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Posts from the ‘Documentation’ Category

Sep 26

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.

Feb 23

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Marching Orders

The down and dirty way of getting a good care plan out the door for signature.

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Jun 24

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End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

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Jan 11

Home Health Conditions for Payment

We have looked and have been unable to find specific guidance on the new CoPs.  There was a phone conference scheduled with NGS that was cancelled and nothing so far from Palmetto GBA.  Help us out if you know anything.

Meanwhile, some people who are very knowledgeable and well respected in the industry differ from us in how we interpret what ‘estimating how much longer the patient will be on service at the time of recertification’ means.  Look for it below in larger bold text.

§424.22   Requirements for home health services.

Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.

(a) Certification—(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s eligibility for the home health benefit, as outlined in sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, as follows in paragraphs (a)(1)(i) through (v) of this section. The patient’s medical record, as specified in paragraph (c) of this section, must support the certification of eligibility as outlined in paragraph (a)(1)(i) through (v) of this section.

(i) The individual needs or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services as defined in §409.42(c) of this chapter. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification form, in addition to the physician’s signature on the certification form, the physician must sign immediately following the narrative in the addendum.

(ii) Home health services are or were required because the individual is or was confined to the home, as defined in sections 1835(a) and 1814(a) of the Act, except when receiving outpatient services.

(iii) A plan for furnishing the services has been established and will be or was periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)

(iv) The services will be or were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.

(v) A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in paragraph (a)(1)(v)(A) of this section. The certifying physician must also document the date of the encounter as part of the certification.

(A) The face-to-face encounter must be performed by one of the following:

(1) The certifying physician himself or herself.

(2) A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health.

(3) A nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(4) A certified nurse midwife (as defined in section 1861(gg) of the Act) as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(5) A physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(B) The face-to-face patient encounter may occur through telehealth, in compliance with section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.

(1) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.

(2) [Reserved]

(2) [Reserved]

(b) Recertification—(1) Timing and signature of recertification. Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Recertification should occur at the time the plan of care is reviewed, and must be signed and dated by the physician who reviews the plan of care. Recertification is required at least every 60 days unless there is a—

(i) Beneficiary elected transfer; or

(ii) Discharge with goals met and/or no expectation of a return to home health care.

(2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the recertification form, in addition to the physician’s signature on the recertification form, the physician must sign immediately following the narrative in the addendum.

(c) Determining patient eligibility for Medicare home health services. 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) shall be used as the basis for certification of home health eligibility. This documentation shall be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described in paragraphs (a)(1) and (b) of this section. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.

(d) Limitation of the performance of physician certification and plan of care functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of care may not be established and reviewed, by any physician who has a financial relationship as defined in §411.354 of this chapter, with that HHA, unless the physician’s relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements.

(1) If a physician has a financial relationship as defined in §411.354 of this chapter, with an HHA, the physician may not certify or recertify need for home health services provided by that HHA, establish or review a plan of treatment for such services, or conduct the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act unless the financial relationship meets one of the exceptions set forth in §411.355 through §411.357 of this chapter.

(2) A Nonphysician practitioner may not perform the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act if such encounter would be prohibited under paragraph (d)(1) if the nonphysician practitioner were a physician.

[53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70334, Nov. 21, 2005; 72 FR 51098, Sept. 5, 2007; 74 FR 58133, Nov. 10, 2009; 75 FR 70463, Nov. 17, 2010; 76 FR 9503, Feb. 18, 2011; 76 FR 68606, Nov. 4, 2011; 77 FR 67163, Nov. 8, 2012; 79 FR 66116, Nov. 6, 2014]

Oct 28

2 Comments

Taking Care of Numbers

Medicare is talking once again about value based purchasing in home health.  This is another name for pay-for-performance which was all the rage ten or so years ago and later, fell off the radar. Basically,  Medicare wants to increase payment to providers for being good providers and reduce payment to ‘bad’ providers.  Tonight’s post is about just one of many reasons why I do not like Paying for performance or outcomes.  Read between the lines and see if you can imagine home health and hospice providers chasing numbers when value based purchasing comes around.

My mother had a heart attack several years ago.  My father, an engineer and manager by education called me that Mama was having chest pain but that when he took her blood pressure it was fine.  I told him to take her to the hospital.  He proceeded to tell me that her blood pressure on the other arm was quite different.  A significant difference in readings between the two arms is characteristic of an aortic aneurysm so I told him even more emphatically to take her to the hospital.  He insisted on giving me the actual readings which were off by four millimeters of mercury easing my mind about aneurysms and such but I had not had any coffee so I hung up and after telling him I would see him at the hospital.

At the hospital, he asked me what MI was.  Mama had just been taken in the back and there was no credible information that she suffered an MI.  After a detailed explanation, he asked why they put it on the form between first name and last name.  Still no coffee.  This was going to be a long morning.  Daddy can’t hear very well and in his anxious state, I hated to leave him in search of caffeine.

I spent many years working in a cath lab.  Even looking at the clock, the number of minutes seemed excessive although not as excessive as the number of hours it felt like waiting.  Finally, the doctor called me back and showed me the films.

Nothing.  All I saw was wide open vessels.  Mind you, I’m good at this.  I can spot a diseased vessel that most people miss.  I did not see anything.

He repeated the films several times and challenged me, ‘You still don’t see it, do you?’  Grinning like the winner of an Easter egg hunt who found the golden egg, he showed me the culprit.  The tiniest branch of a branch of a branch at the apex of her heart originating at the right coronary artery was occluded.  He explained he couldn’t find it either which accounted for the delay.  He had to review the films and reshoot a couple of times to be certain.  Even with coffee and even if I had seen it, I might have written it off to a flaw in the images.

I was relieved.  Mama felt stupid as though she should have known that it was insignificant and Daddy continued to wax eloquently about the variable blood pressure readings.  All was well except my son was very angry that we forgot to tell him that his favorite person in the world had a heart attack.

A couple of days later, Daddy called to say Mama was tired and cranky and not able to do her stuff at church.  I went to see what was up and found that she had been placed on a beta blocker, aspirin and a statin drug because it was hospital protocol for anyone with a diagnosis of MI.  Mama is petite on good days and just short on other days and 25 mg of Lopressor was taking it’s toll on her.  She was fine after she stopped it.

She did not need any of the three.  Her drug of choice for pain is old fashioned Bufferin.   I have almost had to admit her to detox for it any number of times.  Her cholesterol is within normal limits and her coronary vasculature was award winning.  She exercises regularly and eats so well, I imagine there is an ICD-9 code for her self-imposed dietary restrictions.

Meanwhile, the hospital’s outcomes are keeping up with the Jones’s.  In the wisdom of evidence based practice my mother was prescribed three meds that would do her no good.  Granted, they were cheap and if I had to choose, I would prefer a global policy of prescribing them for everyone rather than miss a few who needed the medications.

I don’t have to choose as it turns out.  Medicare has already determined what pretty much every heart attack patient in the country needs.  With all of the critical thinking required to open a refrigerator door, our physicians order medications for all patients according to pre-printed recipe. The hospitals and the physicians with privileges at the hospitals are chasing numbers instead of taking care of individual patients.

What bothers me the most about treating the numbers is that although minor, there are side-effects to the medications prescribed to my mother as she was discharged from the hospital.  There was a potential for dizziness and orthostatic hypotension resulting in a fall from the beta blocker.  There are side effects of statins including memory loss.  An aspirin a day shouldn’t hurt anyone but nobody stopped to ask Mama what she ordinarily took for pain and too much aspirin can cause problems as well.  The chances of side effects for Mama outweighed the benefits of treatment.

Treating the hospital’s outcomes should never be mistaken for quality care of individuals.  This is something we need to remember when our reported data is being evaluated for purposes of payment.

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