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Posts from the ‘Palmetto GBA’ Category

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.

Care for the (whole) Person with Diabetes


A couple of months ago, I contacted Palmetto GBA about the LCD requiring agencies to obtain Hemoglobin A1C’s on diabetic patients every 90 to 120 days.  Included were the ADA guidelines as well as a Medscape continuing education offering that spoke to the dangers of over-testing.  Palmetto agreed to reconsider the current Local Coverage Determination and today, a response was received from Dr. Harry Feliciano MD, MPH – Senior Medical Director of Palmetto GBA.

It seems that Dr. Feliciano read the information I sent and additional research concerning the prevalence of hospitalizations related to hypoglycemia.  He pointed out that the research I sent excluded diabetics who were on insulin and agreed that the current LCD should be updated.

As such, we can expect some changes in late April to be effective in early May regarding Palmetto’s policy regarding A1C’s.  Based on information from Dr. Feliciano, I would expect to see:

Testing reduced to twice yearly for stable diabetic patients who have met their treatment goals. 

Physicians may adjust treatment goals to lessen the risk of hypoglycemia.

Patients receiving insulin will continue to have quarterly A1C testing.

Patients who have their diabetic therapy changed or are not meeting treatment goals should have quarterly A1C’s monitored.

The purpose of requesting a reconsideration was to lessen the risk of denial for patients who are provided care by your agency.  I am not going to insult you by reminding you that you still have to give appropriate care to patients with diabetes.  You already do that, even when documentation is lacking.  But is it enough?  I ask because the incidence of diabetes keeps climbing and the costs are staggering – 245B per year.  If you do the math, 245B is roughly equal to a whole lot of misery for millions of people.  Maybe its time we up our game.

For very good reasons, the OASIS data set and Home Health compare put a premium on diabetic foot care but there is more to good diabetic care than looking at feet.  The following is from the ADA guidelines regarding diabetes and older adults.

Recommendations[1]

  1. Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. E
  2. Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. E
  3. Older adults (>65 years of age) with diabetes should be considered a high priority population for depression screening and treatment. B
  4. Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B
  5. Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E
  6. Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E
  7. Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E
  8. Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E
  9. When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E
  10. Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E
  11. Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose lowering agents based on their clinical and functional status. E
  12. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E

How many of you ensure that your patients have annual eye exams?  How well and how often do you screen for depression?  Do you run through the PH2 on the OASIS or do you stop and consider each answer carefully in both what is reported to you and what is revealed by other factors?  When was the last time diabetic training for staff was offered at your agency?  If you are visiting a hospice patient, have you adjusted the diabetic regime to provide for comfort as opposed to tight glucose control?

Clinical Record Review

Here are some of the things I see when reviewing records.

  • A patient is taught to drink juice and have a snack when experiencing hypoglycemia.  The same patient is dependent on a walker, has vision loss, moderate to severe pain and is occasionally confused.   Documentation is absent any provisions made for a patient who cannot stroll to the fridge and pour some juice.
  • A patient has a CBG barely over the reporting parameters and the nurse explains it by reporting the patient just ate and took insulin late.  No MD notification. If you think that’s okay, look at the upper parameter.  If it is 150, you might get a pass on patient care but it’s probably double that.  More importantly, surveyors take exception to nurses not following orders.
  • Teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.
  • Patients are scolded when they are discovered eating something that will likely raise their blood sugar such as a donut or jam.  Manners, please.  These patients are our elders and they deserve respect.  Nobody was ever embarrassed to the extent their A1C dropped to below 7.
  • Generic teaching of medications that have very specific and unique side effects.

So maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care.  The lowered frequency of A1Cs only applies to stable diabetics with no changes to their treatment but these patients also need eye exams, assessment for depression and emergency teaching for hypoglycemia.  Even if they have been a diabetic for ten years and have been stable for almost as long, make sure they know which medications might cause lactic acidosis and to notify the agency when their activity changes to prevent hypoglycemia.  If you believe that the physician is overly optimistic about your patient’s diabetic goals based on your assessment of the patient in their home environment, respectfully bring it to their attention.

All of these interventions take very little time and can easily be included in care plans when the primary diagnosis is something else.   If we don’t take advantage of ensuring that diabetes is addressed completely when it is not a crisis, the costs – both human and economic – to treat complications will be significantly higher.

To help you get started, her are some resources that may help in developing skills required to assess and treat diabetes.  Please take the time to read one or two and if you find anything that helps your patient care, please share.

Resources for Diabetes

2016 Diabetes Guidelines

2016 Guidelines for Mobile

Lower Extremity Amputation Prevention (LEAP) program

Depression and Diabetes

Coping with Diabetes in Adults

Treatment of Diabetic Ulcers

Diabetic Retinopathy from National Eye Institute

Kidney Disease of Diabetes

Neuropathies in Diabetes

[1] American Diabetes Association. Older adults. Sec. 10. In Standards of Medical Care in Diabetesd2016. Diabetes Care 2016;39(Suppl. 1):S81–S85

Does Anyone Work at Palmetto GBA?

Do real people work at Palmetto? Is 7-10 days a reasonable wait time when your agency is at risk?

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