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Watch out for artificial gaps in therapy visit distribution.

You'd better identify and fix any appearance that you're trying to game the new prospective payment system changes--particularly regarding therapy--before the feds do.

Medicare regulators are on high alert for home health agencies trying to unethically maximize reimbursement by changing therapy visit utilization, experts warn. The PPS refinement regulations "are definitely aimed at closing some loopholes and reducing gaming of the reimbursement system," notes attorney Marie Berliner with Lambeth & Berliner in Austin, TX.

HHAs training staff on the PPS changes must focus on goals of good patient care, stresses attorney Deborah Randall with Arent Fox in Washington, DC. Agencies should absolutely "not suggest to their staff that they need to change strategies to achieve therapy levels and trigger reimbursement maximization," Ran-dall tells Eli.

"Government regulators will be looking carefully for that kind of game-playing," Randall warns. "Either over- or under-serving patients could constitute a violation of the Civil Money Penalties provisions of the law," she says.

Bottom line: "Shifts in practice in order to maximize revenue may draw unwanted attention from Medicare and are not recommended," emphasized consultant and physical therapist Cindy Krafft in a recent Eli-sponsored audioconference about the PPS changes.

How therapy reimbursement works: Under the revisions that take effect Jan. 1, PPS will have three new thresholds for therapy at 6, 14 and 20 visits. But there will also be smaller incremental payment increases for many visits between seven and 19.

For agencies that have always had an even distribution of therapy visits, the new system will reward them financially for formerly money-losing episodes with therapy visits in the six to nine range. They will also benefit if they formerly took on those "train wreck rehab patients" with 20 or more visits, pointed out Krafft, with Fazzi Associates in Northampton, MA.

"The agencies that have been the most scrupulous and precise in their coding and recordkeeping practices in the past will come out ahead after Jan. 1," Berliner adds.

But agencies that have had their therapy distribution bunched right at or above the 10-visit mark are likely to see reimbursement declines for therapy in 2008, Krafft cautioned.

Avoid These Therapy Red Flags

What to do now: Whether you are in the former or latter group, you should focus on dedicating your therapy practice to the patients' needs under the PPS revisions, Krafft advised. Avoid setting artificial target numbers for therapy visits. "Don't start from the numbers and work backwards," she exhorted.

"We don't want to repeat the mistakes of the past," she urged listeners. Don't assign everybody at six visits if nearly all patients used to get 10 or 11. Besides the ethical ramifications, you'll have to answer to regulators looking for just such utilization swings.

If your therapy visits are bunched around certain numbers, examine your practices to see why they aren't in a more gradual continuum, Krafft suggested. "There should be a natural visit distribution with no artificial gaps."

Beware ranges: Also make sure you don't gravitate toward the low end of the visit ranges that pay the same. So don't always assign seven visits instead of nine, or 11 visits instead of 13. "Medicare will have [intermediaries] monitor for this," she warned.

And don't expect to easily rake in the roughly extra $1,200 to $1,400 for episodes with more than 20 therapy visits, Krafft counseled. The Centers for Medicare & Medicaid Services expects those episodes to be very rare. Thus, it won't have any problem having medical reviewers comb through those episodes' charts routinely due to the low volume.

You should also keep tabs on therapy visit length--Medicare certainly will. Regulators will be looking for agencies that have more but shorter therapy visits, presumably stretching out services over more visits to gain extra reimbursement.

Pitfall: If your therapy visits are shorter than the 45- to 48-minute average Medicare expects, you should examine why they're that length before regulators like the HHS Office of Inspector General do.

Often the visits are shorter because clinicians aren't doing the documentation on site. Spending two hours doing documentation paperwork at home doesn't count toward a Medicare visit length, Krafft cautions.

And clinicians' documentation is usually more thorough and clear if it's done right away. "Good documentation is in fact part of good care delivery," Krafft maintained. "We have to stop separating this out."

Coding alert: Diagnosis coding for your therapy patients' episodes also needs to support the level of therapy furnished, Krafft added. And the record must support the code.

Hot spots: You may need to examine overuse of V codes and codes for abnormality of gait and muscle weakness, Krafft offered.

Make sure you're using the most appropriate codes, not just the ones on the case mix list, Krafft said. But also don't lose your rightful reimbursement because you're not coding patients accurately.

Get Ready For Tough Conversations With Staff

If you've encouraged therapy visit targets in the past, you may have a tough time transitioning staff to a patient-driven model of therapy, Krafft acknowledged. Explain how the new reimbursement system works and focus on addressing patients' clinical needs.

You may also need to tighten up requirements for therapy documentation in light of the coming scrutiny of the service and related diagnosis coding (for therapy documentation tips, see Eli's HCW, Vol. XVI, No. 42). That may raise some staffers' hackles, especially in areas with therapist shortages.

"The time has come for us to get better at communicating verbally and in writing so we know what's going on with this patient," Krafft said.