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Tell Me a Story


When working with ZPIC clients, it is important to remember that Zone Contractors have been told to address eligibility more so than quality of care. Quality of care issues are to be sent to local licensing agencies and QIO’s if found in excess in a chart. Keeping this in mind, there are only a limited number of factors that make a patient eligible for home health:

  • They must be under the care of a physician
  • They must be confined to the home
  • OASIS data must be accurate and timely
  • Care must be reasonable and necessary
  • Must need skilled nursing care on an intermittent basis for reasons other than obtaining blood
  • Must be a Medicare beneficiary

Mostly the eligibility requirements are easy to prove. If there is no signed order, the patient is not considered to under the care of a physician. If the patient’s clinical record does not consistently reflect homebound status, the patient is not considered to be confined to the home, etc. OASIS data is either transmitted or not. And if your patient isn’t a Medicare Beneficiary, you simply will not get paid. But what about demonstrating that the patient requires reasonable and necessary care for an intermittent period of time?

The best way that I have found to demonstrate that the patient is eligible for reasonable and necessary services is to write a good 486 summary. I understand that not everyone enjoys writing but anyone can put together a good summary. If your grammar and spelling stink, it does not matter. There is no eligibility requirement stating that good grammar and spelling are required to get paid. Furthermore, while templates can be a useful tool, it often happens that every single 486 summary in the agency looks pretty much identical. Templates also lead to summaries reading like this: During this episode, the patient experienced daily pain. The patient required assistance to bathe. The patient did not require assistance to transfer. The patient ambulated with an assist device.’ This ‘story’ tells me nothing that I want to read over and over again as I review 30,000 pages of documents for a single ZPIC audit.

So let’s try something different. I believe that you can write an excellent summary if you merely answer the following questions:

  • Why is the patient being admitted or recertified and what is the primary diagnosis?
  • On admission, what happened prior to admission to instigate the referral? (Patients do not just wake up and decide to join a home health care agency as though it were a gym.)
  • What secondary diagnoses affect the patient’s ability to participate or respond to the plan of care?
  • What medications does the patient take (list names only because full orders are on the 485)
  • What additions and deletions to the Medication list occurred during the last episode?
  • Is there any significant lab work or diagnostic test that was performed last episode? (Please do not write that NO lab was drawn last episode.)

Next Section – what did the patient look like last episode?

  • Give overall impression of neuro status. Was patient mostly oriented? Was the patient confused?
  • Did the patient have pain? If so describe. If the patient was taking PRN pain medication, state how much was taken and how often over the prior episode.
  • Did the patient have any heart or lung sound irregularities? If not, simply state that patients chest remained clear to auscultation and there were no murmurs, rubs or extra heart sounds appreciated.
  • Did the patient have any issues with his gut? Diarrhea? Constipation? Nausea? Vomiting? If not, state the patient experienced no GI distress. If so, try to tie it to a reason such as a drug side effect, a virus, etc.
  • Did the patient void okay? If incontinent, mention the skin integrity of the areas affected by incontinence.
  • What did the patients legs look like? Pedal pulses bilaterally? Skin flaky or peeling? Describe the patient’s gait.

Next Section – What happened that was extraordinary last episode? A fall? An illness or exacerbation? Surgery? MD visits with changed orders? Gimme something here, folks.

Next Section – What did you do about all the irregular findings?

  • When was the doctor contacted?
  • Were no orders given?
  • Did the MD change the plan of care?

Final Section:

  • What on earth do you think you are going to do for this patient?

Answer that question and you have demonstrated reasonable and necessary. Now the occasional missed weight and missed visit won’t count quite as much in a payment review.  As always, we welcome your comments and emails.

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