As we continue today with our series focusing on the Medicare audits in the homecare industry, we turn to the recently seen partial denial of a therapy claim that was rejected due to a “lack of skilled service”. The analysis of the denial via clinical review reveals where the claim documentation failed to identify skill, and also where the documentation lacked support for required skill. The primary lesson of this example is that a skilled care plan must be supported, 1) at Start of Care, and 2) on a per visit basis. In fact, in our example today, the skilled Physical Therapist clearly provided a quality program that focused on best practices as a means of achieving functional goals.
The episode reviewed involves a 72 y/o male seen status post R Total Knee Arthroplasty performed 5 days prior to the Start of Care via acute hospital admission. The client was in good health prior to the surgical procedure; his painful gait had significantly limited his mobility. He lives in a ranch home with his 70 y/o spouse; children live nearby and are involved. The PT-only OASIS establishes functional deficits in areas including bathing, dressing, toileting and ambulation. In addition to the functional limitations, the therapist also addressed TKA-related clinical concerns, including, edema, pain, ROM, and strength. Edema was minimal and pain was reported as 4-6 out of ten. Range readings were (-15/80) degrees for the R knee, and strength was recorded as 3/3+ out of 5 / R Knee, and 4 out of 5 / R Hip. Gait was 20-25 feet with min assist for safety/balance with fair walker control, irregular gait pattern marked by a shortened R stance phase due to a reluctance to step on the affected limb. RLE stance was not flat-footed, causing a quickened LLE swing phase that was notable in its consistent near loss of balance. Gross motor coordination was poor, resulting in a lack of safe gait without the support of another person. The Plan of Care frequency/duration was 2 x 1 week, 3 x 3 weeks, for strengthening, therapeutic exercise (for strength AND range), gait training and home exercise program.
During the initial visits, the exercises were well documented with desired compliance. Each visit demonstrated gains in R knee flexion, eventually to 120 degrees by the fifth visit. Lesser gains were noted in terminal extension; the only progress noted was to (-10) degrees by the third visit. Exercises and edema reduction resulted in 3+/4 R knee strength improvements by the fourth visit. Pain was also recorded as decreased to 2-3 out of ten during that visit. Gait improved consistently with min assist X 25 feet with rolling walker increasing steadily over the first 6 visits, resulting in Quad cane with verbal cues x 145 feet by visit 7. The most obvious aspect of the gait training was the lack of any specific skilled gait description on a per visit basis since the initial visit: we employ a - device/distance/assist/skill – method of skilled gait documentation. The only information on gait described on a per visit basis was device, distance and assist, which became stand-by on the fourth visit. Upon discharge at the eleventh visit, the patient was ambulating 350 feet independently with the quad cane. R knee range was
(-10/130), and strength was 4/4+ RLE. The episode was audited and the claim was partially denied at the seventh visit, all subsequent visits (8-11) were denied for “lack of skilled service”.
At first glance, this example seems to fulfill the worst concerns of the industry; that audits of clearly skilled care will result in care and payment denials that are un-justified and subjective. But a prudent examination of the case reveals insight into how auditors may be proceeding. The lack of any skilled gait description left the auditor to process only device (walker x 3 visits/quad cane x 4 visits), distance (25 ft to 145 ft), and assist (Min x 3 visits, SBA x 3 visits, VC x 1 visit). In the absence of any specific gait descriptions that outline how the PT addressed all initial gait deficits in a skilled manner, the primary changes noted by the auditor are endurance-based. This improvement in endurance would constitute unskilled care.
In addition, little concern regarding range of motion also dulls the impression of the level of skilled care that may have been delivered. The deficit of 10 degrees in terminal extension can result in an inconsistent gait defined by compromised RLE push-off due to incomplete knee extension. Documentation entries emphasize great gains in the flexion range but fail to address the terminal extension issue in any way. This raises the issue of moving the patient to a different assistive device prior to resolving the important range issue. This also gives the impression that the gains noted in terms of ambulation (initiation of quad cane) reveal a patient whose primary functional goal is about to be, or has been, achieved.
By providing the total picture of the specific skilled interventions and how they affect the progression that leads to outcomes, the clinician will improve the chances that the auditor will recognize the skill component of their care. If the case described today contained documentation that “trumpeted” the clinician’s concern regarding terminal extension, and modified care to address this issue, the author wonders if the audit results would remain the same. By working in a focused, best-practice based manner, and recording diligent documentation that reflects this care, clinicians and providers can provide skilled and reimbursable care that will pass audit scrutiny.