For the past several months, I have been arguing with pretty much every payor source for home health there is trying to get clients paid. After working with dozens of clients in multiple states, I am fairly confident in stating that some of you simply do not want to be paid. If you did, you would give me and other consultants and lawyers something with which to work. Just to be clear, I cannot work with:
- ‘Take meds exactly as ordered’. (variant: take meds at the same time each day.) It does not require the skills of a licensed nurse to tell the patient to take meds exactly as ordered. The general rule of thumb is that if you can learn it on Oprah, it probably isn’t skilled.
- Duplicate medications. Alone, duplicate medications place a patient at high risk for adverse events. Combined with number 1, it shows anyone who cares to read that the patient should not take meds exactly as ordered.
- I read this in a clinical record: I noticed the patient had enough money to buy cigarettes, but claims she can’t afford her medical supplies. Work with me people! You don’t get paid for your personal judgment. The patient was at 77 percent of the poverty level. Refer to evidence based practice when you feel tempted to commit to legal documentation your personal disapproval.
- Prior to charting edema on a lower extremity, please ensure that the extremity is present. I promise that if you have check boxes for right and left pedal edema and you pull all your patients who have less than two lower extremities, you will find phantom edema. The same applies to diabetic foot teaching, pedal pulses, etc.
- It is not enough for a physician to document that a patient has a diagnosis. You must also know what the diagnosis is and how to provide nursing care for the condition. I just read an admit for a patient who was referred with Pickwickian Syndrome which was named for a very round faced portly character in the first novel written by Charles Dickens. Because Mr. Pickwick was known largely for his girth, the condition has been renamed ‘Obesity Hypoventilation Syndrome. There were no orders for diets or attention to respiratory status. I don’t think the nurse looked up Pickwickian, do you?
- Diabetes Type I and II are not interchangeable. Work with me, folks. These older names for diabetes confused a lot of people so they have changed to simply Type I and Type II. Type I diabetes accounts for less than 5 percent of diabetes in the elderly. What on earth are y’all gonna do when when they recognize diabetes 1.5 as a separate diagnosis? (For now, just code as 250.00.)
- MD Awareness Month. It must be MD Awareness Month because every day I read about an MD who is aware. It goes something like this. ‘Pt’s blood pressure is 190/100. Patient has not taken medications. MD aware.’ I believe that is a convoluted way of stating that you didn’t call the physician as warranted by the MD stated parameters.
- Someone named Pt/Cg is wandering through the homes of all home health care patients in the country. Typically this occurs in computerized documentation that has not been edited correctly. It makes less than no sense that you taught pt/cg in an Assisted Living Facility that Alzheimer’s is a progressive neurological disease which results in mental deterioration and eventually death. Which caregiver did you teach?
- Notifying the caregiver is a bad idea. Imagine if you had an INR come back high and you notified the caregiver to hold the Coumadin and documented that you did so. What if the patient had multiple caregivers and none of them held the coumadin? What if the patient had a bleed into their brain and none of the caregivers remember the conversation and you didn’t write down a name. Think that’s over the top? It is. But it happened to a client a year or so ago. Caregivers have names for a reason. Use them.
- Repetitive teaching. The second most common reason for denial is that the documentation does not meet the standards for reasonable and necessary care. Teaching is the most frequently provided skill in home health. You with me? So, in order to be paid for your services, you must teach original material or have a reason for re-teaching. It is unreasonable to teach diabetic diet, foot care, skin care and insulin injections in a single visit. Don’t chart that you did. Use teaching guides. Your patient is elderly, in pain, has poor vision, intermittent confusion, and takes drugs that impair mentation. That might be something to keep in mind. Take your time. Teach at the pace the patient learns and document what you did.
So, maybe I am a little frustrated this weekend but I love my job and I love home health and I take it a little personally when payor sources deny claim after claim sending the message to my clients and colleagues that what we do is not worth getting paid.