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A Slap in the Face

So last week I was reviewing clinical records at the office of one of my favorite clients.  A patient had been admitted six months after having half of her foot removed.  She had not walked since the surgery and was confined to the bed and the chair.

The first thing I noticed was that the description of the surgical wound sounded as though it were partially granulated instead of fully granulated.  Six months is a long time but remember, amputations are not cosmetic surgery.  It would not be unheard of to have a wound slow to heal in someone with circulation impaired to the extent that part of a foot needed to be removed.

I also questioned the diagnosis sequence and a couple of the OASIS questions in the functional domain.

Med orders on the 485 indicated that the patient was on both Dilaudid an Lortab but the chart only mentioned Lortab as being used for pain.  My most humble opinion is that if pain is being managed with Lortab, the Dilaudid should come off the orders – especially after the first episode.  The reason I feel this way is because if the patient had a sudden need for stronger pain relief, she may have other needs than Dilaudid that should be addressed immediately.

She had both therapy and nursing ordered.  The nurse was quick to realize that the new orthopedic ‘boot’ designed to help her walk was causing the surgical wound to become red and irritated.  Both the nurse and the therapist addressed this with the MD and the people who made the boot.  I certainly cannot complain about that.  But, after the boot was refitted properly, the nurse stayed in the home weekly even though therapists should be able to assess wounds.

In summary, I saw was that OASIS scoring left the agency with less payment than they were ethically entitled to for a very expensive patient and services being provided that may not have been required.  And of course, there was the regulatory issue with duplicate pain meds.

While I was busy finding fault left and right, the most important thing almost escaped my attention.

After two episodes the patient who had part of their foot removed and had not walked in six months prior to admission was ambulating with a walker.  The last nursing note state that the patient was in the kitchen upon arrival making coffee and using her assist device.

I am still not happy with the chart.  My slap in the face comes from the fact that sometimes we forget that documentation is second to our real mission of providing care in the home.  It is a very close second but failure to acknowledge what these incredible nurses and therapists did for the patient is the kind of attitude that deserves a slap in the face.  If those of us who review charts on a regular basis cannot read between the lines and respect the care given to patients, we have no right to expect respect from field clinicians when we tell them all the things they did wrong.

Having said that, I have seen like a billion ADR’s and ZPIC denial letters but I have never seen one like the following.  Please forward to me if you have.

Dear Administrator:

After careful review, our Medical Review department has determined that the cases mix weight determined by your OASIS data is in error.  Specifically, a surgical wound and the functional domain were underscored resulting in a lower payment for this patient.  In light of these egregious errors, Palmetto GBA (ZONE contractor or MAC of your choice) is adjusting your claim to reflect the correct diagnosis, surgical wound and functional status of your patient.  This will affect the overall denial rate on your current edit.

As a provider, you have certain rights to appeal.  Please see attachments on how to appeal a Medicare decision regarding payment.


(Insert the name of your MAC or Zone Contractor)

PS  please advise your nurse to take Dilaudid off the current med list and ask the patient to place it in a Ziplock bag with a large note that tells the patient to please call the nurse immediately should it be required in the future.

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