Case Study 01
Missed Occupational Therapy Referral After Reverse Shoulder Arthroplasty
Case Summary
A 70-year-old patient is admitted to home health in Michigan recently discharged from SNF (Skilled Nursing Facility) following a left Neer shoulder arthroplasty.
The patient reports severe left shoulder pain rated at 7/10 and demonstrates significant limitations in upper extremity range of motion and function. Skilled Nursing (SN) and Physical Therapy (PT) are ordered; however, no Occupational Therapy (OT) evaluation is included in the plan of care.
QA Finding
The patient has undergone major shoulder surgery and is experiencing substantial pain and functional impairment affecting activities of daily living (ADLs), including: Dressing, Bathing, Grooming, Toileting, Meal preparation
Despite these deficits, no OT services were ordered to address upper extremity function and ADL retraining.
Impact of patient care: Without OT, the patient may experience slower recovery and prolonged dependence on caregivers.
Lack of OT intervention following left shoulder hemiarthroplasty may increase the risk of joint stiffness, improper movement patterns, noncompliance with surgical precautions, falls during self-care tasks, delayed functional recovery, and potential hospital readmission.
Impact on Reimbursement:
Potential Underutilization of Covered Services: Under PDGM, reimbursement is based on patient characteristics rather than therapy visit volume. However, failure to provide medically necessary OT may result in incomplete implementation of the plan of care, increased risk of rehospitalization, and potential payer concerns regarding the adequacy of services provided.
Impact on Therapy Utilization: OT involvement can improve functional outcomes, promote adherence to post-operative precautions, reduce avoidable complications, and support the overall value and effectiveness of the home health episode.
CMS Regulatory Impact
CMS Conditions of Participation require that the plan of care be based on a comprehensive assessment that identifies all skilled care needs and includes all appropriate services. E.g.: Comprehensive Assessment, Plan of Care), Reasonable and Necessary Therapy Services.
Failure to order Occupational Therapy when clinically indicated may be cited as an incomplete assessment and inadequate care planning, potentially resulting in survey deficiencies and concerns regarding compliance with Medicare coverage requirements.
Business Impact:
Audit Ready
Centre of Medical Services Rating
Rating is done by the Centre of Medical Services (CMS) and is published on the CMS website. Only a 7-star rated home health agency is recommended to patients and payers.
Low Utilization Payment Adjustment
If visits exceed more than 6, the amount per visit is reduced. If a patient is receiving only physical therapy with no occupational therapy, recovery takes longer — this raises the LUPA threshold and leads to financial losses for the company.
Audit & Denial Risk
Payer may deny claims citing gaps in documentation. An auditor may identify this as negligence, which can result in a reduced agency rating.