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47 Days


Every quarter, Palmetto GBA publishes the top reasons for denial and ways to prevent denials on their website. This is their advice about Face-to-Face Encounter documentation which is the second most frequent reason for denial after non-submission of records.

The face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.

Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

  • The certifying physician must document that he/she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter
  • The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services
  • The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification
  • The certifying physician may dictate the face-to-face encounter documentation content to one of the physician’s support personnel to type. The documentation may also be generated from a physician’s electronic health record.

On November 1, I contacted Palmetto GBA through their website. I prefer written responses I can refer to in the future. As a consultant, I find it useful to give clients accurate advice that I can back up with references.  That kind of attention to detail gets me paid.  Specifically, I wrote:

Please review the information provided under the list of April – June HH Medical Review Top Denial Codes. Your advice states that a narrative is still warranted and says nothing about supplemental documentation. When clicking on the link to ‘General Medical Review’, it provides pre-2015 instructions. And the third link is blog post by Dr. Feliciano with a 2013 date. The first link does go to the current manual but it conflicts with the information you are providing. Since providers are being denied at an alarming rate for F2F, it is abundantly clear that correct information be Provided.

Yesterday marked 47 days after my initial email. I received the following email from Palmetto:

Thank you for your e-mail received on November 01, 2018. You wrote to us regarding F2F information. You indicated there was some conflicting information in the April – June 2018 Home Health Medical Review Top Denial Reason Codes article.

Thank you for your information. We have submitted the information you provided to the Provider Outreach and Education Department for them to review the information provided.

By way of reference, e-mails are answered within 45 business days. Anytime you need immediate assistance, please call us at the telephone number listed below so that a representative can assist you with your questions quickly. You may also use our secure eChat feature that is available on our website at www.PalmettoGBA.com/hhh.

As a Medicare contractor, it is Palmetto GBA’s goal to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service. For claim status and eligibility or to speak to a Customer Service Advocate (CSA) about more complex issues, please call 1-855-696-0705. You may also visit the Palmetto GBA eServices to view claim status and eligibility at htps://www.onlineproviderservices.com/ecx_improvev2/. For up to date Medicare news and policy information, please visit our website at http://www.palmettogba.com/Medicare. Medicare beneficiaries should contact 1-800-MEDICARE (1-800-633-4227) for assistance.

I have so many problems with this email that if they were lined up they would reach the moon. Nevermind that. Let’s get you paid.

Know that if you follow the information on Palmetto GBA’s webpage about denials, your claim will be denied because four years ago, the Face-to-Face encounter documentation guidelines changed. The Medicare Benefit Policy Manual, chapter seven, section 30.5.1.2 instructs providers:

As of January 1, 2015, documentation in the certifying physician’s medical records and/or the acute /post-acute care facility’s medical records (if the patient was directly admitted to home health) will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined.

This does not mean that you may not use a traditional F2F form or attestation statement and the physician can write as much as he or she wants as a narrative, but even if it is perfect, your claim will not payable unless you also submit the physician or hospital documentation. Furthermore, the dates must match. If the physician inadvertently dates the form on the day he signs it instead of the date of the encounter, the documentation will be invalid. The physician names must match, too. If a qualified practitioner other than the certifying physician performs the encounter and prepares the documentation, the certifying physician should sign or initial the documentation to demonstrate that the information was communicated to him or her.  (A link to the manual follows this post with complete instructions.)

I see nothing in Palmetto GBA’s instructions about hospital documentation.  I see nothing in the coverage manual about a narrative.  

I do not feel good about pointing out Palmetto GBA’s lack of response to what I believe to be a legitimate concern on the internet.  Then again, I absolutely hate to see claims for excellent care provided by eligible beneficiaries denied because of stupid stuff. When agencies are taught stupid stuff by the contractors responsible for paying their claims, I get angry. Worse is when contractors are contacted and they take 47 days to say they are passing on my question to a different department. It took 47 days to forward an email? All of that kind of negates the claim that Palmetto GBA’s goal is to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service.  Have Mercy!

For complete instructions regarding the Medicare requirements for documentation of the face-to-face encounter, go to section 30.1 in the coverage manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf.  If you are new to home health, take a minute and familiarize yourself with sections 20, 30, and 40.

Documentation Bloopers


I have an old file of documentation that I have saved especially for you.  These examples are many years old and I have taken great care not to disclose the agency or individuals responsible for this documentation.  Note that these are not my regular clients and I was hired to read the charts after the agency was called upon to submit charts for a ZPIC.  Also, the agencies from which this documentation originated are no longer with us and many of the nurses no longer have licenses.  They were not victims of an overarching regulatory body.  They were victims of themselves.

You may have questions about the clinicians who wrote these notes as I do.  More importantly, where were the checks and balances that ensured that the care was delivered to the patients was sound and documented appropriately?  I could comment and question indefinitely, but you’ll probably see the same thing.

1.       SN instruction given on measures to control hypertension check your blood sugar at least once a day and exercise to lower your blood sugar unless you are sick or have a blood sugar over 240 mg to prevent further complications.

The instruction to control hypertension may include checking blood sugars if the patient has diabetes.  The patient did not.  Exercising once a day may be out of range for most home health patients.

2.       SN assessed all body systems. VSS.  Pt c/o weakness, states I hurt all over.  No meds taken for pain.  SN instructed on factors that increase risk for HTN:  high na+ intake, high cholesterol intake, obesity & sedentary life-style.  Pt verbalized understanding.

This nurse at least tried to follow the care plan.  Could this be the result of a manager demanding that nurses follow care plans?

3.       Instructed if you have any problems with this med go back to ER because we don’t have an order from Dr.

Really?  I wonder if the Doctor had a phone number the nurse could use.

4.       Vitamin A and D ointment topical 1 PO for 7 days.

Sadly, this was repeated over 7 episodes.  Sometimes, it is easy to determine who is reconciling meds on a per visit or per episode basis.

5.       Pt awake and alert but forgetful sitting up in recliner with legs hanging.  Edema noted to BLE.  Slow ambulation assessed.  SN instructed pt to be aware of possible complications of osteoarthritis; Gastrointestinal bleed and stress ulcers.

At first I thought that one little word was missing as in ‘…. be aware of possible complications of osteoarthritis meds….’  A closer look at the chart showed no NSAIDs or arthritis meds.  Still, maybe she took ibuprofen by the boatload and the nurse didn’t deem it important to add over-the-counter meds.

6.       SN assessed all body systems.  VSS.  Denies any discomforts at this time.  SN instructed in possible complications of HTN:  kidney failure, stroke & heart disease.

This patient was on dialysis and had coronary bypass surgery but apparently the nurse was directed to teach only from agency approved teaching guides.  Note that there was no action for the patient to take.  The nurse went into the home and told the patient all the ways he could die and then left.

7.       SN assessed all body systems.  VSS.  SN instructed patient if any problems occur to call 911 or go to ER. Patient verbalized understanding.

Why even bother to send a nurse between ER visits?

8.      Pt is very anxious.  His hands shake – stated he has got to see paleontologist[i] next week.  Client exhibits severe knowledge deficit regarding his disease process and TX regimen.  He is very forgetful and depends heavily on caregiver to assist with his care.  He is highly potential for acute complications of his disease process.  SN to monitor closely and intervene as needed.

Besides the amusement factor of a patient visiting a paleontologist, this was found on four care plan summaries in a row.  With spell check and predictive text, etc., errors happen.  They are corrected when in an agency with checks and balances.

These agencies have other things in common.  Most are making less money than if they hired a couple of extra nurses and employed managers who did not overload their nurses.  Their billing was perpetually late and mistakes in billing were not addressed.   There was a culture of blame instead of support and compliance.  They are owned by people blinded by greed.

I like making money.  I’m sure that you do, too.  We are so lucky to earn our living in an industry that allows elderly patients to remain in their homes and our take-home pay is so much more than a check.  Meanwhile, remember that the real reason for documenting is so that the nurses, therapists and physicians who take care of the patient after you do have access to a true and complete account of the care the patient has received.

Oh, and a Lamborghini has never made anyone’s life better unless they were an Italian race car driver.
[i] I hope nobody was insulted because I linked to the definition of ‘paleontologist’ but I had to look it up the first time I saw it just to make sure I wasn’t slipped LSD.  The definition did not reassure me.  At all.

Five Steps to Improved Documentation


 

Paperwork is part of the job. Next to patient care, it is the most important part of your job. Wouldn’t it be nice to see your patients and document well in time to don your pearls and cook dinner for your family? Or maybe you just want a cocktail or two while you watch the evening news. Pretty much nobody wants to stay up until midnight documenting so that they can be paid on time.

  1. Turn off the Cut and Paste function. There are some clinicians who should have a neon sign on their forehead reading, ‘I document. Therefore I clone.’ Turn it off. If you survived nursing school or have an advanced degree in therapy, it stands to reason that you can compose an original note without copying the prior note.
  2. Write plans of care that address the patient’s issues. No more. No less. If there are two or three pages of orders, the important stuff will be buried in the minutia.
  3. Read the care plan. That sounds obvious but nurses cannot read care plans if they aren’t present and in the chart. This should be a priority and nurses should refuse to see the patient if they do not have one. At the very least, a verbal report from the admitting or recertifying nurse should be given and documented. It is easy to lower the bar on this but very difficult to raise it. But we are nurses. We do difficult things and we need care plans.
  4. Payment is often in the details. If you are not in a position to document in the house, keep a pocket sized notebook with you and write vitals and what was taught.
    1. Weights
    2. Blood pressures
    3. Pain
    4. Heart rate
    5. MD visits
    6. Medications
    7. MD and hospital documentation
  5. Teach only useful information that your patient can understand. The internet has no shortage of teaching guides available from the web. Look for teaching guides that have been published by reputable organizations such as the American Diabetes Association, the CDC, the National Institute of Health and University hospitals. That way, if the information is bad, you can at least credit a reputable source. Upload this information into the computer in the patient’s electronic record. Then you can chart, ‘reviewed pages 1 – 4 of DM teaching guide and taught page 5’. And remember that teaching guides should vary according to the patient’s needs.
  6. Complete a short pre-visit checklist the day before your visit that includes calling your patient to confirm the visit, ensuring that appropriate teaching guides are uploaded and available in printed format for the patient, determining if there are additional orders since your last visit and read any documentation that another clinician submitted. This will ensure that you are able to give the best care possible to your patient.

Although going through these steps may seem like more work, it isn’t. Consider driving 15 miles to a patient’s home only to discover they had an MD appointment. If you are unprepared for teaching, you may waste your time and the patient’s. Reconstructing notes and trying to remember vital signs is a task that is slightly less pleasant than a root canal and takes time. Doing the job right the first time saves so many headaches that the manufacturer of Advil would be in jeopardy if everybody bought into the concept

Perhaps the greatest delay in documentation is finding better things to do. It requires discipline to complete quality paperwork within 24 hours of a visit. It is a habit you need if you are to be in home health longer than a week.  Believe it or not, there is an app for that. Actually, there are fifteen apps for that. Try one. Because although clean documentation that doesn’t boomerang back to you and is submitted on time gets the agency paid, the effect on your life will be even more amazing.

Work Place Violence (and free CE’s)


workplaceviolence_bannerI must say that everyone is pretty good about conducting a home safety assessment. Throw rugs are removed, lights are bright and shiny and and much of the work done by therapists is to reach the goal of the patient being able to safely navigate in the home environment. Geaux, Team!

We’re missing something. What about employee safety in the work environment? Everyday home health and hospice nurses, aides, MSW’s and social workers go into homes where they are separated from the agency and out of view of anyone who might help them. All but the most serious incidents are overlooked.

In addition to the injuries that happen regularly such as sprains, abrasions and other musculoskeletal injuries due to moving patients, these are routinely addressed in orientation and annual inservices. A risk of workplace violence also exists and recent research shows it is more prevalent than you may think.

Homecare workers (n = 1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.1

The CDC along with NIOSH has published an online Continuing Education course addressing workplace violence for healthcare workers. It is not specific to visiting nurses but does offer useful advice. It also offers 2.4 continuing education credit but if you want the credit, read the ‘instructions for credit on the first page. It is provided at no cost and includes short video clips, written text and discussion questions.

In taking this course, I learned that when adhering to the strict definitions of Workplace Violence, many homecare workers have experience with verbal and physical aggression. We also under report workplace violence and ‘forgive’ our patients. It may be a fact of life that nurses eat their young but it doesn’t have to be and agencies should not tolerate bullying of their employees. Regardless of the kind of workplace violence that takes place, visiting staff may suffer stress, depression, insomnia and burnout as noted in the study cited above. Without support from management, the agency’s morale will deteriorate to the point where nothing gets done.

If you know of any other resources to reduce the risk of workplace violence in the workplace, please share in the comments. Our workplace includes most zip codes in the country and all types of people. Reducing the risk of violence and supporting visiting workers can go a long way to making sure you’re agency doesn’t lose its best employees to burnout.

  1.  Hanson, G. C., Perrin, N. A., Moss, H., Laharnar, N., & Glass, N. (2015). Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study. BMC Public Health, 15, 11. http://doi.org/10.1186/s12889-014-1340-7

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