Haydel Consulting Services

Jul 9

Secret Codes

Do you remember hoping for a magical decoder ring at the bottom of a cereal box? I do and to this day, I haven’t found one. The good news is that you don’t need one even though it would be fun.

I have a stack of denials on my desk and nobody was more surprised than me when I realized that the denial reasons were related to the Face-to-Face documentation. The reviewers noted that the visit documentation was within the time frame, signed and dated by the correct provider, but the claim remained denied because the agency plan of care was not related to the reason the patient was receiving services. I hate it when someone goes to the trouble of telling me how close we were but missed by an inch.

Here are some of the reasons given.

Diagnoses from the initial plan of care are static regardless of how long a patient is on service. Well controlled hypertension after a couple of weeks will not get you paid even if it’s your blood pressure that’s high. Be careful not to change diagnoses just to change them. Some diagnoses such as wounds may remain primary.
Similarly, some patients are readmitted after being discharged in the past and the plan of care from the prior admission is pulled up and copied without attention to the coding.
Sometimes, the wrong primary diagnosis is chosen. Remember that nurses do not learn diagnosis coding in school. The tendency is to choose the worst diagnosis suffered by the patient but it may not be the reason the patient is admitted to home health. Consider the patient who is paralyzed and has pressure wounds because they are confined to a wheelchair. Paralysis is a very troublesome condition but you can’t do much about it. Wound care may be a more appropriate diagnosis. Other diagnoses like diabetes and hypertension have so many options that it can be difficult to discern the correct diagnosis as well as the sequence.
Often patients are discharged from the hospital and the reason for the hospitalization is resolved or the physician or biller at a clinic does not code like home health does. Remember that we are instructed that the primary reason for home health must be related to the Face to Face document. The diagnoses need not be identical and often, copying the clinic or hospital diagnoses results in a poorly coded plan of care. Diagnoses like Diabetic Coma in an awake and alert patient are often questioned. In order to ensure that the Face-to-Face document relates to the reason for care, the document must be read thoroughly. Call the MD if there is any doubt if a patient has a certain diagnosis.

Regardless of whether your agency does the coding or it is outsourced, coding is an expense to the agency. Agencies with a corporate entity may decide to have in house coders. Agencies with one or two locations might consider outsourcing coding. Like everyone else, coders go on vacation, get sick and sometimes quit. That usually happens right after you pay for annual training which is necessary for your coders to keep up with changes to the codes. We are happy to help anyone with their coding. We can cover you when your coder gets sick or if you don’t know coding, review your coder’s work to ensure it meets standards. We don’t want you to be denied hard earned money for care given to patients who need it. Call 225-253-4876 or email us.

May 1

2 Comments

Denied?

If you saw the list of UPIC denials a client recently received you’d probably want their license pulled. I would have stopped working for them to be honest if I hadn’t already read the charts.

The first red flag was that there were multiple denials for each chart. The second red flag was that many denials repeated themselves in essentially every claim on the list. There were approximately 60 clinical records and after my initial horror subsided, I started pulling charts one by one.

I know we all forget to add pertinent things to the plan of care from time to time. But did my client neglect to include wound care orders on almost 60 patients? Truthfully they did not include wound care orders on about 45 – 50 patients. But that’s understandable when you consider that these patients did not have wounds. The patients with wounds had orders.

The reviewers recognized the physical limitations of patients who were confined to the home but determined that the patients were not homebound because there was no documentation that it was medically contraindicated for the patient to leave home. Let’s review. The patient has to meet certain criteria to be considered confined to the home. They can be found in section 30.1 of the Medicare Benefit Policy Manual. The patient must meet two criteria. There are two ways to meet Criteria One. The word ‘OR’ in all caps indicates that this is an either/or situation.

The patient must because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence

OR

Have a condition such that leaving his or her home is medically contraindicated.

If they meet Criteria 1, they must also meet criteria 2 which has two components and both of these must be met.

There must exist a normal inability to leave home;

AND

Leaving home must require a considerable and taxing effort.

The patient who relies on a walker with human assistance and is short winded after 10 feet does not need to have documentation that it is medically contraindicated that they leave the home (assuming that they do not leave the home often).

I’d like to assume that you know this but if the contractors who are ensuring your compliance to Medicare coverage regulations don’t know it, I can’t very well expect you to know it.

More than one chart noted that a patient had a caregiver in the Medical Necessity section of the reasons for denial. Please note that the presence of a caregiver does not disqualify a patient from receiving home health services. That would found in section 20.2 of the Medicare Benefit policy manual. If the caregiver is willing and able to meet all the patient needs, then home health would not be necessary. It is rare that a caregiver knows all of the medications, can give injections, perform wound care (if the patient has a wound) and know what out of range parameters need to be reported and to whom they should be reported.

All of the denials included the fact that there was no measurable level of understanding by the patient of teaching. Let’s assume that the caregiver is included. On every single note by the agencies in question, the nurse documented that the patient understood or partially understood the teaching provided. But just for fun, let’s go back to our Medicare Benefit Policy Manual. It lists those services that are usually considered covered and the circumstances under which they are covered. It can be found in section 40.1.2.3 See if you can find anything about documentation of a measurable level of understanding of the patient’s understanding.

Teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family, or caregivers how to manage the treatment regimen would constitute skilled nursing services. Where the teaching or training is reasonable and necessary to the treatment of the illness or injury, skilled nursing visits for teaching would be covered. The test of whether a nursing service is skilled relates to the skill required to teach and not to the nature of what is being taught. Therefore, where skilled nursing services are necessary to teach an unskilled service, the teaching may be covered. Skilled nursing visits for teaching and training activities are reasonable and necessary where the teaching or training is appropriate to the patient’s functional loss, illness, or injury.

Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient’s illness, functional loss, or injury.

In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction. Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered. Where the teaching constitutes reinforcement, an analysis of the patient’s retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits. Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home. Where the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered.

Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient’s condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task. The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education.

I know this is a lot but should your agency ever have records requested, you must be familiar with these (and all) the coverage guidelines. It is reasonable to believe that the contractors are authorities on the coverage guidelines. Although they have made mistakes before and been overly tedious in my opinion, I have never seen such creative writing in denials. Worse, all of the stated reasons for denial should be addressed because the assumption might be that you agree with the reason for denial if you don’t. That’s a lot of time, folks and your deadline is 30 days.

You work hard for your money. More importantly, you work hard for your patients. That’s where your focus needs to be. If anyone else has dealt with a UPIC audit like this, please email or call me at 225-253-4876.