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.
