 2004 PDF

Here's how to stay off the OIG's radar screen.

It was only a matter of time before the extra payment for home health episodes with high therapy use became a compliance target for the HHS Office of Inspector General - and the time has come.

Home health agencies frustrated with unexpected downcoding of high therapy threshold visits can go back to the basics to prevent it, experts say. And the same concentrated effort serves to prevent problems with the OIG as well.

The 2004 OIG work plan announces the agency's intent to determine if high therapy threshold cases comply with Medicare regulations, says Bob Wardwell with the Visiting Nurses Associations of America. This effort will include looking at both the number of therapy visits and the length of the visits, the OIG says.

Caution: It's also likely the OIG will look into the issue of therapy visits for wound care. "Given the issue [the Centers for Medicare & Medicaid Services] has with therapy visits for wound care," Wardwell predicts the OIG might be "mining that issue as well."

Protect yourself: Agencies would be wise to retrospectively audit charts for patients with 10 or more therapy visits, "especially those with 10 or 11," advises Burtonsville, MD-based health care attorney Elizabeth Hogue. In cases very close to the threshold, it will be "easy pickin's" for the regulators or enforcers to argue that one or two of the visits were not reasonable and necessary, she says. "Then agencies stand to lose a great deal of money," she adds - from $1,800 to $2,200 per episode.

If an agency finds many cases close to the threshold, especially if those cases usually share the same therapist, review them carefully, Hogue advises. And counsel and monitor a therapist who may be providing unnecessary visits.

It may also be instructive to look at the number of therapy visits you provided for specific diagnoses before and after the prospective payment system began, Hogue says. Intermediaries may view a significant increase in visits as an indication of a problem with medical necessity, she cautions.

Regional home health intermediaries "always have been a bit paranoid that therapy visits are 'padded' services," warns Chapel Hill, NC-based clinical consultant Judy Adams with the LarsonAllen Health Care Group. And it may be even more important to clearly document skills and progress under PPS, she speculates. Many more patients are not using 10 therapy visits under home health, as hospitals encourage patients to use outpatient department therapy services as soon as possible, she adds.

The bottom line:

1. Answer M0825 "yes" only when you expect the patient will need at least 10 therapy visits and there are orders to support either 10 visits or close to 10 with an order to re-evaluate, Adams advises.

2. Documentation should show the patient is making reasonable progress at home and needs the therapy visits, Adams warns. Each therapy visit note should clearly show the skilled intervention provided.

Be specific: For example, cite "number of feet ambulated and degree of assistance needed as well as specific exercises provided and number of repetitions and sets tolerated," Adams suggests.

3. Periodic progress notes need to show progress toward the established goals. Identify any special needs the patient has and show increased strength through muscle measurement as well as progression toward less adaptive equipment if appropriate, Adams cautions.