Part 2; RACs, MACs, Z-PICs
Part 2 of 3 on RACs, MACs, Z-PICs:
The Home Health Industry and Insufficient Documentation for Medical Necessity and ICD-9 Coding.
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.
Tags: CMS, Home Health, ICD-9CM Coding, MACs, Medicare Reimbursement, RACs, Z-PICs
Thank you for the short, sweet and concise information!
Hi. Great at a glance too. Do you have a more detailed reference to the “skill” teaching? I would like to find a place where I can get case studies of patients who might require extensive teaching (specific cardiac) over a long period of time and what the notes should indicate to support ongoing nursing visits. This has been quite the controversy in our office. Thanks!
Hi Linda and Merridee, Thanks for the comments re the RACs, MACs, Z-PICs etal… I am seeing an increasing amount of literature on the subject of heart failure and patient control symptoms in the home because, of course, CMS is adding focus. Best practices are becoming important in providing quality home care.
I am presently researching a blog post and my sources include the American College of Cardiology and the American Heart Association. You may wish to visit their sites. Evidenced-Based Standards for Heart Failure Care include: B/P standing/sitting, heart and lung sounds assessed, HR, RR, and Jugular venous distention (JVD) every visit by clinician, daily weights by pt, pt taught to assess for abdominal and peripheral edema daily.
Patients are usually taught re diet (is patient on a low fat, low sodium diet). Do they have impacting co-morbidities such as Diabetes? Do they smoke? Do they have a physician approved aerobic exercise program (brisk walking) or regular walking program approved by their physician?
Though I have not read the book, I have heard positive comments re a new book “Best Practices for Heart Failure Interventions”. The author is Laurie Salmons, BSN, RN
I hope this assists you. Please let me know. Thanks, Susan
Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality
Executive Vice President, Quality and Standards
Chief Compliance Officer
Select Data
4155 E. La Palma Ave
Suite 250
Anaheim, CA 92807
714.524.2500 x235
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