HomeCare Association of Louisiana Blog

The 45 y/o Medicare patient was admitted to Home Health after a skilled nursing facility (SNF) stay for a fractured left leg with open reduction/internal fixation. Additional diagnoses present include low back pain, left lower extremity pain and weakness, and decreased mobility. Patient lived independently in a second floor apartment that included steps necessary to enter and exit the residence; some assistance was available from extended family members. Start of Care findings resulted in Skilled Nursing, Physical Therapy, Medical Social Work, and Home Health Aide services. The Physical Therapy evaluation identified dyspnea, low back and left lower extremity pain (5 of 10), bed mobility and transfers contact guard/close supervision (except tub transfers – unable), lower extremity weakness (3- out of 5), and contact guard ambulation with walker (standard cane x 30 feet with contact guard). The plan of care addressed these clinical areas and also stated they would assist with coordination of outpatient services as indicated.

The Physical Therapy plan of care included therapeutic exercise, gait training, and establishment of home exercise program at a frequency of 1-3 x per week for a 9 week frequency. The PT program that was delivered was skilled and comprehensive, lower extremity exercises were progressive and compliant, ambulatory status improved steadily with safe ambulation present within the home with either walker or cane. By the fourth visit, the patient ambulated 125 feet with the straight cane and navigated 15 steps with railing and contact guard, and pain was reduced to 3 of 10 during activity. On the fifth visit, the patient continued ambulation independently on level ground (with a walker) and refused stair training. Additional visits described different levels of independent ambulation and increased stair performances up to 32 separate steps. The PT program ended after eight visits with all goals met.

The Fiscal Intermediary approved four PT visits. By denying the last four PT visits, the claim was reduced to a LUPA (Low Utilization Payment Adjustment) episode. This significantly lowered the income received for this case, and the provider posted a fiscal loss as a result.

HHSM Analysis

The patient that was recently discharged from a SNF rehab stay required Home Health to stabilize and assure safety in the home. The functional level of mobility present at the Start of Care seemed to identify a patient with comparatively minimal needs regarding Home Health. Regardless of the SNF admission history, this clinical episode will be defined by the functional deficits present at the Start of Care. Intermediaries are clearly under the (not unfounded) impression that much or all of the care issues may have been resolved at the prior treatment level, in this case the SNF.

The reduction of this program to the 4-visit LUPA level illustrates the audit focus on this 6-7-8 visit claim. Not in-accurately, many reviewers felt that these programs were extended to this visit level as a means of avoiding the lesser LUPA reimbursement. This occurrence has been present in some form in most agencies in America.

HHSM Comments

This example illustrates many of the programming and management concerns that become relevant issues in the audit era. First, the understanding of what the SNF patient means in terms of Medicare (and homecare) programming. What did occur in the SNF, and how will that affect the Home Health programming in real-time? Home Health providers must remain conscientious of the fact that Medicare has a separate version of a claim for this patient from another provider, and that includes clinical results from the SNF stay.

Second, the program in the home should focus on restoring previous levels of independence, in this case, stair safety in and out of the home. We also must remain conscious of the difference between ability and strength in scenarios such as these. When the patient successfully navigates the steps, continuing to address stair training (up to 32 steps) reflects endurance and unskilled services.

Third, we all need to be mindful of the LUPA issue; i.e. the natural tendency to attempt to avoid these low-reimbursement programs in response to directives from well meaning administrators’ of agencies who employ us. Medicare auditors are aware of this phenomenon and as a result, increased scrutiny seems to focus on these types of claims.

Finally, we should examine what impression the generic 1-3 x 9 orders gives the auditors. When we propose a 27 visit program for an intervention that requires no more than 4 to 8 visits, are we proposing a program based on an individualized assessment; one that considers all of the realities discussed today? Or are we fitting the patient into some type of generic slot that fails to recognize the specific programming factors and needs evident at the initial visit? And how does this approach affect the mindset of the auditor as they peruse our claim and documentation for ongoing evidence of “reasonable and necessary”?

If this article interests you, sign up for the “Surviving RAC Audits” workshop, May 25th (Baton Rouge), 26th(Alexandria), or 27th(Monroe) presented by Arnie Cisneros.

Special thanks to Arnie Cisneros, PT for supplying the article from Home Health Strategic Management’s newsletter.

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.

If this article interests you, sign up for the “Surviving RAC Audits” workshop, May 25th (Baton Rouge), 26th(Alexandria), or 27th(Monroe) presented by Arnie Cisneros.

Special thanks to Arnie Cisneros, PT for supplying the article from Home Health Strategic Management’s newsletter.