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