As a homecare therapist, I have been receiving specific instructions from the agency I work for regarding the discharge visit I make for programs serviced by PTAs. It seems the agency has recently come under focused review for having ten-visit, high-therapy claims. Many of these bills were downcoded by the Fiscal Intermediary when it was determined that the DC visit by the supervising PT lacked a skilled component. Because some of these programs may have been my own, I am eager to understand what Medicare expects.

The 2007 Office of Inspector General (OIG) audits you are referring to were focused on agencies with episodes completed at, or near, 10 total therapy visits. As a result, many agencies nationwide have been put on notice that Medicare plans to review specific episodes to assure that reimbursement matches clinical necessity. Examining practice patterns that seem to center on specific fiscal realities (~$2300 increase for achieving the 10-visit high therapy threshold), individual agencies were targeted for documentation review. Each and every visit must meet the skilled criteria that Medicare requires; when it did not, that visit was subtracted from the therapy total. When this occurred in a home health episode with 10 therapy visits, the 10^th visit was eliminated so that the total of official skilled therapy visits was 9. Agencies in the position of having these cases downcoded had to pay back high therapy threshold monies that they’d already received from Medicare.

One of the first areas to be reviewed is the discharge visit. Under the scenario you describe from your own practice, the physical therapist performs the eval and discharge visits while the PTA provides all or most of the treatment visits. This is not an unusual occurrence in today’s home health environment. The commonly made mistake involves the discharging PT during the last visit. This visit cannot just be a “completion of paperwork”, so to speak. Each visit must meet the requirement that the services delivered are reasonable and necessary to completion of the plan of care as certified by the physician. There also must be a skilled element included – progression of HEP, gait or transfer training, or caregiver skilled instruction, for example – in order for that visit to count toward reimbursement and to “contribute” to the total of 10 or more visits under the pre-2008 high-therapy threshold system.

As of January 1, as you surely know, there is no longer a 10-visit, high-therapy threshold level to exceed. Instead, there is a tiered system of visits (the same combined PT, OT & ST totals), that denotes reimbursement levels. Clearly, the 2007 audits you experienced were a pre-cursor of the new home health era; one in which all visits must stand alone in their skilled component. In addition, those agencies who experienced significant numbers of post-audit downcodes have received an early lesson in the reimbursement realities of the 2008 PPS New Rule. In our practice, we have met very few home health clinicians who actively seek to skirt the Medicare regulations. Most mistakes, such as the example you describe, come from practitioners who don’t remain mindful of the Medicare requirements. All agencies would be well served by using the New Rule as a mechanism for re-education of both clinical and office staff regarding the skilled requirement for ALL home health visits.