The patient was admitted by a nursing Start of Care visit after a hospital stay for exacerbation of congestive heart failure. Nursing addressed medication issues, disease education, and edema management concerns in her 6 visit program. At the Start of Care, the patient was safe in ambulation with a roller walker, and ADL questions on the OASIS identified independence with dressing, laundry and meal preparation. The patient required some instruction on safety with showering. The patient had family assistance available; a daughter that lived nearby.
Discharge orders from the physician indicated a need for both Physical and Occupational Therapy. The primary nurse followed the physician’s orders and the care plan included orders for both PT and OT to evaluate and treat. The physical therapy program focused on distance ambulated (125 feet at eval), endurance, and exercises. The occupational therapist provided a home exercise program and simple modifications to bathroom set-up. The combined visit total of the therapy component was 10. All clinical goals were achieved during the episode.
Upon audit by Fiscal Intermediary, the entire therapy component of the episode was deemed non-covered as it was not reasonable and necessary.
HHSM Analysis
The qualification of the nursing component of the claim leads to the conclusion that the nursing care met the standard of reasonable and necessary, particularly in contrast to the therapy programs. The deficits and care needs are expectable in this type of clinical scenario, and the nurse obviously proceeded in an acceptable and reasonable manner.
The Physical Therapy program addressed three specific areas. First, distance ambulated creates a goal based on ambulatory endurance. CMS regulatory interpretations do not consider the improvement of endurance a skilled activity in most cases. In addition, the ability of the patient to walk a functional distance during the evaluation (125 feet) paints the picture of a safe client in her home. Second, the goal of increasing endurance also produces an unskilled program. If this was based on dyspnea, the ambulatory distance recorded renders the patient “not short of breath” in terms of the OASIS scale (MO 490/OASIS-B). Finally, the exercises prescribed are not necessary in terms of addressing weakness (musculoskeletal or respiratory) that doesn’t compromise function (as per the Start of Care).
The Occupational Therapy program provided a home exercise program and addressed bathroom set-up as a function of ADLs. Again, the lack of functional deficits in the ADL area renders the exercise program not necessary, and the simple modifications are clearly not considered the basis for a skilled program.
HHSM Comments
The lack of safety concerns in the therapy areas in our example represent a consistent theme seen in many recent denials. Therapy programs are interpreted as heavily based on safety deficits noted objectively on the OASIS. Clinical profiles that exhibit functional levels of safety (125 feet) often result in short or no therapy need. This is particularly evident in the areas of ambulation (PT), bathing, dressing, or toileting (OT).
The loss of 10 rehab visits causes the provider to lose an average of $1600 of expected income on this episode by the downward adjustment of the “S” component of the HHRG score from an S4 to an S1. In addition, the agency must assume the costs of providing the unnecessary therapy care, resulting in a double loss. Many providers follow MD orders in lieu of utilizing the OASIS as the PPS-programming guide it is intended to be. Inquiries into this type of approach are often met with concerns about alienating the referral source. With the prospect of self-funding all this type of uncovered care in terms of protecting referral sources, it seems likely that this strategy will be re-examined in the near future by many providers. Will all disciplines placed in the home for evaluation be compelled to create clinical programs? How do we manage clinicians on an individual case basis to assure skill in-episode?
In closing, it is obvious that the Fiscal Intermediary feels this client has no therapy needs that meet the standard of reasonable and necessary. Is it offensive that this patient and her daughter manage the “safety with showering” issue with the guidance of the skilled nurse while the prior level of function is ultimately realized? Clearly, the auditor felt that this was capable without therapy.
Special thanks to Arnie Cisneros, PT for supplying the article from Home Health Strategic Management’s newsletter.
