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.

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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.

Two More New Conditions of Participation


Assessment and Plan of Care

The current Conditions of Participation are not specific about the scope of the assessment or the plan of care, but most agencies are already meeting the CoP’s due out in January.  In the current CoP’s, the scope of practice for each discipline is defined, followed by a section on clinical records.  It reads:

A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary. The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient’s medical and health status at discharge.

The new Conditions of Participation have details about what is expected to be in your assessment and plan of care.

Assessment:

The condition reads: Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment

The standards that fall under this condition are as follows as I understand them.  They are not verbatim.

  1. The RN must conduct an initial assessment to determine the immediate care and support needs of the patient and for Medicare patients, determine eligibility, including homebound status. This visit must occur within 48 hours of referral or return to the home or on the specific date ordered by the MD.
  2. When nursing isn’t ordered, Physical Therapy, Speech Therapy or Occupational Therapy can perform the initial assessment. This is later clarified to read that Occupational Therapy can perform the assessment if the need for OT services establishes the need for services.
  3. The initial assessment must be completed in a manner consistent with the immediate needs of the patient but no later than five days after the start of care.
  4. Content of the plan of care is expected to include:
    1. Patient strengths, goals and care preferences – including information that may be used to demonstrate patient progress to the patient’s goals and measurable outcomes identified by the agency.
    2. The patient’s continuing need for home care
    3. Medical, nursing, rehab, social and discharge planning needs
    4. Medication review of all drugs the patient is using to include
      1. Potentially adverse effects
      2. Drug reactions
  • Ineffective drug therapy
  1. Significant side effects
  2. Significant drug interactions
  3. Duplicate drug therapy
  4. Non-compliance with therapy
  1. The patient’s primary caregiver(s) and other support including their willingness and ability to provide care, their availability and schedules and the patient’s representatives, if any.
  2. Incorporation of the OASIS dataset into the comprehensive assessment.
  1. The assessment must be updated at least every 60 days and also at the time of a significant change in condition, beneficiary elected transfer, transfer and discharge to the same agency within the same 60-day period, within 48 hours of return to home after a hospitalization and discharge.

Surely you have realized by now that most of these criteria are already written into the OASIS regulations, prior Conditions of Participation and sound clinical principles.   Now they are Conditions of Participation and while similar to what we already do, note that Occupational Therapy can now perform OASIS assessments.  Also, it’s worth noting that whenever the comprehensive assessment is mentioned, it is followed by the assessment of Medicare eligibility for Medicare patients including homebound status.

Careplanning, Coordination of Care and Quality of Care

 This is a new condition and while many agencies already do most of this, there are some standards that some agency’s haven’t done in the past.

The actual condition is:

Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.

The standards that agency’s will follow to ensure and demonstrate compliance are as follows:

  1. Each patient must receive services that are written in a patient specific plan of care identifying patient goals and outcomes, established and reviewed periodically and signed by a doctor of medicine, osteopathy or podiatry acting within his or her scope of practice.
  2. If the physician refers a patient and the plan of care cannot be completed until after an evaluation visit, the physician is consulted to approve additional orders.

Contents of the Plan of Care

  1. The individualized plan of care must include the following:
  • All pertinent diagnoses;
  • (mental, psychosocial, and cognitive status;
  • The types of services, supplies, and equipment required;
  • The frequency and duration of visits to be made;
  • Prognosis;
  • Rehabilitation potential;
  • Functional limitations;
  • Activities permitted;
  • Nutritional requirements;
  • All medications and treatments;
  • Safety measures to protect against injury;
  • Risk assessment for emergency room visits and rehospitalizations and all necessary interventions to address the risk factors.
  • Patient and caregiver education and training to facilitate timely discharge;
  • Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
  • Information related to any advanced directives; and
  • Orders, including verbal orders
  1. Drugs, services and treatments are administered only as ordered by a physician
  2. Flu and pneumonia vaccines may be administered per agency policy developed in consultation with a physician and after the assessment of a patient to determine contraindications.
  3. Verbal orders must be accepted only in accordance with state laws pertaining to verbal orders. When a verbal order is obtained, services are to be carried out as ordered without waiting on the signed order. Verbal orders must include the signature, date and time that the order was received and be placed in the clinical record.  They are to be authenticated and dated by the physician who gave the orders in accordance with state laws and regulations as well as agency policies.

Review and Revision of the Plan of Care

  1. The plan of care is reviewed and revised by the physician who is responsible for the for the home health plan of care as often as indicated by the patient’s condition but at least every 60 days. The agency  must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  2. The revised plan of care must reflect current information from the patient’s updated comprehensive assessment and contain information concerning progress towards goals identified by the agency and patient in the plan of care.
  3. Any revisions to the pan of care due to a change in health status must be communicated to the patient, representative (if any) and all physicians writing orders for the patient.
  4. Any revisions to discharge plans must be communicated to the patient, representative (if any) and all physicians ordering care, the patient’s primary care practitioner or other health care professional who will provide care to the patient after discharge from the agency.

Ensuring Care Coordination involves:

  1. Communication with all physicians involved in the plan of care.
  2. Integration of orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
  3. Integration of services provided by the agency or under arrangement to assure the identification of patient needs and factors that affect patient safety and treatment and coordination of care.
  4. Involvement of the patient, representative (if any), and caregivers as appropriate in coordination of care activities.
  5. Ensure that education is provided by the agency to the patient and caregivers regarding care and services in the Plan of Care and to ensure a timely discharge.

The agency must provide written information to the patient that includes:

  1. Visit schedule of all agency and contracted personnel
  2. Patient Medications and instructions on how to take meds including medication name, dosage and frequency and which meds will be administered by the agency or contracted personnel.
  3. Al pertinent instructions related to the patient’s care and treatments that the agency will provide specific to the patient needs.
  4. The name and contact information of the agency’s clinical manager.

So that’s a lot.  Agencies who choose to wait will be working weekends and holidays to be in compliance by mid-January.  The first thing I might do is call my software vendor.  The plan of care requirements haven’t changed but the information that is required to be given to the patient has.  Could a patient friendly medication sheet containing frequency as well as the name and strength of the med be generated?  Depending on your patient population, there may be questions about whether or not you want to leave the entire plan of care in the home.  Will the computer generate a separate form?

Notice that teaching must be specific to the patient.  This may seem self-evident but I have seen nurses teach that Neurontin is for seizures when the patient never had a seizure in their life but was taking Neurontin for neuropathy.  Still, the patient verbalized understanding.

Care coordination and communication is an ongoing Condition and an ongoing problem.  I thought that software messaging would reduce the problem but sadly it has not.  The software accounts I have for clients have so many emails in the inboxes and the vast majority of them do not concern me. One of you has a better idea.  Care to share?

Look for more next week.  Meanwhile, get through these Conditions before moving on to the next.

5 ADRs – Your Risks


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.

  1. 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.
  1. 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.
  1. 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.

  1. 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.

  1. 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.

 

Home Health Conditions for Payment


We have looked and have been unable to find specific guidance on the new CoPs.  There was a phone conference scheduled with NGS that was cancelled and nothing so far from Palmetto GBA.  Help us out if you know anything.

Meanwhile, some people who are very knowledgeable and well respected in the industry differ from us in how we interpret what ‘estimating how much longer the patient will be on service at the time of recertification’ means.  Look for it below in larger bold text.

§424.22   Requirements for home health services.

Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.

(a) Certification—(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s eligibility for the home health benefit, as outlined in sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, as follows in paragraphs (a)(1)(i) through (v) of this section. The patient’s medical record, as specified in paragraph (c) of this section, must support the certification of eligibility as outlined in paragraph (a)(1)(i) through (v) of this section.

(i) The individual needs or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services as defined in §409.42(c) of this chapter. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification form, in addition to the physician’s signature on the certification form, the physician must sign immediately following the narrative in the addendum.

(ii) Home health services are or were required because the individual is or was confined to the home, as defined in sections 1835(a) and 1814(a) of the Act, except when receiving outpatient services.

(iii) A plan for furnishing the services has been established and will be or was periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)

(iv) The services will be or were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.

(v) A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in paragraph (a)(1)(v)(A) of this section. The certifying physician must also document the date of the encounter as part of the certification.

(A) The face-to-face encounter must be performed by one of the following:

(1) The certifying physician himself or herself.

(2) A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health.

(3) A nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(4) A certified nurse midwife (as defined in section 1861(gg) of the Act) as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(5) A physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(B) The face-to-face patient encounter may occur through telehealth, in compliance with section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.

(1) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.

(2) [Reserved]

(2) [Reserved]

(b) Recertification—(1) Timing and signature of recertification. Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Recertification should occur at the time the plan of care is reviewed, and must be signed and dated by the physician who reviews the plan of care. Recertification is required at least every 60 days unless there is a—

(i) Beneficiary elected transfer; or

(ii) Discharge with goals met and/or no expectation of a return to home health care.

(2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the recertification form, in addition to the physician’s signature on the recertification form, the physician must sign immediately following the narrative in the addendum.

(c) Determining patient eligibility for Medicare home health services. Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. This documentation shall be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described in paragraphs (a)(1) and (b) of this section. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.

(d) Limitation of the performance of physician certification and plan of care functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of care may not be established and reviewed, by any physician who has a financial relationship as defined in §411.354 of this chapter, with that HHA, unless the physician’s relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements.

(1) If a physician has a financial relationship as defined in §411.354 of this chapter, with an HHA, the physician may not certify or recertify need for home health services provided by that HHA, establish or review a plan of treatment for such services, or conduct the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act unless the financial relationship meets one of the exceptions set forth in §411.355 through §411.357 of this chapter.

(2) A Nonphysician practitioner may not perform the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act if such encounter would be prohibited under paragraph (d)(1) if the nonphysician practitioner were a physician.

[53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70334, Nov. 21, 2005; 72 FR 51098, Sept. 5, 2007; 74 FR 58133, Nov. 10, 2009; 75 FR 70463, Nov. 17, 2010; 76 FR 9503, Feb. 18, 2011; 76 FR 68606, Nov. 4, 2011; 77 FR 67163, Nov. 8, 2012; 79 FR 66116, Nov. 6, 2014]

Incarcerated Prisoners


 

 

The telephone is often our most sacred source of amusement.   We love email, texts and blog comments but there are some things that people will not commit to writing.  When we need a break, we simply turn our volume up and answer the phone.

The question of my day was, ‘If a patient moves, can we still see them if they are in the service area?”

The answer was too obvious so the caller was answered with a question.  “Where did the patient go?”

The answer was less than articulate but the word ‘jail’ was in there somewhere.  Apparently, the patient got a little tipsy and loud and someone called the police and there were outstanding warrants and he is taking a little vacation courtesy of the county.

Not wanting to give bad advice, a little research was done on behalf of the caller – after all, this was cheap entertainment.  What we found, though, was not as amusing as we had hoped.  The definition of incarcerated includes beneficiaries who are:

‘• Imprisoned;
• Escaped from confinement;
• Under supervised release;
• On medical furlough;
• Required to reside in mental health facilities;
• Required to reside in halfway houses;
• Required to live under home detention; or
• Confined completely or partially in any way under a penal statute or rule.

The patient is not eligible for services.  This is important.  If someone is incarcerated, the incarcerator picks up the tab for all medical expenses.  (Consider that if you don’t have insurance and need surgery.)

If you are providing services to someone who has escaped from confinement, you have bigger problems and my recommendation is to pretend you do not know that your patient is an escaped convict.  If you let on that you know, you may experience a sudden reduction in staff.   If your conscience bothers you, don’t bill for the care and enter into a Corporate Integrity Agreement with the OIG when you are able to safely discharge the patient.

The risks to home health and hospice providers are further down on the list.  The United states has more prisoners per capita than any other country and Louisiana tops the list of states with 867 people per 100,000 meeting the definition of ‘incarcerated’ as provided above.  And yet, earlier in the week, researchers from Harvard University together with the University of British Columbia announced that they have determined that the five happiest cities in the nation were in Louisiana.   (Mardi Gras?)

In fact, it appears as though CMS Region 6 is well represented in the list.  In addition to being Region 6 states, it is noted that all of them are in the South and none of the very cold states have many prisoners.

Medicare Regional Map and Density of US Prison Population

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But, you have a bigger problem than the weather in Region 6.  Specifically, it appears as though the various prison systems across the states are very slow to update their systems.  In some states, Medicaid is auto-cancelled when someone is incarcerated.  Released prisoners do not always know to reapply.  In other states unless someone applies to be taken off of probation they will remain on probation until a judge approves their release.

Medicare is denying claims for the incarcerated.  States can decide if they want to use Medicaid dollars but most don’t.  The ones that pay for prison healthcare forego the matching Medicare funds.  In Louisiana, we don’t have to worry about those required to reside in Mental Health facilities because our jail is our mental health facility but like everyone else we need to be concerned about halfway houses, supervised release and those on Medical Furlough.  If a patient on House Arrest gets past you, shame on you for not checking pedal pulses.  You don’t deserve to get paid if you missed the ankle bracelet.

If you inadvertently bill for a a person who is under the jurisdiction of the court, it will result in a denial.  If you live in one of the northern states, this should be an isolated incident.  If you live down south, it could become an expensive issue.  Medicare is supposedly getting on to states to tidy up their prison rosters but meanwhile, if you live in a state like Louisiana or Mississippi, my suggestion is, quite frankly, to include an assessment of their legal history at time of admission.  Don’t be rude about it.  Just ask something like, ‘Are you able to transfer from both the top and bottom bunk?’

10 Common Documentation Flaws


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Stop and use caution before documenting your visit!

 

If you are not concerned about poor to mediocre patient care, getting paid or your license, read no further.  If any or all of these issues are of concern to you, keep reading.  Below are ten of the most frequent flaws in nursing documentation reviewed by the coders.  We know that these oversights and omissions are most often the result of a busy schedule or inattention to documentation because we know our clients.  State surveyors, Medicare contractors and agencies named with 3 letters and an Eagle (OIG, FBI, DHS, CMS, etc.) do not express any great interest in the underlying causes of poor documentation.

1.  No MD Contact Documented when appropriate

Many times, the MD is not called at the house due to time constraints or other issues.  When orders are received, they do not tie back to any communication in the chart.  Documentation of two way communication is critical to both sound clinical practice and payment.

2.  Contradictory Information

The 486 summary indicates that the patient lives with a daughter but the OASIS states the patient lives alone.  The OASIS data states that the patient becomes short of breath with minimal activity but the plan of care does not include shortness of breath in the functional limitation.

3.  Blind Adherence to Rules of Thumb

Somewhere along the way, nurses were told that they must always document on the primary diagnosis on every visit and follow the clinical pathway written by someone who has never visited the patient.  This has led to visit notes that read like, “Pt found on floor with scalp wound bleeding profusely.  Reports she fell yesterday and wasn’t wearing life alert button.  Taught to avoid soda and other concentrated sweets to manage blood sugar.”

4. Failure to Document Sensitive Information

A chart found in one the best agencies I know of had multiple notes reading that the patient complained of extreme pain.  The physician was notified after every visit with a fax and a copy of the med list.  No new orders were received.  The Director of Nursing explained that the patient had recently been the subject of an evening news story involving the sale of her pain meds to supplement her Social Security check. 

5. Missing the Little Stuff

When little things like vital signs, weights, and blood sugars are omitted from the clinical record, it causes problems.  A weight gain of ten pounds after two weeks of forgetting to weigh the patient is negligent but not as bad as forgetting the third week when the patient is hospitalized.  Most nurses take vital signs.  I spend many nights staring at the ceiling wondering why they aren’t on the chart.  Then I remember that I tend to write them on my arms and if I bathe before I chart, they are lost to the water supply.  What’s your reason?

6.  Missing the Big Stuff

Missing new orders, teaching on medications that have been discontinued and not notifying the MD for problems is more common than you think.  It is what feeds many malpractice attorneys.  It is why state surveyors might not trust anything you say during survey.  It is why nurses find themselves answering very difficult questions to the state board of nursing.  If you do not have a current care plan, refuse to see the patient until you have a verbal report.  Document the verbal report.  If you see a patient without looking at prior orders, shame on you.  If the prior orders taken by another nurse are not written and as a result you teach a patient to take a med that has been discontinued, write an incident report.  This is stuff that kills patients.

7.  Lack of Follow-Up

Lack of follow leaves gaping holes in the chart, and often, results in missed opportunities to provide better care to patients.  Consider a clinical record where you read one week that the patient has a doctor’s appointment the following day and that’s the last time it is mentioned.  Did anyone call to see if there was lab or new meds ordered?  It’s hard to believe but sometimes patients don’t tell you these things. 

8.  No Ongoing Medication Reviews

One of the easiest way to prevent re-hospitalizations, adverse reactions, and non-compliance with medication is to simply review all medications against the med list on each and every visit.  Every time a med is missing, a new med appears, or there seems to be confusion in dosing, there lies an opportunity to improve the care of a patient and to increase your level of skill ensuring payment. 

9.  Taking the patient’s word at face value

If a patient tells you they had a lab or diagnostic test and the results were fine, by all means document it.  Also call the physician who ordered the test and get the scoop.  The physician may have told the patient it was ‘fine’ or ‘no change since the last MRI’ but in the context of the specific patient, that same test could show degenerative disease, a low hematocrit or some other information important to support eligibility for your patient.  If possible, always get copies of the final reports for lab and diagnostic tests.

10.  Evidence of Ignorance

This sounds harsh but it is evident en masse in the clinical records reviewed by The Coders.  A new medication will be ordered specific to a disease that is not documented anywhere.  Eye drops for glaucoma, Zemplar for hyperparathyroidism secondary to renal disease, Invokana for Type II diabetes are all medications seen within the last week that have no corresponding diagnosis.  These meds both have serious side effects and teaching to ‘take medications as ordered’ will not help the patient avoid untoward adverse reactions or recognize side effects. 

All of these shortfalls in clinical documentation can be avoided by simply reviewing the charts.  The average time for a skilled nursing visit is 30 minutes and the average payment is equal or more to what nurses would make in the hospital.  This means that nurses have the time to review the clinical records, go to case conference meetings and call physicians.  If a nurse has ten fingers and a keyboard or two thumbs and a smart phone, enough information regarding medications is available around the clock.  Medscape has a great completely free app for mobile phones that has data that can be stored on your phone when you are away from Internet connectivity.

We all want to get paid.  If agencies don’t get paid, they have no money to pay consultants and coders and that reason to document well falls second only to improving patient care.