Since the implementation of the refined Home Health Prospective Payment System on January 1, 2008, the industry has been challenged to adapt to a structure quite different from what it used to be. Of particular focus has been Outcome and Information Assessment Information Set (OASIS) item M0826, which asks for the "indicated need" for therapy visits over the next 60 days.

Nurses and therapists alike are now attempting to predict the number of physical, occupational, or speech pathology visits that will be made during the episode of care. Many agencies are trying to set up a process to find the most consistent way to answer this item. Others are relying on the admitting clinician to make a "best guess."

Tension and anxiety are running high as to what is the correct way to project therapy visits as agencies try to be as accurate as possible at the start of care. I suggest that we collectively take a moment to put this item in the proper perspective by looking at what we are realistically asked to do and the impact of any plan we choose to implement.

In developing the new payment structure, a defined mechanism for predicting therapy visits was attempted. Factors such as preadmission status in the activities of daily living, specific diagnosis groups, and the functional assessment items in OASIS all were considered. With the proposed rule, it was concluded that "models that included these particular explanatory variables predicted the probability of using therapy, but not how much therapy would be used." This information needs to set the stage for any predictive plan we are evaluating.

If the developers were not able to put together a model reliable enough to implement in the industry based on these factors, agencies that choose to use the models must understand that reliability will never be near perfect. This does not mean we cannot, or should not, consider them as options. We need to keep in mind that there is no direct relationship between these factors and the exact number of therapy visits, but these factors can give us guidelines to help staff select reasonable answers.

Admitting clinicians need to be equipped with some type of direction for predicting therapy visits. Many agencies are using the 5-day window available before the OASIS is locked to encourage conversation between nurses and therapists to decide on the answer. Other agencies are looking back at historical practice patterns to develop internal guidelines for nurses to use based on diagnosis groups. Still others are implementing specific tools that use factors such as the OASIS functional assessment items to predict therapy visits.

The specific needs and structure of the agency should be key elements in choosing a plan. If therapists and nurses are communicating effectively to get a timely answer to M0826, implementing a written tool in addition to this may be unnecessary additional work for clinicians. The good news is that there really is no "right" or "wrong" way to answer M0826 because the final claim will be adjusted to reflect the actual number of therapy visits completed.

I have been asked on several occasions why MO826 was even created if the total payment is only ever going to be based on the actual number of therapy visits. Why not just leave it off and pay the amount when the episode ends? The issue is cash flow-not to be confused with gaming. The initial payment received for the episode is influenced by the projected number of therapy visits. If MO826 did not exist, the initial payment would be lower, and although it is corrected at the end, expenses are incurred in the interim and need to be paid.

I have encountered agencies that prefer to underestimate the visits, and in some cases, to put in only 1 to 3 visits depending on the number of therapy disciplines ordered. They are content with the revenue coming at the end. There is nothing inherently incorrect with that practice, although some may find it different from what they would choose to do.

What concerns me in all this is the time and energy some agencies are spending in pursuit of the "accurate" number. Even if the therapists themselves answered M0826, there still would be a significant number of adjustments. Although theirs is an educated guess, therapists also are making an estimate as to the number of visits a patient will need. Patients progress at different rates, and the plan of care calls for more or less visits over time. Some patients refuse further therapy interventions or go to the hospital and do not return within the episode of care. These variations are expected. The larger issue surrounding M0826 is about therapy utilization and practice patterns. We do need to know a number, but the clinical reasoning behind this number requires further investigation by agencies to ensure that care delivery is truly patient driven and supported in the documentation. Understanding therapy practice is more complex than just choosing a number of visits for this item. Any tool or plan we use can be altered as needed. If the final claims indicate that the prediction is consistently too low or too high, then future predictions can be made in a way to compensate for that and help to level out cash flow.

Agencies have limited time and resources to ensure OASIS accuracy. Only 2 items, M0110 regarding early and late episodes and M0826, have a mechanism built into the payment structure that will correct as needed. Final claims should be monitored to confirm correct payment. No other OASIS item has a correction feature, and agencies therefore must monitor accuracy internally. If a clinician incorrectly scores items such as dyspnea, pain, or the functional assessment, there will be no contact from Medicare indicating that the mistake has been found and additional funds will be sent. From that perspective, agencies need to spend more time focused on overall OASIS competency and not be excessively concerned about M0826. The predicted number of therapy visits needs to be reasonable, based on the indicated needs of the patient and supported in the documentation of all clinicians involved in the episode of care. Periodic assessment of the financial implications will guide how and when to adjust the instruction given on prediction. Let us not focus on one item to the exclusion of others that are significant in representing the condition of patients we are treating in the home health setting.