Home Health & Hospice

Incomplete Orders Can Dock Payment

Homecare Insider, January 18, 2010

Under the Prospective Payment System (PPS), an agency receives payment for an episode, not a visit.  Some might think that visits are no longer important so we can pay less attention to the basics.  However, the only thing the PPS changed was the payment methodology.  It did not change the coverage criteria or the basic requirements affecting service delivery.  This question emphasizes that point.

The intermediary denied four therapy visits, which took the case below the six-visit therapy threshold into LUPA territory.  The intermediary said the orders were not complete.  I don’t know what’s wrong.

CMS Publication 100-2, Chapter 7, §30.2.2, says, ”The orders on the plan of care must specify the type of services to be provided, both with regard to the professional who will provide them and the nature of the individual services, as well as the frequency of orders.”  In the instructions for completion of the plan of care, CMS 485, you’ll read, “The physician must specify the frequency and expected duration of the visits for each discipline.  The duties and treatments by each discipline must be stated.”

So, putting those references together, an order must include:
• the date the order is received
• all details for any medications or treatments involved
• the discipline with the frequency and duration of visits
• duties or responsibilities, and
• signature of the staff member receiving the order.

A sample order from the agency asking the question read, “Extend PT services for one more week – 3 wk 1.  Patient is making good progress.”  This order noted the frequency and duration of visits but it did not include a description of what the therapist would do.  Chances are the therapist was continuing with the original plan.  In that case, the verbal order should include a phrase such as, “Continue with plan – exercises, gait training.”

There’s no doubt that attention to detail will pay off in the long run. Because duties and responsibilities were missing, this agency’s verbal order was not complete, leading to a denial of services..  That’s how the agency ended up with a low-utilization payment adjustment (LUPA).

The Beacon Guide to Medicare Service Delivery provides the guidance you need to comply with the Medicare regulations.  The 2010 edition will be available soon.  Check out this reference publication at — http://www.beaconhealth.org/cgi-bin/ccp51/cp-app.cgi?pg=prod&ref=BGMSD10.