Eli's Rehab Report

Published on Thu Feb 04, 2016 PDF

Bad news: Potential recoupments related to therapy downcoding in the offing.

If you haven’t kept your eye on the 11 elements which Palmetto GBA had listed for therapy evaluations/reevals documentation, this MAC’s recent medical review results should warn you of what to look out for in the coming months. It’s not just denials this time, recoupments could add to your reimbursement woes.

Reminder: Home Health & Health Medicare Administrative Contractor (HHH MAC) Palmetto GBA has added requirements for “Short and/or Long Term Goals Within the Initial (PT/OT/ST as Appropriate) Therapy Evaluation Documentation” via Local Coverage Determination: Home Health-Physical Therapy (L31542) (see Eli’s Rehab Report, Vol. 22, No. 10). Palmetto has used the requirement to downcode and deny millions of dollars in home health agency reimbursement.

In its latest examples, Palmetto reviewed 87 claims with seven HIPPS codes beginning with a “5,” indicating high therapy usage (20 or more visits). It downcoded or denied 29 of the claims, many of them based on the therapy goal requirement.

“In the initial physical therapy evaluation, the short-term goal(s) and long-term goal(s) were not stated in objective, measurable terms, and their expected date of accomplishment,” Palmetto explains in analysis of the results. The MAC also lists the 11 elements it expects to find in therapy evaluations/reevals (see Eli’s Rehab Report, Vol. 22, No. 10 for the elements and related information and advice).

However, due to the low volume and relatively low charge denial rates, Palmetto is discontinuing its reviews of the HIPPS codes starting with “5.”

Latest topics: Palmetto has continued its reviews of HIPPS codes 1BGP (0-13 Therapy Visits, Lowest Scores in the Clinical and Functional Domains and Maximum Score in the Service Domain) and 2CHK (Early Episode, 14-15 Therapy Visits, High Score on Clinical Domain, High Score on Functional Domain), it says on its Active Medical Review webpage updated Dec. 7, 2015.

Otherwise, the MAC’s reviews are not HIPPS-code targeted. Instead, they target length of stay and average payment per beneficiary. Palmetto also lists the general “Home Health Services” topic.

Watch for Therapy-Related Recoupments in Coming Weeks

Watch for potential recoupments related to a therapy downcoding problem coming soon.

Problem: “Claims reporting Health Insurance Prospective Payment System (HIPPS) codes beginning with 5 are not being recoded correctly when fewer than 20 therapy services are provided. These errors affect only home health claims with receipt dates on or after October 1, 2015,” Palmetto says on its website. They also affect only claims that resulted in overpayments, Palmetto adds.

Solution: “A resolution to this issue will be implemented January 4, 2016,” HHH MAC CGS says on its website. MACs “will make the necessary adjustments to claims/adjustments with receipt dates between 10/1/2015 and 1/4/2016 and a provider submitted HIPPS code of 5, and fewer than 20 occurrences of therapy visits (042x, 043x, and 044x). Home health agencies do not need to take any action.” CGS expects its adjustments to be completed within two months of Jan. 4, it adds.