For years we have been reading clinical records from many agencies. Therapy has been overutilized in some and underutilized in others but mostly, therapy use has been responsible.
Medpac and others advising the congress don’t believe that. They have been advising Medicare to do away with payment per visit for therapy for years.
These are mostly people who have never been in a home health agency. They are looking at claims data and OASIS. Their interest is in reducing healthcare costs.
Welcome to PDGM where therapy no longer results in an add-on payment. Medicare is expecting that therapy will be included in the payment rate for diagnoses and functional scores that were typically associated with therapy in PPS.
For example, we made up a patient falling into the rehab group (an ortho diagnosis) with a comorbidity of atrial fib which is a med management cardiac group. The actual diagnosis was a recurrent dislocated hip. Our made-up patient was given scores in the functional domain as follows:
Hospitalization: History of falls, five or more meds, two or more hospitalizations, reports exhaustion.
Grooming: Someone must assist
Dressing: Someone must assist dressing upper and lower body
Bathing: Unable to bathe and requires the assistance of another person to bathe
Toilet Transferring: Can use a bedside commode
Transferring: Able to bear weight but someone must transfer patient
Ambulation: Able to walk with the supervision of another person at all times
Our patient came from a hospital and this was the first admission (institutional; early)
Payment, per the CMS grouper, came to just under $2,700.00 for 30 days with a LUPA threshold of 6.
There are some other considerations but hopefully, this is close enough to convince you that you can afford therapy. In fact, because the patient required no surgery and was likely already knowledgeable about anticoagulation, it would be difficult to justify six nursing visits in the first 30 days.
This exercise in payment is probably pointless for the nurses and therapists read blogs about home health. It is rare for agencies to allow payment to determine clinical care. To be certain, we must all work within the confines of the payment system and it can be done. You will lose a few dollars on some patients and other patients will be more profitable.
Heaven help the patients of those agencies who are motivated solely by payment when a greed ridden owner figures out that payment will not change if they withhold therapy from their patients who need it. If there are enough of those agencies, Medicare will notice that therapy has been reduced and all agencies will suffer another payment reduction. Hopefully, Medicare will be analyzing claims data because outcomes will be slow to reflect changes.
Agencies that have no plans to reduce needed therapy or skimp on care in any way should include advice to referral sources that therapy orders need to be reviewed. When they see no therapy or very little therapy for patients that would benefit, they need to take time out of their day and call or merely alter the care plan. If this becomes a pattern with an agency, the referral source should look for another agency.
We can’t do anything about how Medicare payment policies but we can give our patients everything that they need. There is always going to be a way to game the system but Medicare will catch on and until then, you fight as hard as you can on the front lines for your patients. Like you always do.
Call if you have questions. If you have any sage advice for us as your first claims are going out, we want to know. Leave your comments or email us. And remember, we are always willing and able to help you with your OASIS review and coding so that you get the maximum ethical payment.