The following is a case analysis completed by Home Health Strategic Management:
The patient was a 74 y/o female residing in an assisted living facility and was referred to the Home Health agency after reported falls in her residence. There was no recent inpatient stay and the referral came from her family physician. The MD order was for both Physical and Occupational Therapy, and the Start of Care was performed by the PT. Primary diagnoses included OA, weakness, debility, and CHF. The patient had previously received a 3-visit program (6 months prior) based on safety education and instruction in proper use of the walker. The Start of Care OASIS revealed safe ambulation with a walker (M1860 – 2); it was discovered that the patient had not been using the walker properly and this contributed to the falls. No CHF related concerns were identified; the PT described lower extremity weakness and the OT described upper extremity weakness and reported little change from the prior level of ADL function; “needing some help”.
The PT care plan outlined an eight visit program (2×4) based primarily on exercises, gait training and mobility safety, and home program establishment. The OT care plan identified a four visit program (2×2) to include equipment, exercises, ADL training and home program establishment. The patient ambulated 150 feet with the roller walker on the third visit, and completed the program after four weeks ambulating 350 feet safely. The OT completed the 4-visit program and described improvement in ADL function.
The Fiscal Intermediary denied five PT visits; choosing to cover a program similar to the previously provided 3-visit educational episode. The three visits were considered sufficient to re-instruct the patient and to re-emphasize the importance of correct walker use. Subsequent visits were, “non-covered as they were repetitive teaching and supervision”. The FI clearly felt that the establishment and compliance with a skilled Home Exercise Program designed to maintain safe strength and balance could be re-installed through this three visit vehicle. The entire OT program was denied because, “the PT was addressing the patient’s issues”.
The denials reduced the “S” component of the HHRG score from an “S1”, Equation 2 to an “S1”, Equation 1 LUPA. The agency lost over $3300 in billing income, and combined with delivery costs of the episode, the agency lost over $4000 on this case.
HHSM Analysis
This denial confirms a theme seen consistently in response to a specific patient profile; clients with no recent inpatient stay, declined but safe ambulation, and an ability to exhibit compliance with home program maintenance, are programmed with a 3-visit therapy program designed to address safety education and establish a home program to maximize and maintain outcomes on a post-program basis. The answer to the OASIS M1860 question identifies the patient as safe in ambulation with a two-handed device; any concern regarding safety here is limited by this response.
In addition, the referral for the PT/OT combination commonly utilized to address global declines that may occur in the area of rehab seems to have outlived its’ usefulness. Programming requirements for both of these expensive disciplines now require a specificity regarding declines that compromise the value of this type of referral order. Correct application and implementation of the Start of Care OASIS is required for coverage of any of these specific disciplines.
HHSM Comments
Ambulatory distances greater than 150 feet can be attained through post-DC compliance with the Home Program; this limit to covered distance references the Functional Independence Measures (FIM) System utilized since 1994 as a measure of rehab outcomes. Agencies wishing to provide rehab services to their clients when necessary will have to integrate these new coverage models and requirements. In addition, assertive education of both referral sources and clinical staff will be required to avoid crippling denials that will lead to focus review. This is clearly the direction that CMS is heading regarding covered Home Health claims. The changes to how these services are to be delivered will resemble the difference in how hospitals managed length-of-stay issues from a pre-DRG to post-DRG basis.
Arnie Cisneros, P.T., is renowned for his adaptation of traditional care philosophies to address current and future healthcare initiatives. His status as a practicing clinician provides a working level insight into program development and care consultation needs for Home Health providers. He authors “Home Health Forum”, a bi-weekly column addressing contemporary homecare issues and is a contributor to “The Remington Report”, CARING, and Decision Health publications. He presents nationally on homecare topics including S.U.R.C.H. – UR for Home Health, OBQI Case Conference, and PPS/P4P strategies. He is President of Home Health Strategic Management, a homecare consulting firm in East Lansing, MI.
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