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Posts from the ‘The 2012 Agency’ Category

May 1

Thanks AdvanceMed!

Still working a ZPIC so I am short on time to keep you up to speed.  Luckily, AdvanceMed has done most of my blogging for me tonight.  On a spreadsheet from the Zone, there is a column for the reasons for denial.  Below are some examples.  Read your charts and see if maybe one or more claims could be denied for the same reason.  If the answer is yes, it isn’t too late to do something about it.  Call us!

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The nurse continued to visit for observation and assessment when there were no acute changes in condition and no changes in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. There had been adequate time since start of care of XXXXX to have completed teaching in previous episodes. The medications:  glimeperide, quinapril, atenol, and aspirin are indicated as new on the 485; however, there is no skilled service documented related to these medications.

The documentation provided does not support that skilled nurse visits are reasonable and necessary. The SN continued to visit for observation and assessment when there was no acute change in condition, no new orders, or change in the plan of care. There has been sufficient time since the start of care of xxxx to complete the teaching that was provided in this episode. The documentation provided does not support an exacerbation of the diagnoses as indicated per the 485. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation provided does not support an exacerbation of the diagnoses.

The skilled nurse continued to visit for observation and assessment of patient’s condition when there was no acute change in condition, and no new orders or change in the treatment plan. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation does not indicate that there is likelihood of a change in patient’s condition that requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures. The records provided do not support an exacerbation of the diagnoses as noted on the 485, or a severity rating of 4 for the arthropathy diagnosis. There has been sufficient time since start of care date of xxxxx to complete teaching.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. Sufficient time has been allowed to accomplish teaching in previous episodes since the start of care date of xxxx. The nurse provided teaching related to a medication that was not new or changed. The nurse continued to provide observation and assessment when there were no new orders or change in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The skilled nurse provided teaching on hypertension, fall precautions, range of motion exercises to help joint pain and relieve pressure on bony areas, low sodium diet, taking all meds as ordered, and ways to keep BP down. There has been sufficient time since start of care of xxxx in which to have completed this teaching.

So, there you have it.  What you are looking at represents about 2M dollars in denials.

Questions?

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Mar 22

1 Comment

ADR Checklist

Prissy the Pit Bull available at no charge to review your records. We guarantee they will not be denied for lack of signature. We do not guarantee they will be paid.

Make no mistake that what I am about to say is shameless self promotion.  The safest way to ensure that any medical records requested by a payor source meet standards are to have them reviewed by someone with experience and who does not know the patients or the agency.  This doesn’t always ensure payment but it can alert you to your vulnerabilities so that you can make a plan before the next dance with your MAC.

Short of the the level of security offered by Haydel Consulting Services, you can do your own reviews.  More important than the actual content of the review is the attitude of the person doing the review.  Attacking the charts like a rabid Pit Bull will ensure that most errors are identified but Pit Bulls do not implement action plans.  Your reviewer needs to be cognizant of the fact that any errors or omissions identified are  tools to help cover their coworkers back and they need to be willing to help out their colleagues.  If they can be ethically corrected, they should be.  If they cannot, a team with members from every part of the organization needs to implement a plan to prevent repeat errors.

Here is what I look for:

  1. Orders signed and dated by physician.
  2. Face to face in all charts.
  3. Medications
  4. Diagnoses – note meds came first.  Are there any meds for dx’s not listed.
  5. Frequency – does it correspond to the patients’ needs?
  6. Functional status – if the patient is minimally impaired in the functional domain, are they homebound for psychiatric reasons?
  7. Is teaching original and relevant?
  8. If re-teaching is present, is the reason why re-teaching was necessary explained?
  9. Does teaching require the skills of a nurse?  It does not require the skills of a licensed nurse to tell a patient to take medications timely.
  10. ARE THERE ORDERS FOR THERAPY?
  11. Are therapy re-evals done on schedule?
  12. Is there any lab or other diagnostic tests that support care for the patient even if they were performed in a prior episode?
  13. If subcutaneous injections are given, is there a reason why the patient cannot be taught?
  14. Is there a documented predictable end to daily skilled visits when daily nursing visits exceed 21 days?
  15. If the patient is seen for Management and Evaluation, is an RN performing the visit?
  16. If Observation and Assessment is documented as a skill, are there any clear indications that the patient is likely to become unstable?
  17. Are patient and clinician signatures consistent throughout the record?
  18. Are there any hospital or MD reports that will support services?
  19. Does the clinical note contents support OASIS?
  20. Is the primary diagnosis the focus of care?

Notice again that two questions that are critical to payment are asked last.  It is only after reading the entire episode that you can truly answer these questions.

There are so many other important elements in a chart that are required in order to reflect good clinical care.  This is a payment review only.  So, if the patient had 12 nursing visits scheduled and two were missed, that will not affect payment but I want to go on record as saying that it is unacceptable to find out about two missed visits on ADR review.

If you find egregious mistakes that cannot be ethically corrected, back out the claim.  For instance, if there were no therapy orders after the initial order to evaluate and treat, back out the claim and resubmit it less the therapy.  Print all paperwork and send it with the ADR.  This will not prevent a denial but you won’t look stupid either.  After that, find the therapist culprit and violate your work place violence policy.

I am very interested in knowing who is getting denied for what.   Please email me privately if you have the goods.

And if you are not pleased with what you are finding, do not hesitate to call us.

Mar 14

1 Comment

OIG Reports 22% of Home Health Claims In Error

 

No time to blog today.  Luckily the OIG has written more than enough. 

One in five claims? 

Wow.

Feb 28

2 Comments

Homebound Status

Last week, I posted about two patients who were driving but otherwise met the homebound criteria.  Your responses impressed me.  Above all, I was glad to see very few cut and dry answers and responses both sides of the fence were very convincing.   The best part was that it occurred to me that if you put that much thought into the answers, then maybe I wasn’t insane after all.

In order to be completely objective about it, I had to return to Chapter 7 of the Medicare Benefits Manual and review these patients compared to Medicare’s definition of Homebound.  Here’s the heart of the matter cut and pasted  from the manual but divided into two parts:

  1. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
  2. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.

So, both patients meet the first criterion.  It is a considerable and taxing effort to leave the home.  In fact, I meet that criterion.  I live on the third floor and at least twice I week I forget something upstairs.

One patient definitely does not meet the second criterion.  Parking at the lake does is not how the patient receives healthcare or treatment and apparently this occurs ‘regularly’.

Based on the information I posted which is all I have, we cannot tell how often patient number two leaves the home.

The regs specifically address non-medical absences later in the section.  Again, this is cut and pasted directly from the manual:

However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.

Now, go read it again.  How often is occasional?  What is meant by ‘relatively short duration’ and ‘infrequent’.  Steven Wright illustrates relativity even better than Einstein when he says that everywhere is within walking distance if you have the time.

Since Medicare offers no further clarification of these definitions, we have no choice but to use the most conservative definitions and therefore, neither of these patients are confined to the home.  I was so happy with my readers that none of you were happy with just stating that they weren’t homebound.  Neither am I.

My suggestion to my client with patient number 1 was that they go out and assess him and explain to him why he should not be cooped up in a car for hours at a time.  Homebound status is the least of my concerns at the point of referral.  That would come in later after I assessed his risk of blood clots, ulcers, etc. from immobility.  If he was willing, my client through diligent nursing care and therapy could restore his functionality to the point that it would be safe again in the future.  If he was willing to comply with a treatment plan that included diet and weight loss, he could improve his life to a level he had not experienced in years.  These things are not known prior to assessment.  In fact, it is often the non-verbal language that clues us into the sincerity of the patients’ desire to comply with a care plan.

The report I received on the second patient is that he had dementia.  Dementia as a diagnosis used on home health plans of care is very poorly defined in my opinion.  Patients with early memory loss who end up on Namenda with no diagnosis of Alzheimer’s are often put into the broad category of ‘dementia’.  Dementia can mean mild confusion at times or flat out psychosis.  Furthermore, patients will often come out of the hospital with a diagnosis of Dementia that is carried over to the home health chart.  Often times, quite sane people lose it considerably in the hospital due to drugs, illness, unfamiliar environment, etc.  and get right in the head again once home. (I am re-reading this before posting.  My first inclination was to find clinical terms to replace ‘lose it considerably’ and ‘get right in the head’ but those of you who live in other states will need to know these terms should you ever decide to work in the South.)

Pretty much everyone was on target with their responses.   If the patient only has mild memory loss, he may be able to drive but will get lost and end up on Crack Alley negotiating deals for those pretty little rocks.  If he is beyond mild dementia, the police or elderly protective need to be contacted immediately.  My experience with Elderly Protective Services or whatever they are called in your community is that their scope of usefulness varies widely between communities so choose carefully.

Sadly, sometimes we are best suited to be the bad guy.  The kindest thing to do may involve being the one who is willing to go toe to toe with a patient until they surrender their car keys.  I mean that figuratively, by the way.  There are laws against assaulting patients.  We cannot take keys from patients or steal them but we can be the ones who tell the patient that we are by law obligated to report dangerous situations.  We can notify the physician and even help him draft a letter to the Department of Motor Vehicles.  Remember, the life you save may be your child’s.  And even though it is no fun, it really is okay if the occasional patient doesn’t like you because truly caring for them means making them angry.

This is what upset me and why I asked the question of you.  These two patients were referred to two separate clients in two different communities 200 miles apart.  In both instances, other agencies had refused these patients due to the fact that they were driving.

I am not at all impressed with those agencies.  Either they are much better than us in their assessment skills because they were able to make that determination without seeing the patient or they were not able to think critically and assess patients as individuals.  In nursing, there are very few black and white decisions.  Our patients are people and they are all unique and deserve consideration in these grey areas.  Even if an admit isn’t forthcoming after the initial assessment, as nurses we should look at all the assessment data and determine what is best for the patient.   If they turn out not to qualify for Medicare home health, perhaps we could find an alternative.  And no.  Medicare doesn’t pay for that but that doesn’t mean we don’t benefit from taking care of our elderly.

And so on……

Feb 17

20 Comments

Foot Assessment Tutorial

It is not my style to knock the advice given by the American Diabetic Association, Podiatrists, the Lower Extremity Amputation Prevention Program or all of those other so-called experts who teach foot exams.  I certainly buy into their position that assessing feet is important for so many reasons but I find that their instructions are incomplete.  In response, Haydel Consulting Services, LLC has stepped up to the plate to provide you with the missing pieces for a complete foot exam.  Pay close attention.  The skills you learn could save a limb or a life.

  1. Start with a foot encased in a shoe and sock.  Take a look at the shoe to make sure it is appropriate for the patient and fits well.  High heels, flip flops and all the other really cool kinds of shoes are not appropriate for many of our elderly patients.  No matter how ugly the shoe is, do not criticize the patient’s choice of footwear if the shoes meet the above criteria.
  2. Untie the shoe.  This may add some time to your visit but it will definitely make it easier to complete the following steps.
  3. Gently ease the shoe off the foot.  Do not pull, tug or otherwise force the shoe off to prevent the foot from coming off with the shoe.
  4. Inch the sock down from the top towards the toes until the entire foot is visible.  DO NOT ATTEMPT STEP 4 UNTIL STEPS 1 – 3 ARE COMPLETE.
  5. Attentively assess the foot according to the incomplete guidelines published by above referenced agencies.  Notice how the nurse in this photo (Susie Soskin, RN) is at eye level with the foot.  If you cannot get down to eye level, find someone who can or get the patient to lay down in the bed.  If your knees are too old to bend down then chances are your vision is not good enough to assess feet from a distance.
  6. These are perfect feet.  I know this because they belong to my son.  I have bought hundreds of shoes for these size elevens.  At the cash register, I have often been a bit overwhelmed at the cost of keeping him in shoes.  After taking care of a few amputees, I am honored to have had the privilege to buy full pairs of shoes for him.  I hope when I am dead and gone, he still has to pay for a full pair.

A high resolution copy of the above tutorial is available by clicking here.  Please feel free to print it, share it or ignore it.  And yes, I know the vast majority of us do take shoes and socks off every visit and look at diabetic feet.  This is good but diabetics are not the only patients who benefit from foot assessments.  Patients with heart failure or take diuretics will show signs of fluid build up in their feet, compromised circulation from cardiovascular or other disease can result in discoloration or stasis ulcers and injuries to the feet can be overlooked by any patient with loss of sensation or callused skin.

So, if this helps you to remember, all is well.  If you don’t need reminding, kudos to you.  If you think that one of your nurses or coworkers is not taking the time to do a complete foot assessment, draw a happy face on the bottom of the foot and see what shows  up in the documentation:)

As always, questions and comments are welcome below or via email.  As so on…..

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