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Proper Coding, Homebound Status, and Awareness of Common Edits: Paid But Will You Retain Your Revenue?

Wednesday, March 2nd, 2011

No matter if your agency deals with an RHHI or a MAC, high risk probes are on the rise. The intermediaries are mandated by CMS to monitor areas of greater risk. When they see trends of concern they will launch probes usually of at least a 100 records of several agencies. Some of these high risk areas include revenue in relation to diagnoses in relation to visits, certain stand alone diagnoses or diagnoses in combination with a certain number of episodes or number of visits.

The OIG has announced that, in 2009 Medicare-Medicaid paid over $54 billion in improper payments. There have been 2500 persons/entities involved from Federal health care programs. There have been 625 criminal actions with 399 civil actions including actions involving the False Claims Act. There are another 2400 investigations pending. The GAO has reported that improper payments due to fraud and abuse are escalating.

Dollars and processes have been approved to target areas of high risk. Monitoring that the principal diagnosis code accurately portrays the patient’s focus of care is a MAC mission. Probe edits are one such process expected by CMS from the MACs to achieve that goal. Monitoring for homebound status is yet another area of focus review.

The Edits

Select Data has routinely made clients aware of edits and areas with insufficient documentation to substantiate proposed diagnosis. Edit 5023T with a second recertification proposed that continues to identify  hypertension as a primary diagnosis and has 5-10 skilled nursing visits is a probe edit risk. This edit holds a 98% risk of denial.

A second recertification of Lymphoma will trigger a long used edit.

A second recertification of Cardiomyopathy NEC will also trigger an edit.

Recertifications with a primary diagnosis of diabetes and a secondary diagnosis of CHF will be monitored if the edit continues after each MAC quarterly review. Because the FIs have found merit, this edit has continued for years.

Other Edits include:

Recertifications with a primary diagnosis of Alzheimer’s Disease.

Recertifications with a primary diagnosis of Schizophrenic Disorders.

Recertifications with daily skilled nursing visits yet no therapy ordered.

Recertifications with a primary diagnosis of Long term Use of Anticoagulants and no therapy ordered.

Claim Denial Potential

The above diagnoses run a great risk for denial because of probe edits and recertification. If the file is pulled and  there is not “clear documentation that it is with considerable and taxing effort for the beneficiary to leave home, the episode or specific visits could be denied for lack of homebound status.  (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 requires rest period.”

See: The Home Health Industry and Insufficient Documentation/Medical Necessity: Meeting the Challenges of Quality Care and the RACs, MACs, and ZPICs etc at the Select Data Website (Part 1).

Claims can be denied if skilled nursing care is not intermittent,

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.”

Common documentation deficiency areas include lack of progress:

¡  Repetitive clinical notes are frequently seen stating the same things over and over with no progress 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.

¡  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 casemix 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, note if:

¡  There is significant change in meds, treatments, or conditions

¡  There is teaching and training needed

¡  The condition or disease symptomology 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.

¡  Teaching on new medications must include instruction or intervention on the related diagnosis.

The clinician providing injections such as insulin, require specific documentation to support the need; specifically why the patient cannot self inject the med such as tremors, impaired cognitive function, or no willing and capable caregiver.

One of the most common home health reasons for denial is that the documentation does not support medical necessity.

Therapy is under scrutiny

Functional ability improvement is expected or why is therapy present?

Therapy may be covered if the patient or caregiver receives teaching that is  reasonable and necessary.

In 2008, claims chosen with 10-11 therapy visits and discharge in episode two had a 74% rate of denial essentially due to poor or insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment. The 2011 changes are rigorous and denials are imminent if documentation is insufficient.

The therapy treatment plan must:

¡  Relate to the exact diagnosis that has required therapy intervention.

¡  Identify visit frequency and duration.

¡  Identify the present and prior functional level.

¡  State specifically the procedures, treatments, and/or exercises to be performed.

¡  Clearly list the reasonable and measureable goals to be achieved.

¡  Care must be specific, safe, and effective supported by the diagnoses according to accepted practice.

¡  Specify the rehab potential.

¡  Specify the discharge plan.

Additional Ways to Decrease Risk

Adequate documentation begins with the correct diagnosis and being alert for edits. Besides agency PI projects, consider professional coding teams to decrease risk. Third party coding and auditing can provide the buffer needed to diminish risk and increase compliance. It is hard for one or two or a few in-house coders to not only keep up with the average 350 coding changes each year, but to also locate the ever changing edits of each FI. The edits are usually disclosed AFTER the MAC probe results. At Select Data, we monitor the FI sites, newsletters, and alerts to dig for present edits.

Agencies need to be aware the edits will increase over the next two years as CMS, the RACs, the MACs, and the Z-PICs ready for ICD-10 and the move from the present 17,000 codes to over 155, 000 codes or a 900% increase in codes. Will there be a 900% increase in edits also? Will there be a 900% increase in claim denials? Let us hope not.

Protecting justly due reimbursement starts with proper data gathering, coding to the highest level of specificity with sufficient documentation, and somebody looking out for the edits.

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Coding Whitepaper

Monday, January 31st, 2011

“Industry Changes are Driving Increased Coding and Financial Complexity.”

Every home health agency wants their deserved reimbursement for the care delivered to their patient and just as importantly, they want to retain that revenue. A good start toward achieving that goal is having coding team expertise.

According to one source, the average loss on a miscoded record is hovering around $1200+. The reasons for the errors vary; experience of the coding team, training level, maintaining competency and adherence to coding guidelines and conventions with the hundreds of changes that occur annually and not to mention the over 100,000 changes coming with ICD-10. A coding team needs to be dedicated to just that: coding, not other distracting duties. The team needs coders and clinicians so the full prospective of the patient portrait is accurately presented and the proper codes are compliantly assigned.

With tighter reimbursement, outcomes affecting future reimbursement, and coding driving certain audit alerts, coding is the area that requires emphasis.

Select Data has written a white paper on this subject. Looking at industry complexity and how coding importance came to the forefront to identifying the relationship of case-mix profile and case-mix adjustment models to coding. In addition, understanding the components of the HIPPS Codes as well as how supplies must link to diagnostic codes is included.

Success in this industry usually means the home health leaders have a good understanding of why the change in CMS focus as well as what is expected from that focus. Included in this white paper, you will also find the documentation requirements for coding in general as well as examples of the therapy risk areas. Documentation must be objective and specific. Just what does that mean? Clear examples are presented.

Being alert for “alerts.” Do you know what MAC alert 5023T means? You need this kind of information from your coding team.

The value of compliant coding is proper payment and peace of mind. This is not a trite statement. It is a desire of agency leaders who are working diligently to comply with quality parameters, best practices, and regulatory statutes and law.

To read the full white paper, please go to: Coding Whitepaper PDF

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CODING 2011: ICD-10-CM and Other Deadlines Looming

Monday, January 24th, 2011

Agency leaders know that now more than ever, coding is driving reimbursement. Agency leaders want appropriate payment and compliance. Besides coding itself, and CY 2011 changes, agency leaders need to be aware that other dates are looming in this area that can impact upon an agency’s success.

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 7th 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?

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Part 3; RACs, MACs, Z-PICs

Tuesday, August 24th, 2010

Part 3 of 3 on RACs, MACs, Z-PICs:
The Home Health Industry and Insufficient Documentation for Medical Necessity and ICD-9 Coding.

Therapy and Home Health ICD-9 Coding and Supportive Services…
The therapy treatment plan must:

  • Relate to the exact diagnosis that has required therapy intervention
  • Identify visit frequency and duration
  • Identify the present and prior functional level
  • State specifically the procedures, treatments, and/or exercises to be performed
  • Clearly list the reasonable goals to be achieved
  • Specify the rehab potential
  • Specify the discharge plan in clear, easy to understand goals and plan.

In 2008, claims chosen with 10-11 therapy visits and discharge in episode two had a 74% rate of denial essentially due to poor or insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment.
NOTE: Do not use V57.1 Physical Therapy if SN is also involved with the care. (CMS OFFICIAL CODING GUIDELINES 2009).

  • If 781.2 Abnormality of Gait is used to justify PT care, PT needs specific documentation and objective testing to support gait and balance and strength e.g. TUG or Tinetti Test Tools.
  • Gait training should be specific with objective measurement progress.
  • The gait should be described specifically and graphically; ataxic, spastic, staggers with increase in ambulation of ___feet this day. Lack of complete documentation means payment denial risks will increase.
  • If 719.7- Difficulty in walking is coded, the therapist should be clear that this is due to e.g. degenerative and chronic joint disease.
  • Use for e.g. gait deficiencies due to lower extremity joint stiffness or effusion.
  • If muscle weakness 728.87 is coded, there should be manual muscle tests indicating weakness.
  • The therapeutic plan should have specific exercises and goals related to the weakness.

NOTE: Absence of a specific exercise plan can jeopardize visit payments.

  • The OT evaluation and documentation should reflect prior and present level with realistic goals.
  • If PT is also involved with care the OT should clearly delineate a plan that justifies the OT intervention.

NOTE: Have objective tests with clearly defined short and long term goals that are measureable and can be achieved within a realistic time point with direct relationship to the specified diagnoses.
Medical necessity must be evidenced EVERY visit. Document progress towards goals every visit is vital and must be stressed to therapists.
NOTE: There is a high incidence of visit denials when both PT and OT are providing care.
Of the ADRs selected, 1 SN and 4 OT visits have a denial rate of 71% essentially, because OT is not an initial qualifying skilled service.

The Plan and Supportive Services:

  • Medical Social Services can be added when skilled services are in place.
  • Covered services include:
  • Assessment of financial situation, community services available, personal/family social factors, and the potential for counseling
  • Patient risk areas must be clearly identified. Remember that assisting a patient to apply for Medicaid services is not an MSS skilled service.

NOTE: If a patient has a LUPA, 5 visits or less, and 1 visit is a MSW, the denial rate, as of 2008 data, was 67%.
Medical Social Services have non covered services that, if required, may be performed along with a covered service.
Non-covered services include:

  • Assistance with Living Wills and Advance Directives
  • Assistance with Medicaid Applications and Meals on Wheels
  • MSS is a service requiring a physician’s approval and the MSS may not be the only home health service being provided to a service. A qualifying service must also be providing care to the patient.

The Home Health Aide…
This service is provided by the least skilled individual and requires the most specific supervision as defined by CMS.
Home Health Aide Services are supportive and under the supervision of an RN, if multidiscipline case. If therapy only, the therapist may supervise the home health aide.
Supervision must be in the patient’s residence but the home health aide need not be present at the same time as the clinician performing the supervision.

Endpoint criteria to daily visits …

  • When skilled nursing visits are ordered daily, there must be a , “finite and predictable endpoint to daily skilled nursing visits.” It can be listed in days, weeks, months, or have a specific date.

The visit documentation must substantiate the skill and substantiate the endpoint. The Medicare Home Health Benefit was not established to provide daily skilled visits but rather, to provide intermittent skilled nursing services. CMS states that, “The one and only exception to this rule is a patient who requires and qualifies for skilled nursing services to perform daily insulin injections.” Remember, that because of the abuse of daily insulin injections they have a high likelihood of ADR review.

The Plan of Care:

  • The Plan of Care must be signed PRIOR to submission of the submission of the claim
  • A date stamp in Box #25 should be present when the Plan of Care is received
  • The POC must be supported by the clinician visits with a final claim.

There must be congruence between the OASIS 6 coding spaces: POC/485: 9 spaces+ E code on the UB-04 claim.

  • From the 6 lines of M1020 and M1022, CMS makes a payment decision.
  • Agencies should review progress notes and case management coordination to the POC.
  • Documentation should support the codes which are sequenced on the OASIS and POC.

NOTE: Clinicians should learn to establish an audit trail on the way toward expected patient outcomes.
ICD 9 Coding has become very important in home health. References include:

  • Official Coding Sources:
  • -The annually published CMS ICD-9-CM Coding Guidelines
  • -The Coding Clinic
  • Allowable Coding Sources:
  • -OASIS Chapter 3
  • -Appendix D to Chapter 3
  • -OASIS Q&As published quarterly by CMS
  • Promoting accurate coding selection in M1020, M1022, and M1024 requires:
  • Compliance with provisions of HIPAA, Title II.
  • Compliance with refinements to the PPS Grouper effective January, 2008.

Compliance with Section 1862 (a)(1)(A) of the Social Security Act to ensure payment is reasonable and necessary can be monitored with internal audits. Deal with an expert coding firm that places high regard on compliance for your peace of mind.

  • Diagnoses must comply with specific criteria to qualify as a primary or secondary diagnosis:
  • -Code by adhering to ICD-9-CM coding Guidelines
  • http://www.cdc.gov/nchs/icd.htm
  • -Code only relevant medical diagnoses
  • -Code only diagnoses supported by OASIS, POC, and clinician documentation

The 2011 changes in coding effective October 1, 2010 have become increasingly specific, preparing for the transition to ICD-10 Coding. It will be at that time when home health moves from 17,000 codes to more than 87,000 codes. It is only increasing in complexity and financial risk.

  • List diagnoses in the order that best reflects the seriousness of each condition and supports the disciplines and services provided.

SOURCE: Official CMS I-CD-9-CM Coding Guidelines

  • Assess the degree of symptom control in relation to identified signs and symptoms, medication profile review, frequency and duration, as well as care plan and treatments.
  • Clarify which diagnoses and symptoms have been controlled in the past.

The primary diagnosis should be the key reason for the POC and the most intensive service. CMS has noticed an increase in incongruence between primary diagnosis and actual plan of care and resulting visits. Do your agency visits support the patient POC? Are diagnoses truly reflective of patient condition at assessments?

The secondary diagnoses should coexist at the time the POC was established.
Agencies must be careful to use approved co-morbid diagnoses that could affect the plan of care even if that diagnosis is not a focus of care. Agencies should strive to have the diagnoses and codes describe the care to be provided in a specific episode. Approved co-morbidity diagnoses should be listed if the patient has one of the diagnoses, as it is believed that these approved co-morbidities will impact care.

There are diagnoses that can cause specific alerts.

  • These codes require VERY specific plans of care to substantiate need as they are case mix diagnoses. Once named case mix, these diagnoses were more frequently used by agencies and are now closely reviewed by CMS. They include:
  • -Low Vision
  • -GERD
  • -Depression
  • -HTN as a non SOC primary diagnosis
  • -Alzheimer’s (primary non SOC).

The wisdom of the home health clinician and the ability to use critically reflective thinking is essential.

  • Acute care coding is retrospective.
  • Home Health coding is prospective.
  • The diagnoses on the OASIS must match the POC/485 and the UB04

Clinicians must be certain the POC (primary/secondary diagnoses) and the discipline specific care plan are substantiated by each visit note and that each visit can withstand scrutiny on its own.

  • Documentation to substantiate coding and care have become critical to agency providers.
  • Documentation has become the key communication tool for care.
  • Documentation has become the first and last line of defense with the scrutiny of the industry auditors.
  • Documentation provides the demonstration of the skills of the clinician and justifies the retention of the agency payment received.

Truly, it is the critical thinking assessment and planning skills of the front line that will determine an agency’s bottom line. As we all know, it is easy to file a claim and be paid prospectively in home health. It is becoming more difficult to keep that payment, especially if fine skilled clinicians do not chart with the same fine skill.

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Part 2; RACs, MACs, Z-PICs

Monday, August 23rd, 2010

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.

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