Missed and PRN Visits
With the advent of the new Surveyor guidelines that went into effect May 1, 2011, the focus is data collection and outcome achievement moving away from the prior focus on process. Outcome achievement starts with a great assessment, careplan, and visit strategy that means adherence to physician frequency orders. What happens if the clinician misses a visit?
In home health care under the CMS guidelines, a missed visit occurs when a scheduled RN, LVN/LPN, HHA, PT, PTA, OT, OTA, S/LP, or MSS does not keep an appointment with a patient. Examples: 1) Because of an ice storm, a PT does not visit the patient as planned. 2) The RN wound care specialist does not visit the patient as she is detained with another patient.
If calls to the agency to apprize them of the situation and a call to the patient results in the rescheduling of the visit to maintain the physician-ordered frequency, then there is no missed visit. The agency must communicate with the patient to ensure that his or her needs are met and there is no jeopardy.
Though the physician must be notified, there is no need to get an order. The agency can notify the physician by phone, fax, e-mail, or mail.
If no rescheduling within the physician prescribed frequency can be accomplished, then a call to the physician to apprize him/her of the missed visit is necessary and, in this case, a new order may be necessary.
Make certain documentation reflects the missed visit and is a part of the clinical record.
The Interpretive Guidelines for the Conditions of Participation, §484.18, discuss notification of the physician when a visit is missed.
A PRN visit is an additional visit or visits, ordered by the physician, that can be made when the specifics of the identified care are warranted.
It must include a specified number of visits during a designated time (usually a certification period) and a specific reason or a delineated description of signs and symptoms necessitating the visit. The reason for the visit must be anticipated and the frequency predicted based upon the assessment of the situation. Reasons for a PRN visit might include the need to change a catheter, manage an IV, or reassess vitals if a B/P exceeds specific parameters. Other situations might include a description of signs and symptoms that are linked to the patient’s specific medical condition, such as specific fluctuations in blood glucose readings. PRN orders can apply to any discipline if they are written specifically. Examples of complete, valid orders include:
2 wk 6 + 2 PRNs when blood sugar is over 280 then 1 w3 + 2 PRN visits when BS over 280 .
PRN visits can be denied if the order was found invalid/ lacking in specificity. Both the services and the number of PRN visits to be permitted for each type of service must be clearly identified as well as predictable. CMS state that “Open-ended, unqualified PRN visits do not constitute physician orders since neither their nature nor their frequency is specified”.
- PRN orders are acceptable only when the orders are qualified for a specific potential need of the beneficiary and quantified to a specific number of visits to meet this need.
- When a PRN visit is made, the date and reason for the visit should be explained in the medical record.
- When an extra visit is billed and the plan of care contains open ended and/or unqualified PRN orders, an additional physician order must be obtained for the visit. If the agency does not have a signed interim order for the visit, the visit will be denied as in excess of orders.
Example 1: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders “Two (2) PRN visits per month for problems with the Foley catheter including blockage and/or leakage around the catheter.” Visits are allowed because the physician specifically quantified the number of visits and qualified the visits to a specific need.
Example 2: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders include “PRN visits.” In this instance, since the orders are not quantified as to the number of visits or qualified as to a specific potential need of the beneficiary, no PRN visits are allowed.
Well written PRN orders and clear concise documentation supports patient need The orders are acceptable (per CAHABA), if audited, when they are qualified for a specific potential need of the patient with a quantified number of visits to meet this need. Make certain the physician is made aware of PRN visit use, where appropriate. Also, be certain to inform the physician of trends in use of PRN visits which begin to identify a clear need for order frequency modification.