A PDGM Primer


It’s almost time for PDGM, the payment system that could dampen our holiday spirits if agencies are not ready. As you can see by the chart below, provided by our friends at CMS, the HIPPS code, which determines payment, will be calculated a little differently than the current PPS HIPPS code.

Position 1 will refer to a new 30 day billing cycle and only the first 30 day period of care will be considered ‘Early’.  Bring your billers Starbucks or Redbull.  They will need it as twice as many claims will be dropped.  And yet, OASIS will still be collected on the same 60 day cycle.

Look at next column. There are 12 different groups into which patients will fall according to their diagnosis codes. Most agencies have certified coders (presumably us) and the assessing clinician’s job is to provide accurate assessment information to assist The Coders in finding the correct codes and sequence. Many codes that are currently used will not be accepted as primary in PDGM and The Coders will be searching for clues to refine the diagnosis codes.

The source of the episode is not very flexible but agencies can change marketing strategies to try to increase the number of patients admitted post hospital. Understand that refusing community referrals that meet your admission criteria policy to improve your ‘numbers’ is highly unethical and possibly illegal. But, if you have a very high percentage of community admissions, there is nothing wrong with increasing marketing efforts to surgeons and other physicians who typically admit patients directly after a hospitalization.

elderly-folksThe admitting clinician’s largest contribution to payment is the functional domain which has been chronically under assessed and given the least attention of all payment elements. Many agencies will be leaving money on the table and risking denials for homebound status if nurses and therapists don’t know how to respond to the questions make up the functional status. There are eight OASIS questions used to in the PDGM calculations and seven of them are the functional domain questions.

The first place to start is teaching and reteaching the Conventions for completing OASIS. The can be found in Chapter 1 of the manual. They haven’t changed since the advent of OASIS but as new clinicians rotate in and out, they are often overlooked in orientation. The ones that are misunderstood are sandwiched between statements of common sense. Here are two that are frequently misunderstood (without wonder).

  1. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.
  2. If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual status” or what is true greater than 50% of the assessment time frame, unless the item specifies differently.

These two conventions could mean that some of your patients who had a procedure the day before admission are being underscored.  Misunderstanding them  could also cause a nurse to underscore a patient if they simply record what is true at the time of the visit. (Read about a real life example from 2009 here.) Sundowning generally occurs after the nurse’s visit. Add a sleeping pill at ten PM and it could be true that the patient wasn’t safe to get to the restroom independently for over 12 hours of any given day. Agencies can improve OASIS scoring and ethically increase payment by understanding these two conventions.

Here are two more.

  1. Understand the definitions of words as used in the OASIS.
  2. When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited to physical contact and can include necessary verbal cues and/or supervision.

The definitions of words as used in OASIS often varies from normal everyday use. This is why seemingly intelligent employees sometimes answer OASIS questions incorrectly. Consider OASIS question m2020 that investigates the patient’s ability to take all oral medications but when you read the OASIS manual it instructs us to consider the medication for which the most assistance is needed when selecting a response.  (Why the bold, italicized font if the definition of ‘all’ wasn’t ‘all’)

If a family member must constantly remind your patient to use a cane, that is considered assistance. If someone must remind them to eat, they need assistance.

This information is from the official OASIS Guidance manual. It is not an invitation to upcode. Rather, it is a warning to not leave money on the table. Don’t wait until PDGM to teach and reteach these conventions. Start checking admission paperwork now and educating the nurses and therapists doing your admissions when you see contradictions between the chart and the OASIS. Good agencies work hard to provide care to patients and deserve to be paid. We have friends and colleagues working in the field and we see how tired they are at the end of the day.

If you have any questions, do not hesitate to contact us. We are always available to check your OASIS and ICD-10 coding but for now, pull ten charts and see if the functional domain questions are answered in accordance with these conventions.

Don’t worry.  We’re making this adventure with you and will post more information next week.

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Predictive Analytics


I just saw an advertisement for a company offering predictive analytics so that within minutes after the clinician inputs data, predictions are made. It even tells you how many visits will result in a good outcome and what kind of visits those are. There’s another tech company that guides you to better allocate your resources (you are the resource, by the way).

Although I love computers, I wonder if we are trying too hard to substitute computer data for critical thinking. Using computer predictions to determine how much care should be delivered has too many opportunities to fail, and failure in nursing harms patients.

The algorithms in this and other programs are based on thousands of patient episodes. In theory this is good. Validation is achieved by the repetition of results across many occurences. TUG tests and PHQ depression assessments are validated but those results are not influenced to any great degree by data that we are unable to measure.

So, agency owners who are interested in these data crunching, predictive programs might want to ask what information goes into making these predictions and what variables can influence the data. OASIS and basic assessment data is readily available but OASIS does not ask about income or education level; both of which influence a patient’s response to care provided. Typical assessment data does not provide insight into family dynamics or how far it is to the nearest grocery store, hospital or their MD office.

If nurses surrender their own critical thinking to these programs, they are primed to violate the most fundamental of nursing standards by not individualizing care for the patient. Only the assessing clinician can do that. If non-clinical managers use these programs to determine the value of a nurse, he or she may end up on the radar simply for providing the patient what is needed.

I have never seen a computer program brought before the board of nursing or any of the therapy boards. If the computer advised the nurse to insert a knife into the eye of the patient, the computer would not be held accountable for the resulting loss of vision. The nurse is and always will be ultimately responsible for the nursing care rendered to the patient.

The legal implications are enough to make me glad I am not a lawyer and cannot give legal advice. That’s not to say you won’t wish you had called a lawyer before you allowed a computer to make clinical decisions for you.

I am an information junkie. If I had access to one of these programs, I would play with it the way Sheldon and Leonard played Halo on Wednesday nights. But I don’t think that is how this predictive technology will be used. My fear is that clinicians will be judged on how many visits they provide and whether the number falls within the computer generated parameters. I am afraid that careplans will be altered to accommodate an algorithm, and the patient will receive care they do not need or not receive care they do need.

There are no recipes for patient care – add five visits and a teaching guide for diabetes; stir well and season to taste with footcare. The best software helps clinicians care for patients. A good system frees up time by handling non-clinical tasks and minimizes the work of complete and accurate documentation . (No routine visit nursing note should require 20+ pages when printed.) Documentation in the home during a visit is ideal but not if it puts the computer between the patient and the clinician. Making information available when needed is much different than a Where’s Waldo game to locate vital signs in a sea of useless information.

Most State Boards of Nursing have a statement similar to the below taken from the Louisiana State Practice Act:

The standards are based on the premise that the registered nurse is responsible for and accountable to the individual for the quality of nursing care he or she receives. Documentation must reflect the quality of care.

If you are unable to find a similar statement in your state’s practice act, look for one that says:

Computer directed nursing is acceptable should the nurse not feel up to thinking critically.

You probably won’t find anything like that. Registered Nurses are able to delegate tasks but never responsibility.

If you have a different opinion, we’d like to hear it. Please email or leave a comment. And remember, we are information junkies and do not want to go into flagrant withdrawals but we also think you can do a better job of caring for patients than any software, anywhere, anytime.

And we can help. We have coding and OASIS certified nurses ready to review your admissions and give you the information you need to craft a care plan.

Happy New Year!


Welcome 2019! If you have performed or reviewed any OASIS assessments since the beginning of the year, you may have been taken aback by the number of changes in the dataset. While its true that more than twice as many questions have been removed than have been added, the questions added have multiple parts and are quite different from the traditional OASIS C questions.

After being immersed in OASIS-D for a couple of weeks, I decided to rest my weary mind today and look at a chart created for a patient who broke her hip. She was admitted to the hospital where she had an ORIF followed by a rehab and then SNF stay. Guess what I found? All the OASIS questions that are new to Home Health Care. This proves to illustrate the ultimate goal of standardization across post acute care providers described in the IMPACT Act. Very simple math will let payor sources know which providers are making patients better. And of course, they already know how much providers are paid. This could be a true advantage to home health. If we can achieve results that are equal to or better than other providers, Medicare will favor home health as providers because we cost less.

The good news is that therapists should be easy to train. In fact, CMS invites a multidisciplinary approach to the OASIS-D assessment and therapists might be the key to getting it right the first time.

The new questions are not difficult but they will require time and thought in order to arrive at the correct answer. There’s a new type of fall to be counted; the intercepted fall where a patient is caught by another before they hit the ground. Witnessed and unwitnessed falls will be documented so like most good agencies, falls will be assessed on each visit. Hopefully, reports will be engineered by software vendors so that you can run reports from your software. OASIS data will tell you how many falls were experienced, what kind of falls they were, and if there was an associated injury. QA will be easy although it is possible that an initial uptick in the number of falls will be the result of constantly assessing. Be sure to count each fall only once.

Mobility has subsections A through S. That’s almost an entire alphabet. The questions are interrelated but each one needs an answer. Only one goal is needed.

The Coders has education available for your agency. Contact us and we will find a day we can spend with your staff educating them about the magical powers of OASIS-D.

To find out if you need additional training, take our OASIS-D Quiz.

And until you are confident that your agency is proficient in the OASIS-D updates, we are always available for OASIS review and/or coding.

Good luck. More later.

Opioid Use in the Elderly


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A few years ago, I was reviewing the clinical record of a patient who had just been discharged from the hospital with a severe GI bleed. While he was hospitalized, a drug screen was run and it was determined that he had no opioids in his system despite the fact that he had Lortab ordered three or four times a day. Going back further, I read that while his wife was present during visits, she was often ‘napping’. I do not know how the physician knew to order the drug screen but it’s not a long leap to figure out why Adult Protective Services were called. As it was discovered, the patient’s wife was substituting two aspirin for the Lortab doses; hence the bleed.

Fast forward to a couple of months ago when I read a chart of a man who had chronic back pain. He had been taking oxycodone for years and had recently underwent surgery which mostly corrected the cause of his pain. He then fell and was admitted for pneumonia. The admitting physician said the patient asked for much more than his prescribed dose of pain medication. When he received it, he was somnolent and showed other signs of overdose.

Then there was a patient whose chart indicated that she had very severe 10/10 pain on each visit. The physician was not called. I called the agency on this during a meeting as multiple clinicians had seen the patient. They told me that what I didn’t see was the five o’clock news when the patient was arrested for selling her prescription medication.

Here are some facts.

  • Pain affects approximately 100 million American adults each year, resulting in a national cost of $635 billion annually in medical treatment and loss of productivity.
  • Medicare beneficiaries (aged and disabled) have among the highest and fastest-growing rates of diagnosed opioid use disorder at more than 6 of every 1,000 beneficiaries (CMS, January 2017).
  • In 2011, on an average day, 80 adults aged 65 and older visited the emergency department for problems with narcotic pain relievers and seven older adults’ visits (on an average day) involved heroin (Mattson et al., 2017)

Obviously, there is more information and statistics about Opioid use in the elderly. Half of the internet could be filled with the complex reasons of how the epidemic began but that is hardly useful information. The most useful intervention that a visiting clinician can employ is common sense which is exceedingly uncommon in healthcare. Consider the following:

  1. Blind adherence to CDC guidelines is causing some patients who have been on large doses of narcotics for years to have their doses abruptly dropped by a significant level. This Huffington Post Story tells the story of Jay Lawrence who had his pain medication reduced by 25%. Shortly before the next pain management visit, when he expected that his dosage would be reduced again, he committed suicide. If a visiting nurse or therapist had been in the home, they could have tried to intervene by documenting the patient’s history including prior and current abilities. Although awkward, the CDC guidelines should have been reviewed with the physician as he appeared to be following guidelines for patients new to narcotic pain relievers.
  2. Disabuse yourself of the notion that narcotics given for legitimate pain do not cause addiction. Many of you will be insulted by this tidbit of advice but this information was shared with healthcare providers for years by pharmaceutical sales people. In fact, there is no ICD-10 code for addiction – only for dependence which occurs after taking the medication for a prolonged period of time regardless of the reason.
  3. Do not hesitate to code an F11 code if you have physician documentation.
    Assess the patient completely for pain remembering that assessment is more than interview. For years, we were told by very respectable organizations that the patient’s pain was what the patient said it was. That’s not always true. A full assessment includes observation of the patient’s ability to participate in daily activities, assessing sleep patterns, appetite and nonverbal behaviors such as grimacing, inability to focus on what you are saying and guarding the area the area where the pain is. Ask family members when present during assessments if the patient shows signs of pain during the evening or in the mornings when getting out of bed.
  4. The blind adherence to CDC guidelines has physicians focusing on the amount of opioids ordered but they seem to be oblivious to the recommendation that they find treatment and/or support for patients who may have a serious problem. The physician is more likely to refer a patient for help if you have suggestions handy. Waiting for an order takes much longer than asking for an order for a referral to specific providers.
  5. If your patient has been abruptly cut off or has had a sharp reduction in pain medication, be aware that suicides increase dramatically after the cessation of opioids. Depression is part of the withdrawal process and can be intolerable for patients who have an existing diagnosis of depression.
  6. Include both long term and short term effects of opioid pain relief. This is especially valuable for patients who do not take opioids on a regular basis but are undergoing a procedure that will leave them with pain. Help them set realistic pain goals. Teach your patient that pain medications should reduce the pain to where it is tolerable but can cause falls, confusion and impaired judgement. Long term, speak to the idea of tolerance to the medication and dependence. Reassure them that problems do not occur if they take pain meds infrequently for a short period of time and return to tylenol or NSAIDs as soon as their physician allows. Teach caregivers to wait until the patient asks for the medication instead of giving it routinely.
  7. Visiting clinicians probably see diversion more than most other healthcare providers. If there is any suspicion of diversion, ask the pharmacy to dispense only a week at a time so that missing medications will become obvious sooner if that is allowed in your state. Alternatively, ask for two pill bottles and keep only seven days worth and (with the patient’s or trusted caregiver’s knowledge) hide the remainder. If you know with reasonable certainty that medications are being taken from a patient, call elderly protective services and allow them to investigate. If there is doubt about why pills are missing, call in the social worker.

The extremists on either side of the opioid crisis are costing money and in some cases, lives. Complications from opioid use have resulted in opportunities to create new laxatives specific to Opioid induced constipation that are priced upwards of 350.00 per month. The sexual performance pharmaceuticals are also benefiting as patients suffering Opioid induced sexual dysfunction need a little boost. Falls in the elderly taking opioids are common and should a hip be broken, there is a 25 percent chance that they will not be alive in six months.

And yet, there is no feeling more powerful than shooting some morphine into the veins of a patient suffering from kidney stones. Hospice patients have a better quality of life with opioids and they are very useful for fracture and burn patients. Make no mistake. Opioids have their place as do antihypertensives, diabetic medications, etc. but they need to stay in their place. Patients should be cautioned about taking opioids for chronic pain unless all other avenues of pain relief have been explored and nurses and therapists need to be honest and unreserved in their teaching of medication safety.

Ding!


A client just received their certification report and it was good but not deficiency free as they had been in the past.  The reason?  Although the risk factors for hospitalization were pulled from the OASIS assessment, they were not identified on the Plan of Care as risk factors for hospitalization.  The interventions were similarly not tied to the risk factors even though they did address them.  The DON reported that she talked to a friend at another agency and learned that the other agency had received the very same tag.  Coincidence or survey trend?  Time will tell.  For now, smart agencies will go with ‘survey trend’ as their final answer.

The Condition of Participation is §484.60(a)(2).  It reads:

(2) The individualized plan of care must include the following:

  1. All pertinent diagnoses;
  2. The patient’s mental, psychosocial, and cognitive status;
  3. The types of services, supplies, and equipment required;
  4. The frequency and duration of visits to be made;
  5. Prognosis;
  6. Rehabilitation potential;
  7. Functional limitations;
  8. Activities permitted;
  9. Nutritional requirements;
  10. All medications and treatments;
  11. Safety measures to protect against injury;
  12. A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
  13. Patient and caregiver education and training to facilitate timely discharge;
  14. Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
  15. Information related to any advanced directives; and
  16. Any additional items the HHA or physician may choose to include.

This is a new requirement included in the 2018 Conditions of Participation.  It’s something that (hopefully) has been done by agencies in the past but risk factors haven’t always been labeled.  The requirement is consistent with the CMS goal of avoiding unnecessary admissions.

There are no instructions on how to do this.  Prior to the final regulations, the proposed regs suggested stratifying patients as high, medium or low risk.  That was omitted from the final rule.  From the 2018 CoPs:

While there may be benefits to establishing more inter-HHA consistency in the application of this requirement, we do not believe that those benefits would outweigh the cost of reducing HHA flexibility and innovation to determine the best possible way to achieve the overall goal of reducing unnecessary emergent care visits and hospital admissions.

The OASIS question that examines risk factors for hospitalization is M1033 reads:

(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)

  •  History of falls (2 or more falls – or any fall with an injury – in the past 12 months)
  •  Unintentional weight loss of a total of 10 pounds or more in the past 12 months
  •  Multiple hospitalizations (2 or more) in the past 6 months
  •  Multiple emergency department visits (2 or more) in the past 6 months
  •  Decline in mental, emotional, or behavioral status in the past 3 months
  • Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
  •  Currently taking 5 or more medications
  •  Currently reports exhaustion
  •  Other risk(s) not listed in 1–8
  •  None of the above

Additionally, M1036 looks at smoking, obesity, alcohol dependency and drug dependency.  There is a falls risk assessment which may score high in patients who have not fallen in the last 12 months such as those who had a recent hip replacement.  Depression is assessed and is known to impair recovery in most illnesses and conditions but is not included in the question specific for risk factors unless it has an onset within 3 months.

Some of the most dangerous risks to our patients are not captured by OASIS at all.

  • Elderly patients living alone in a rural area
  • Patients unable to afford or prepare food; may have frequent interruptions in utilities due to financial limitations.
  • Transportation or willing caregiver to pick up medications.
  • Functionally illiterate patients

It is possible that drawing in some information from OASIS might meet the condition, but it may not serve the patient.  On the other hand, it is highly unlikely that you would be hit with a survey deficiency if you included risk factors that were based on a full assessment even if they are not included in the OASIS assessment.

You won’t find many interventions to address isolation, depression and lower socioeconomic status in care pathways for other conditions, but they are equally as important for some patients as falls precautions which are ordered for pretty much everyone.  It may cost a little more but in the long run, lower hospitalization rates will correspond with higher margins.

The CoP’s mandate that care plans include patient risks for hospitalizations and Emergency Room visits and corresponding interventions to mitigate the risks.  Since you must do it, make it meaningful.

Contact us if you need help setting up a system for this or if you would have us review your careplans for you.

Home Health Denials


During January to March of this year, the top reasons for denial for Home Health Palmetto GBA claims were published on their website as listed below. They can be confusing in their meaning and so we have attempted to clarify as we understand them.  Without further ado:

56900—Medical Records not received
This has been the number one reason for denials for years. This occurs most often when an ADR is not seen in the system.  Alternatively, it is noticed too late to get records together and sent. To avoid this denial:

CGS encourages providers to use the Fiscal Intermediary Standard System (FISS) to check for MR ADRs at least once per week. To check for MR ADRs,
in the FISS system:

  1. Use Option 12
  2. Enter your NPI number and status/location of ‘S B60001’
  3. ADRs will appear as reason code 39700
  4. The ADR date is in the upper left corner.  45 days from the date of the ADR
    date the claim will auto cancel.

In addition to the above, we suggest:

  1. Uploading the documents when you are able.
  2. Mail the documents with proof of delivery requested.
  3. Track delivery.
  4. Retain copies of everything including the completed ADR.  If you sent by overnight mail five days before the due date and the records are not there two days later, you will have the opportunity to resend.
  5. Use the address and mail code on the ADR.  This is on the last page of the printed document and may differ from the return address on the first page.
  6. Print the ADR from the computer and include a copy with Your submitted documentation.

5FF2F Face to Face Requirements not Met

This should be easy by now but it’s still confusing. Our favorite cheat sheet is the PDF on CGS’s website. Additionally, we see denials that can be prevented by being mindful of the following:

  1. Regardless of the episode within the sequence of multiple episodes, the Face-to-Face document must be included even if it occurred six or more months ago.
  2.  The physician clinic visit or hospital documentation will be used to establish eligibility.
  3. If the information sent by the doctor does not clearly indicate that the patient is confined to the home or the need for skilled services, the agency can supplement the information.  Here’s how.  Send you Admission OASIS to the physician with a request to sign and date it, make a copy, file one in his records and return the copy to you.
  4. Teach everyone in the agency how to evaluate Face-to-Face documents.  You should never come into contact with one without reviewing it.

5F023 No Plan of Care

It is a rare event that an agency omits the plan of care from an ADR.  When an ADR is denied for not having the plan of care, agencies often assume that the mistake is on the part of the reviewer. Look again.  Often this means:

  1. The plan of care was not signed.
  2. The plan of care was signed by a Nurse Practitioner or Physician Assistant
  3. A different physician than the one listed on the plan of care signed it.
  4. The signature was not dated although there is a seperate code for this.
  5. The date of the signature was after the date of billing.

5CHG3 Partial Denial of Therapy

A reviewer will often deny visits based upon an arbitrary number of feet that a patient can walk or problems with individual notes. Because therapy adds significantly to the dollar amount of a claim, these services are an opportunity for Medicare contractors to save a few Medicare dollars at your expense. To avoid these denials:

  1. Document not only how far the patient ambulated but how they tolerated the ambulation.
  2. Take pre and post vital signs.  Document balance and gait disturbances.
  3. Always document pain and discomfort in quantitative measures.
  4. Document any complaints or new orders not related to therapy and report them to the case manager.  Follow up in writing.
  5. Most importantly, request a case conference and schedule discharge when the patient no longer needs therapy.

5FNOA – Appropriate OASIS not submitted

This code means that the OASIS was not found in the repository when the claim was billed.  Palmetto GBA explains this denial code as follows:

Under the HHPPS, an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

Since this list was generated from 2018 claims, it is unlikely that agencies would receive this denial code in response to an ADR because they are auto-rejected upon dropping the claim.  Yet, this reason for denial is ranked fifth.  If you have received a denial for reason code 5FNOA in response to records submitted in response to an ADR, please let us know.

5T072 – No physician Orders for Services

This denial refers to services provided in excess of what the MD ordered, or services provided before an order was obtained.  This is frequently seen when a physician orders PT to evaluate the patient but there are no subsequent orders. It may also be related to the date next to the nurse’s signature on the plan of care.  Nurses new to reviewing and signing plans of care will often date their signature with the date that the document was signed instead of the verbal SOC date.

To prevent this denial:

  1. If possible (and it should be possible), include therapy frequency on the plan of care.
  2. Consider amending your standard therapy contract to state that the agency will not pay for unauthorized visits.
  3. If the therapist includes the frequency and goals on the evaluation and that is signed by the MD, make a second copy to include with orders when an ADR is received.
  4. Educate and spot check the POCs of new case managers.  If a plan of care is not complete by the first day of the episode and the nurse contemporaneously dates his signature, all days prior to the date indicated are not billable as there are no signed orders.
  5. The same signature and dating rules apply to MD signatures on interim orders.
  6. The correct way to write an order that was received earlier is:
    1. Date the document on the day it was written
    2. Begin the order with, ‘Effective on (the date you received the order)
    3. Date your signature when you signed the document.

5F041-Information does not support medical necessity

This denial is listed twice with the same code.  It is also the easiest one to avoid when clinicians understand and appreciate the importance of their documentation. To avoid this denial:

  1. Read and distribute chapter 7 of the Medicare Beneficiary Coverage Manual.  Review specific topics at case conference.
  2. As much as possible document in the home.  Some patients complain that the nurse spends too much time focusing on the computer.  To prevent that, as you are finishing up, ask the patient if you can sit and document before you leave.  That way, you are not taking your attention away from the patient and if you forgot anything, you are still in the home.
  3. Display some clinical notes that are truly impressive as examples.
  4. Turn off the ability to cut and paste if duplicate notes by a nurse are found.
  5. Read The Z-Factor on the Haydel Consulting Services blog.
  6. If your job is to review notes, focus on what is important. Medicare does not pay for spelling and grammar and there is little virtue in embarrassing your nurses.  Focus on the contents of chapter 7.

Remember that the best reason to document is to communicate the condition of the patient to other clinicians.  You don’t have the luxury of shift change report.

5T070 – Visits/Supplies/DME Billed Not Documented/Not Documented As Used

Although this code includes visits, supplies and DME, Palmetto GBA’s explanation of this denial appears to be limited to visits.

The services(s) billed (was/were) not documented in the medical records submitted in response to the Additional Development Request (ADR). As a result, medical necessity for these services could not be determined.

It looks very similar to a denial for medical necessity.  Palmetto GBA advises:

To avoid unnecessary denials for this reason, the provider should ensure that adequate documentation is submitted to substantiate the medical necessity for all the services billed when responding to an ADR. The provider may submit discipline visit notes and/or a summary of the services rendered for the billing period. If a summary is submitted, it should include the following: (1) the information for the dates of service billed, (2) documentation of the services that “were rendered” by each discipline billed, (3) documentation of the patient’s condition, and (4) documentation of the patient’s progress/response to the treatments/services rendered.

This information appears to be outdated as visit notes are specified in the list of documentation required for ADRs. Our advice is to:

  1. Ensure that the recert and therapy evaluation are included if they were performed prior to the starting date of the episode.
  2. Include lab and other diagnostic tests that substantiate a diagnosis even if is not included in the episode.

5A301 Info Provided Does Not Support the M/N for Therapy Services

The same information that applied to the partial denial for therapy services also applies here so we won’t be redundant and repeat it here.

We hope you don’t need help with appealing denials but we are here for you if you do and to answer any questions about denials you might have received.  We would also appreciate any input if you have anything to add, especially about the denial for OASIS and the denial for Visits/Supplies/DME Billed Not Documented/Not Documented As Used.  Email us at TheCoders@hhcoding.com.

Don’t Archive Your Agency


When the list of documentation required by AdvanceMed  for UPIC audits included a complete Medicare census, we were confused; or rather, we thought they were confused. Surely they can get their own lists based on any number of databases.
A report by the Office of the Inspector General reveals they are not confused. The OIG has noted that 9 of 28 agencies reviewed had discrepancies between Medicare data derived from claims and Casper and the list provided to surveyors at the time of state survey. It is this list that surveyors use to choose patient’s and they were not inclusive of all patients Medicare has on their lists.
Occasionally a difference of one or two patients can be explained. Many times a ‘missing’ patient is a typo -sloppy but not fraud. Changing out computer systems can be messy. Yet, when an agency presents a list to surveyors that is 150 patients light, equal to 90 percent of their patients, a very bad outcome is lurking on the horizon. Active patient lists that are incomplete ensure that absent patients are not visited by surveyors. In some cases, patients were omitted from the unduplicated census resulting in surveyors being unaware that the patient existed.
The OIG has arrived at the conclusion that while there are many possible reasons for these omissions, some agencies might be deliberately trying to avoid scrutiny for the omitted patients. Honestly, do you feel just a sorry for the OIG because they are only just now arriving at this conclusion?
The OIG also noted that patients were discharged from one agency on the day that the roster was requested by surveyors eliminating them from the ‘active patient’ list. These same patients were readmitted later in the year with no intervening events or claims from other providers such as hospitals, rehab facilities or other home health agencies. There are references a prior report that found frequent discharges and readmissions were often characteristic of fraudulent agencies.
The OIG suggests a couple of possible solutions to ensure that the list given surveyors has not been manipulated by the agency.
  • Instead of using an agency provided list, arm surveyors with a claims list provided by CMS
  • Spot check by asking an aide or a nurse about their patients and determine if all of those patients are on the agency provided lists.
  • Monitor the person in the agency who is running the list from the computer. Doesn’t this sound like fun for both the surveyor and the agency?
  • Conduct a retrospective review post survey using Medicare claims or Casper data.
Obviously you are not going to manipulate patient lists but it will instill confidence in surveyors if you are able to provide accurate information in a short period of time. Because surveys are unscheduled, multiple people should be trained to:
  • Run an active patient list
  • Run an unduplicated census (list of all patients regardless of the number of times they have been admitted. Each patient will be listed only once).
  • Run a duplicated census (the name of every admission regardless of whether the patient has been admitted more than once. This list is longer than the unduplicated census list.)
  • Speak intelligently about any potential flaws in your data and offer a work around. (Your biller should be able to provide a list of RAPs dropped or a referral log from the computer)
I know that agencies have rushed to ‘archive’ records of patients that who don’t have anything good to say about the agency and records that might be train wrecks due to documentation errors or poor care. Surveyors are very much aware that these patients exist. All agencies have at least one or two.
Unless care is egregious, state surveyors will allow the agency to provide a corrective action plan. If the deficiency is a repeat or widespread throughout the agency, you may be subject to financial sanctions and a hold on admissions until corrections are implemented and verified by the state agency.  It’s embarrassing to be certain but rarely fatal.
If you provide false information to the surveyors, you have crossed a line into a whole new level of non-compliance. Your Provider Agreement has been violated and you are at risk for losing your agency’s license or worse. And yes, there are consequences worse than being shut down because you have no license to operate.
Most agencies want to do the right thing. Knowing that the agency down the street with patients who do not need care or are not homebound and yet has a perfect survey while your agency has five or six deficiencies has been known to boil the blood of nurses but at least they know where to focus attention.
The agency that hides patients from surveyors now has a very real chance of being caught.  Depending on how patient lists are compared, it may take a while, too, contributing to insomnia.  If you have archived patients to avoid scrutiny, consider keeping a current passport handy. This could be fun.