Home health care agencies that bill Palmetto GBA are currently in the midst of receiving five ADRs each across the board. As such, clinical record review has been ongoing at our office. What we’re finding is almost typical but not identical to what we have been seeing in clinical records in the past. Here are the top five risks for denial that we have identified.
- No physician statement of how long services will continue for second or later episodes. This is occurring even when the agency’s software has a blank for the information. Remember, if your physician’s estimate is a little too optimistic, it is not mandated that you discharge or otherwise do away with the patient. Help your physicians arrive at a reasonable time frame based on your combined experience. If you have no experience, consult your DON. If new needs arise, revise the end date on the following POC if any.
- Unsupported diagnosis codes. If a physician documents that a patient is forgetful and your assessment reveals that the patient is not oriented to person, place or time, you are likely both correct. However, in a case like this, a code for dementia is not supported by the MD. Another thing – it really is okay to let a diagnosis of hypertension stand-alone if the patient has hypertension. It does not need to be dressed up with additional diagnoses such as hypertensive heart disease or heart failure. It only ‘looks better’ at first glance until someone realizes that there is no MD support the code. When a physician’s documentation does not support your codes, it really is okay to ask. Send a fax to the MD asking if your codes might be accurate. There is always a chance that the doc’s documentation is not accurate and your question may be the catalyst to better overall care for the patient.
- Unmet needs for additional disciplines. When we look at ADRs, we ask for a copy of the packet that will be going to Palmetto or whomever. In limiting our view to only what Palmetto reviewers see, we sometimes see glaring omissions that may not be obvious to clinicians up to speed on the patient. We see patients with falls and no therapy and patients with difficulty with ADLs and no home health aide ordered.
Usually these services were provided in a previous episode or admission or refused by the patient but unless documented, it is impossible for a reviewer to see these omissions. A lot of agencies have moved away from 486 summaries (against our better judgment). If your agency does not write summaries as a rule, be sure to at least include that the patient is being ‘readmitted’ to indicate that there is more to the patient’s story. When you see the word, ‘readmitted’ when preparing documents for an ADR, ensure that you mention prior disciplines and treatment modalities in a cover letter to accompany the ADR.
- Signature issues. It seems that most agencies understand the signature requirements imposed by Medicare but not all. Ineligible signatures a ‘gimme’ for Palmetto GBA where the reviewers of clinical records deny entire episodes based upon one undated signature.
What’s curious about signature issues is that until an agency receives a denial, they don’t believe they have a signature issue. They have strict policies about billing and have created a work environment where fraud is not tolerated. When someone reminds them about signatures, they are confident in the high ethical bar the agency has set. They don’t see the problems we do.
The truth is that without diligence, inadequate signatures slip through. Stamped signatures, NP signatures and the signatures not matching the name on the plan of care are found occasionally and when those charts are reviewed by a payor source, a denial results.
There is no great clinical skill in checking signatures and agencies without signature problems encourage everyone who sees a signed 485 to verify the presence of a date and the correct name on the signature line. If the problem is pervasive, pay a bounty for every ineligible signature. Remember, it is far easier to convince a physician to sign an attestation when he or she clearly remembers when they signed a document.
- Lack of Communication. There are numerous instances when we believe an MD should have been notified that just sit there in the chart. In the past couple of months, we have seen an established PEG tube that was leaking, blood pressures and blood sugars that are outside of the stated parameters and increased pain that is not reported to the physician. New meds show up on recertifications and we can only assume a physician ordered them. Nobody takes
Some clinicians feel as though they are ‘bothering’ the physician when they call for orders. Others are confident that the physician does not want to be called. Our all-time favorite is the statement, ‘MD Aware’ and better yet, ‘MD fully aware’.
These examples of lack of communication will almost certainly result in a survey deficiency. They may also result in a denial if the episode has no new exacerbations, orders, meds, hospitalizations, etc. The patient becomes ‘static’ or ‘chronic’ and it becomes unfair to say that the patient has an acute, intermittent need that can be met by home health.
Faxes are wonderful things. So is secure email if you are lucky enough to have an MD who uses it. You can write up your non-critical concerns and send to the doc at the end of the day with a phone call to verify receipt. (Don’t trust the fax verification sheet because who knows what happens to faxes once they are received at the MD office.) That will certainly take care of any deficiencies on state survey.
To make payment for claims more likely, ask for orders if none are forthcoming. Not every high blood sugar or blood pressure requires a change in medications but when changes are warranted, it is usually because of a trend. Ask the MD for an extra visit to ensure that the errant numbers fall back to within parameters. Think of it this way. If your assessment reveals numbers that are the start of a new problem requiring a change, would you want to wait a week or more to get a second reading?
Ask for lab if indicated. A patient who is no longer responding to Lasix may have kidney disease. You can ask if the MD wants a metabolic panel or for you to advise the patient to schedule an apt.
When a patient reports severe pain, ask for therapy orders or non-pharmalogical relief. Do your homework by verifying pain meds are taken as ordered. More than one patient has stayed in pain because they are afraid of getting ‘hooked’ on pain meds. Work with the patient and the MD to find non-narcotic pain relief.
If the MD complains about your frequent communication, consider if you are overdoing it. Review the information with peers. If the communication was necessary for good care, ask the MD for suggestions on how to minimize it. If none or forthcoming, it may be time to accept the fact that he will be referring to another agency in the future – at least until a patient is hospitalized because the MD was not notified of a serious problem with his patient.
So far, all we have done is review the ADRs. No results have been forthcoming. We would be interested to know what you are finding as you review your charts and/or hear from Palmetto about your ADRs.
my agency was lucky enough to receive 8 ADR requests. I have found that although the documentation was sent with the original ADR documentation, i have gotten denials for missing POC and F2F documentation. It is difficult to appeal this as it becomes their word against ours. Is anyone else experiencing this issue?
In these cases, I would appeal with a cover letter stating that you examined your copy of the ADR and located all the ‘missing’ documents and are resubmitting the entire packet. I would also copy the missing documents and put them directly behind your cover letter.
Going forward, always number the pages of the packet.
you can also add to a reconsideration if something was inadvertently omitted. You should eventually get paid but it is frustrating to wait so long to get paid!
Stacey, I just realized you were hospice. In hospice, the billing periods, the IDT is an ‘update to the POC’, right? So if you have an IDT meeting before the dates requested and that IDT covers any part of the claim period being reviewed, the initial days of the episode will be denied. Call if you need clarification. 225-253-4876.