The MACs are looking at current claims filed. The RACs have taken a retrospective look at claims, but it has been the Z-PICs who have been busy. They are the auditors using refined algorithms to identify risk patterns.

The RAC auditors have been authorized to recover “improper payments “of preapproved areas of risk.  In the demonstration project, high areas of risk included incorrectly coded records, therapy appropriateness, and medically unnecessary services. The industry has concerns that therapy 13^th, 19^th visit and 30 day assessments will be a prime target. What about the Face–to-Face encounter?  RACs are expected to be busy, busy, busy when probing compliance with that regulation.

The HSS and the U.S. Department of Justice have teamed up to create the new Health Care Fraud Prevention and Enforcement Action Team (HEAT) to investigate and work to eliminate fraud in healthcare. They are using predictive modeling algorithms and high level technology as key tools for their mission. Their initial focus  has been directed toward Durable Medical Equipment, as well as services paid for by Medicare Part C (Medicare Advantage) and Part D (Prescription Drug Programs).

Now, more than ever a strong Corporate Compliance Program is essential in the industry.

Agencies should be auditing samples of past claims, reviewing present processes, educating personnel, and updating their present Corporate Compliance Plan. The OIG believes that effective compliance programs should include the following components, which are based on the seven steps of the Federal Sentencing Guidelines.

Components of a Compliance Plan:

1. Compliance Policies and Procedures to include written standards of conduct

1. Designation of a Compliance Officer and Compliance Committee
2. Ongoing Education and Training
3. Effective lines of communication; Process for Reporting Concerns, such as a hotline

1. Enforcement of Standards
2. Development of an Auditing and Monitoring System
3. Corrective Action Process for Correcting Compliance Problems

The Corporate Compliance Plan should represent the corporate wide initiative designed to detect and prevent problems of noncompliance and include:

• An Introduction and Purpose complete with expectations.
• Directives
  • Key Personnel
  • Standards
  • Reporting
  • Confidentiality
  • Response and Corrective Action
  • Enforcement and Discipline
  • Ø Standardized Conduct
  • Standards for Business Conduct
  • Code of Conduct

Code of Ethics

• Employee Open Communication
  • Agreement with the National Hotline Service
  • Tracking all calls including interventions

Effective programs have strong internal controls to promote adherence to applicable federal and state laws. They will also include internal auditing components of agency processes, services, and products with feedback mechanisms. There is a well defined agency code of conduct with a compliant culture and frequent employee training.  An infrastructure includes a Corporate Compliance Officer who, in addition to other duties, will monitor industry areas audit focus. The agency can then explore their vulnerabilities.

The OIG Top Medicare PPS Compliance Issues include:

• Reporting additional visits not made in order to exceed LUPA and therapy thresholds
• Providing additional visits to avoid LUPA and therapy thresholds
• Upcoding  and downcoding on the OASIS
• Duplicate bills and timeliness
• Returning credit balances promptly
• Routine waivers of copays
• Billing for services without physician orders

The RAC Demonstration Project issues include:

• Incorrectly coded 35%
• Lack of Medical Necessity 40%
• Insufficient documentation 10%

What are your audits reflecting? Is documentation adequate to support all diagnoses? Does the documentation support the skill necessary for each visit?

Besides the above areas that might include potential claims fraud and quality of care false claims (False Claims Act 31 U.S.C. 3730), home health Corporate Compliance Officers must also  be aware of HIPAA compliance, Patient Freedom of Choice 1802, Conditions of Participation (COP) and licensure violations as well as monitoring referrals to prevent referral kickback violations (Stark II, Phase III, SSA 1877) and Civil Monetary Penalties, SSA 1128(a)(5).

Home health agency compliance officers should expect to remain on the frontline of risk assessment and enforcement of health care regulations. The RACs are only beginning their audits.

A positive by-product of an organization that effectively implements a Corporate Compliance Plan is the emergence of a renewed vision of the future. In this age of government audits, a forward thinking organization will create or update their program for all of the right reasons. However, corporations will soon realize that they can leverage their compliance programs as public relations tools, which not only affirm their role as solid community citizens, but, also as business associates who share commitment to integrity and ethics.

This week Select Data has provided a sample Corporate Compliance Power Point Presentation for your use. This can be used as a solid shell to have specifics of your organization added. It reinforces the basics. There is no such thing as no need for reinforcement in compliance, especially not in this climate.

To download a copy of this PowerPoint click here.

by Ed Buckley 
with Tim Rowan

Lost revenue and poor compliance go hand in hand. They infiltrate a home health care agency together. 
Managing revenue cycle means improving compliance as much as it means ensuring complete and accurate billing processes and A/R follow up procedures. 

Compliance is the responsibility of all staff, especially those with clinical and financial responsibilities. In today’s Medicare environment — and it is not much different if a provider’s primary payer is insurance or the patient — mere automation is insufficient. Quality Revenue Cycle Management (RCM) processes are required today more than ever.

In fact, RCM is the number one key to meeting today’s home health compliance challenges. Considering the current regulatory environment, where we are seeing sharp increases in ADRs, the imminent rise of collection agencies such as Recovery Audit Contractors, and intensive, relentless MAC, MIC and Z-PIC audits, home healthcare processes and systems dare not fall short of the challenge.

RCM processes must build in compliance, not treat it as an afterthought or a luxury. Patient care is a complex proposition. Building in compliance requires that communication and interdisciplinary coordination are part of a plan of care that manages a patient’s medical needs. There are four key components to the process of building compliance into a plan of care:

• technology
• documentation
• coding
• billing

These four business pillars support RCM and form a foundation for compliance. Think of RCM as permeating the entire life cycle of a patient care episode, from referral to assessment to plan of care to patient record and finally to the revenue derived from that care. When a plan of care is carefully developed and managed through compliant systems and processes that all talk to each other, a complete management cycle results. When done right, the benefit of this cycle is that it provides the agency with a comprehensive, dynamic, profitable, accurate and compliant home healthcare business.

Most importantly, it results in the ability to provide the highest possible level of patient care, making the agency the first choice among doctors, hospitals and care planners.

Technology only part of the answer

In order to achieve compliance in the contemporary regulatory environment, home healthcare providers must employ more than just point-of-care technology and a centralized billing/coding system. It is imperative to utilize the RCM processes in order to verify assessments, review clinical processes and reconcile resulting data as part of compliant revenue generation. Incorporating RCM processes as part of an overall business strategy often results in improved reimbursement, bullet-proof billing compliance and stellar clinical outcomes.

Lost revenue and poor compliance go hand in hand because OASIS and coding errors are often the result of incomplete and incongruent assessments. Billing mistakes typically occur because visit activities vary from physician orders. Data errors are frequently triggered by hurried keying into point-of-care and EMR systems. A well-developed RCM system as part of operations, implemented in real time, can mitigate most of these costly mistakes. 

With compliance comes control and peace of mind. Compliance leads to more positive patient outcomes, fewer hospital readmissions, more retained revenue, greater efficiency and more predictable cash flow, while providing the business peace of mind that comes only when patient outcomes match plans of care. A home health agency’s business depends on the quality of patient care provided. Doctors, hospitals, and care planners need an agency they can trust to deliver quality care and outcomes, period. 

RCM begins with a complete data capture and error mitigation philosophy impacting every staff member and virtually every aspect of a healthcare provider’s business operations. This includes:

• accurate patient assessments, the cornerstone
• correct OASIS documentation
• clean patient data
• physician order monitoring
• visit reconciliation
• clinical coding with review
• QI oversight
• A/R management and collections follow-up

Systems must be designed into processes that identify errors prior to revenue generation. Catching up with after-the-fact chart audits is no longer an adequate process in today’s environment. Operations must have built-in processes that catch incongruence in real time while it is occurring…not after the bill has flown out the door. RCM systems monitor all administrative and clinical components that contribute to the capture, management and collection of patient service data.

The heart of the RCM process is a team of specialists charged with the responsibility of establishing and implementing policies, procedures, and performance measures and standards.

What RCM is and is not

RCM begins and ends with clinicians 
In order to obtain compliance within the RCM process, coding accuracy is indispensable. For the average home healthcare agency, however, achieving the necessary level of accuracy on a consistent basis is often an impossible dream. Among the most prominent roadblocks to coding success is the speed with which codes change. Dozens of alterations take place each year, seemingly in the blink of an eye. In 2009 alone, a total of 290 new codes were established. 

Coding errors create even more vexing challenges, the majority of which are related to documentation accuracy and completeness. Co-morbidities are missed during this phase, opening the floodgates to improper sequencing and inaccurate primary diagnoses. Clearly, RCM must begin with management’s confidence that assessments are accurate. Crucial to this phase are clinical tools. It is management’s responsibility to assemble the tools — especially comprehensive and ongoing training programs — that will properly channel the critical thinking skills required and expected of field staff.

Then, even with confidence in your staff’s coding and documentation skills, ensure excellence by assigning RN coding experts to review every assessment to see that every plan of care reflects best use of ever-changing codes and regulations. 

Accurate and compliant coding is not only the image of your standard of care that you broadcast to the community. It is the cornerstone of your ability to receive and retain revenue. Getting it right is the best way to grow your business and increase patient and doctor satisfaction with your plans of care. 

Cliché though it may be, there is a bottom line to consider here. Management’s focus on strong patient outcomes through compliance means greater revenue retention and the lowest audit risk. Clearly, effective RCM is a timely solution providing agencies with a foundation for a vigorous bottom line, a solid grip on financial activities, freedom to focus on priorities, and a welcome relief from compliance anxiety.

Ed Buckley is CEO of Select Data, a home care software and clinical services company based in Anaheim, California. He welcomes comments and can be reached at ed.buckley@selectdata.com

CMS has released a revision of the Home Health Agency Survey Protocols and a New State Operations Manual. The new survey process is data-driven and patient outcome-oriented with less structure yet very process-driven. Surveyor worksheets are presently under development and will be released soon by CMS.

The advanced copy of the surveyor procedures introduces a tiered system that directs surveyors to focus on quality of care vs other operations such as HR files. A detailed list of surveyor probes are provided, outlining questions that may be asked throughout the survey process. Agencies should review the questions outlined for surveyors in order to prepare for the survey process. Preparation for this process will reinforce other patient focused processes. Are you ready? To read more, please visit: www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_11.pdf

The survey process is guided by interpretive guidelines and survey protocols established to provide guidance for surveyors. They provide clarity as to intent of the regulations. All surveyors are required, by CMS, to utilize these guidelines when evaluating an agency as to compliance with Federal regulation. Remember, the guidelines do not replace regulation and are not allowed to be the basis of any citation, but they provide guidance.  Violations are to be based upon clinical record reviews, interviews with patients, caregivers, and personnel, as well as the agency’s practices in relationship to regulation and agency policies.

“The survey and certification process provides a method for CMS to evaluate HHA compliance with the Conditions of Participation (CoPs), ensuring that patient services provided meet minimum health and safety standards and a basic level of quality. The HHA survey process incorporates an approach that is patient-focused, outcome-oriented, and data-driven making it more efficient and effective in assessing, monitoring, and evaluating the quality of care delivered by an HHA…” (Appendix B, p.6).

The surveys are required to have at least one RN on the team.  Surveyors are required to attend the HHA Training Course prior to any survey. They are then required to be in an observational role as part of the training.

Types of Surveys

The survey process provides for a standard survey, a partial extended survey, and an extended survey. All HHA must undergo a standard survey.

Initial Certification

The initial certification requires compliance with SS Act1861(0)(4)  as well as 2180 regarding licensing requirements. In addition, follow the guidelines of SS2008 “Early Surveys of New Providers and Suppliers.

The State Agency (SA) surveyor or the National Accrediting Organization (AO) inclusive of Joint Commission, CHAP, or ACHC with deeming authority conducts the initial certification. At the time of that survey, the HHA must

• Be operational and have completed the Medicare Enrollment 855A verified by the assigned MAC.
• Provide nursing and one other therapeutic service (42 CFR 484.14(a).
• Meet the new capitalization requirements and have completed an OASIS test submission.
• Have provided care to a minimum of 10 patients requiring SKILLED care.

Standard Survey

This survey is to be a review of the quality of care and services furnished by the HHA as measured by the medical, nursing, and rehabilitative care indicators. The new changes require this survey to review compliance with regulations most related to high-quality patient care. These highest  priority standards (regulations)  are called Level 1 standards addressing 9 of the 15CoPs. The thinking is that if the agency is in compliance with these standards, it is in compliance with all CoPs.

Therefore,  “the surveyor can make a determination  that the HHA is in compliance with all CoPs when, after a review of the Level 1 standards, and after completing the required clinical record reviews, home visits, and interviews with patients and HHA staff, he/she does not discover any findings which would support a deficiency citation.”

Partial Extended Survey

This survey occurs when a standard level survey identifies a non compliant Level I standard and/or a deficiency practice may exist at a standard or conditional level not examined at the standard survey.  During this survey, the surveyor reviews at a minimum, the Level 2 standards under the same condition which are related to the non compliant Level 1 standards. See Table 1 Level 1 and Level 2 Standards.

Extended Survey

This survey includes a review of all conditions. It may be conducted at any time at the discretion of CMS  and is required to be conducted when any conditional level deficiency is identified. The surveyor is required to review all agency policies, procedures, and practices related to the substandard care (one or more condition –level deficiencies).

Recertification Survey

All HHAs are mandated (SS1891) to have a recertification performed no later than 36 months from a previous recertification survey. These surveys are standard unless a Level 1 citation is leveled.

Now, you know the types of surveys. The following chart lists the standard and partially extended surveys with their related priority standards. The more you know about the new process, the better prepared you will be for your next survey.

Next segment: Surveyors Prep for Survey, Entrance Interviews, Interview Questions They May Ask of Field Personnel and Clinical Managers. Are You Ready?

While Home Health Agencies were focusing on new CY 2011 regulations and plenty of changes, leaders need to remember that there was the change to Version 5010 for handling electronic claims. CMS will still accept Version 4010 claims until January 1, 2012. CMS expects that software vendors have been conducting internal testing so testing of the new version is now externally underway and full Level II compliance is completed by December 31, 2011.

To make this process as well as the transition to ICD-10 easier, the Coordination and Maintenance Committee has proposed ICD-9-CM coding changes be frozen, effective October 1, 2011.

“Recognizing the ICD-9-CM as a dynamic statistical tool that must be flexible to meet expanding classification needs, the ICD-9-CM Coordination and Maintenance Committee was created as a forum for proposals to update ICD-9-CM.  A representative from the National Center for Health Statistics (NCHS) and one from the Centers for Medicare and Medicaid Services (CMS) co-chair the ICD-9-CM Coordination and Maintenance Committee meetings.  Responsibility for maintenance of the ICD-9-CM is divided between the two agencies, with classification of diagnoses (volumes 1 and 2) by NCHS and of procedures (volume 3) by CMS”. (http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm).

The ICD-9-CM Coordination and Maintenance Committee’s role is advisory.  All final decisions are made by the Director of NCHS and the Administrator of CMS.  Final decisions are made after the December meeting and become effective October 1 of the following year. Official code revision packages, which are referred to as addenda, are available from this site.

The transition to ICD-10 is a major change for the industry. To better effect that transition as well as the Version 5010 to handle electronic claims, the ICD-9-CM Coordination and Maintenance Committee has proposed and accepted a partial freeze at a recent meeting. This freeze identifies:

• The last regular annual updates to ICD-9-CM and ICD-10-CM would be made October 1, 2011
• Limited updates to ICD-10 October 1, 2013 (ICD-10-CM is expected to be fully in use in Home Health by 2013)
• Full regular updates to ICD-10 to be reinstituted October 1, 2014

Agencies need to be certain billing software vendors are in full testing for Version 5010 and are planning for ICD-10-CM. CMS reminds everyone that ICD-10-CM is far more comprehensive than ICD-9-CM and preparation should be underway now.  (www.cms.gov/ICD10).

What are the Differences between ICD-9-CM and ICD-10-CM?

ICD-9-CM:
17 chapters and V and E code chapters
13,000 disease codes plus V and E codes
3,000 procedure codes in Volume 3
3-5 digits in disease codes
Essentially numeric system
Codes usually do not indicate timing encounter
No differentiation between left/right

ICD-10-CM:
21 chapters- V and E codes in disease chapters
68,000 disease codes, including V and E codes
87,000 procedures codes in ICD-10-PCS
3-7 digits in disease codes
Alphanumeric system
Codes specify initial and subsequent encounters
Differentiates between the right and left
Expertise in anatomy, physiology, and diagnostics will be a must

Third Party Coding experts should already be actively into their plan for additional education of their coding teams. Some, like Select Data, have been stepping up training sessions and will be offering ongoing Anatomy, Physiology, and Diagnostic seminars to refresh and maintain currency among their credentialed experts. It may look like ICD-10 is far away but, an additional 55,000 diagnostic codes, an additional 84,000 procedure codes, and increased coding specificity to the 7^th digit means increased risk for payment and more importantly, increased risk for payment retention. If your payment retention has been in question, can the MACs, RACs, or Z-PICs be far behind? Could you survive what is coming with what you have right now?

Home Health Eligibility Criteria Includes:

• Homebound Status
• Must be Under the Care of an MD, DO, or DPM
• Medical Necessity and Skilled Need

Homebound Status per CMS
CMS expects that the patient’s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home.
NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1

Homebound status is…

• Dependent on the limitations of the patient
• Dependent on the patient’s illnesses
• Can be acceptable for patient to attend partial hospitalization
• Can be acceptable for the patient to attend medical appointments

NOTE: For a patient to be eligible to receive home health services, the regulation requires a physician to certify that the patient is confined to his/her home.

Homebound status requires…

• Clear documentation that it is with considerable and taxing effort for the beneficiary to leave home. (74% of ADRs reviewed for lack of homebound status were denied).

NOTE: Documentation of “short of breath” does not justify homebound status. Acceptable documentation would include “short of breath after ambulating 10 feet and requiring rest period.” Agency documentation frequently stresses a problem with little justification.

Homebound status requires knowing the definition of a patient’s home. It is:

• The patient’s residence is where the patient makes their home
• Their personal dwelling
• Residing with a family member or friend
• In an assisted living facility

“The patient’s zip code is used for Home Health Compare to determine places where your agency provided service” Chapter 3, OASIS Guidance Manual, M0060.

CMS requires the beneficiary (patient) to be under the care of an MD, DO, or DPM.
Though there is active lobbying for orders to be signed by an NP or PA, that is presently not the law.

• “A medical treatment plan of care or the optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments”
• See 42 CFR Part484, Conditions of Participation, Subpart A General Provisions and 484.18 Plan of Care. Note the term, “attending physician”. CMS is frowning on a hospitalist signature with no patient follow through.

CMS accepts no stamped signatures and can disallow an entire episode with a stamped signature used by the physician.

“The physician’s signature on the Plan of Care must be obtained as soon as possible and must be obtained prior to billing Medicare for reimbursement” CMS Benefit Manual.

Skilled nursing visits must be intermittent.

The Medicare Benefits Manual, Chapter 7 states:

• “To meet the requirement for “intermittent” skilled nursing care, a beneficiary must have a medically predictable recurring need for skilled nursing services…at least one every 60 days.” Therefore, a single nursing visit will usually trigger an alert if only one SN visit was scheduled. It will usually be denied, if selected for review.

Skilled nursing must be specific to justify medical necessity.

• Skilled services are those services that are medically reasonable and necessary to the treatment of a patient’s illness or injury.

It must be clearly documented that the services provided required the skills of the professional clinician AND that the patient condition/illness/injury warranted those services:

• Services can be performed by a Registered Nurse or RN supervised LVN/LPN
• Physical Therapist, Speech/Language Pathologist (referred to in CMS home health operational and billing manuals as Speech Therapist)
• Occupational Therapist (OT may not perform RFA1 OASIS assessment certification but may perform a recertification).

The Clinical Record…

• The clinical record MUST have a specific order for EVERYTHING the clinician does
• The clinician: MUST do EVERYTHING that has a physician order and MUST document EVERYTHING she/he does…thoroughly.

There are common documentation deficiency areas; one of which is a series of notes that reflect no real patient progress. Some other deficit areas include:

• Repetitive clinical notes are frequently seen stating the same things over and over with no patient progress identified. How is it that the clinician is unable to teach a new med successfully within a visit or two?
• Notes from different disciplines reflect lack of plan coordination
• Visit notes do not substantiate orders and goals on Plan of Care/485
• Clinical interventions without orders

Identifying the skilled need: Teaching…
There are three types of teaching that can rise to the skill level:

• Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis.
• Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching.
• Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient has had prior instruction.

Teaching on new medications must include instruction or intervention on the related diagnosis. Do not confuse teaching the task of taking a medication with teaching about the medication and its impact on the disease or condition.
The clinician providing injections, such as insulin, requires specific documentation to support the need, specifically why the patient cannot self inject the med such as tremors, impaired cognitive functions, and/or no willing and capable caregiver. Without that documentation, the skilled need is not substantiated.

Skilled need and skilled nursing means:

• The appropriate care must be coordinated with all clinicians and the patient and
• each documented visit must be able to stand alone and clearly reflect homebound status on EACH and EVERY visit, clearly supporting skilled need, and identifying status of the patient progress with each note reflecting support of the physician’s ordered plan of care.
• The CMS Benefits Policy Manual Chapter 7 states that a skilled nursing need requires the skill of an RN to oversee the nursing care. The manual also reminds us that skills performed by a skilled nurse do not necessarily skill the care.
• Agencies should again be aware that one visit performed by the RN are being reviewed as to meeting the requirement for intermittent care.
• If SN has 1 visit and therapy is the primary service, nursing requires an order for at least two visits (and a skilled need) and a well documented assessment unless SN is conducting the OASIS assessment only. (If the latter is the case, the therapist must skill the case first and the RN must visit AFTER therapy, on the same day or within the 5 day window to complete the OASIS C ). Note: Of ADRS selected in 2008, those with 1 SN and 4 therapy visits have a denial rate of 73%.
• If a chronic diagnosis is the primary reason for ongoing care, the skilled nurse should be VERY VERY clear as to why (s)he is still making visits.
• If visit notes do not EACH stand alone and justify care, the nurse’s visits are at risk.
• The case-mix co-morbidities; such as CHF, CAD, COPD, DM, Parkinson’s disease should be included in the diagnoses list. If they are standing alone, the nurse should carefully justify the skilled need because of the chronic disease.
• In justifying observation and assessment, the note must reflect that:
• There is significant change in meds, treatments, or conditions
• There is teaching and training needed
• The condition or disease symptomatology has exacerbated or changed in another
• way

NOTE: the SN care must tie to the POC and the discipline specific care plan as well as the ultimate outcomes.

Additional Development Requests (ADRs)

Per CMS, in 2008, the 5 main reasons for ADR denial included:
1. Downcoding due to inaccurate primary diagnosis
2. Therapy visits not medically necessary and were thus disallowed
3. None or poor documentation for medical necessity
4. Skilled observation was an initial identified need but then no progress was documented

Timeliness with ADR response has been a key reason to agency loss of the appeal process. (Agencies should check weekly for ADRs on the FISS system).
An increasing number of physicians are being interviewed re POCs and patient homebound status.

• Denials for no physician orders, lack of homebound status, and untimely orders are on the rise.

NOTE: Recertifications require a verbal or signed written order prior to ongoing visits into that episode. Receiving a signed POC within 30 days (with no VO) of the episode, would disallow all visits within that 30 day period.

• Treating a missing order as a late entry is not allowed. Backdating an order is illegal and considered a fraudulent practice.
• If an agency has missing orders, they should discuss the issue with the physician and obtain the appropriate order but note the CORRECT date, it was obtained.

NOTE: Auditors are seeking trends. An oversite, properly corrected and documented reflects intent to correct an omission not perpetuate a fraud. Take action to instill processes so this issue does not reoccur.

Skilled nursing need including venipuncture, wound and psych care:

• Effective February 5, 1998, “drawing blood for laboratory tests is not considered a qualifying skilled service under Medicare Part A home health benefit. If a patient qualifies for home health service based on another skilled service and requires venipuncture then the services may be considered for coverage. “(Balanced Budget Act of 1997)

NOTE: Having a primary documentation of long term anticoagulant therapy (V58.61) should reflect teaching and assessment on the disease process, as well as monitoring of other objective data such as lab results. Venipuncture alone would not skill the visits.

Wound Care

Wound Care coverage must have specific physician orders for one or all of the following:

• Instruction/teaching on the wound care
• Performance of the specific wound care
• Assessment as to wound site progress/complications

NOTE: Documentation must include type of wound with size, depth, drainage, odor, color, skin condition, with specific interventions provided as ordered by the physician. Wound care is under significant scrutiny.

• A stasis ulcer with a status of early/partial granulation adds two points to the Home Health Resource Group (HHRG). A “not healing” status adds 11 points. Auditors will look for the specific documentation to support each.
• In addition, an early/partial granulation adds 25 supply points and not healing adds 36 points. (CMS –Regulation number 1560-F)

Note: Inadequate venous circulation to the affected area should be clearly documented. No such documentation leaves a visit suspect.

Psych Care

• Homebound status can be applied in these cases if the patient refuses to leave the home because of manifestation of the disease or condition process or
• If the patient is unsafe leaving the home because of behavior issues outside the home.

NOTE: Is OT involved with the psych care? While nursing tends to use words, the OT may assist to e.g. displace internalized anger through specific activities, which can also identify an objective sense of outcome achievement. An increasing number of agencies are finding this team; RN and OT, very dynamic.

What can the Psych Nurse do?

• Evaluate the patient
• Teach regarding the disease process
• Discuss ways to cognitively restructure how the patient can approach ADL s
• Psychotherapeutic interventions using techniques, such as cognitive restructuring therapy

Assisting the client to achieve optimal independence is a key goal.

• For the disease combination Alzheimer’s and Parkinsons Disease, there is a 75% denial rate for SN.
• Frequently, there are full denials because SN visits are not medically necessary.
• The psych nurse visit must demonstrate skilled teach or intervention and/or assist with routine establishment and cueing education for the caregiver.

NOTE: If there are no changes in care, the SN visit is not considered medically necessary and visits are at risk.