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Posts tagged ‘ADRs’


Priscilla Demonstrating a Proper Face-to-Face Encounter.  She continues to work on documentation skills.

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

I have never been a big fan of associations and organizations.  I am not a joiner in general.  Specifically, I have been very frank about my feelings towards the National Association of Home Care and Hospice.  I believe that in the past they took on causes that benefited some agencies at the expense of others.  In many ways, it is almost impossible to be an organization representative of all agencies of all sizes in all parts of the country.

As of June 5, that changed.  William A. Dombi, attorney for the plaintiff – your association – has filed suit against the US Department of Health and Human Services.  NACH is challenging the requirements regarding documentation of the Face-to-Face encounter.  They allege that Medicare is enforcing the Face to Face encounter requirements in ways that were never intended and are not legal.  They note that these retroactive denials are made outside of the consideration of the care needed by the patient or the quality of the care rendered to the patient.

This is good stuff, y’all.

Because I was so outspoken and passionately against the position NAHC took in the past regarding other issues, I owe it to the Association (and to myself) to be as outspoken and passionate in my support of this lawsuit.

If NAHC asks anything of its members, please cooperate to the best of your ability.  If nothing else, send the board at NAHC responsible for approving the filing of the claim a note of gratitude.  This is one position that NAHC has taken that benefits all agencies, patients, and the Medicare trusts.

I can respect that.

What Would My Life Be?


Dr. Quaid was a phenomenal cardiologist, now retired and indulging in another talent, art.  He has a fondness for John Deere Tractors, a very wry sense of humour and a quiet demeanor.   I haven’t seen him in ages but he used to run and enjoy outdoor adventures and I think he was secretly proud when his daughter was Mickey Mouse at Disney World one summer.  If you live in Baton Rouge, you can see a drawing he did of the graduating class of Episcopal High at Raising Cane’s on South Sherwood.

So, I have an enormous amount of respect for Dr. Quaid and I can honestly say that I like the man.  He is my second favorite cardiologist after Dr. Wall.  Having said that, please take notice that when I described all of his wonderful characteristics, never once did the words, ‘warm’ or ‘fuzzy’ find their way onto your screen.   He is not one of those men that people call a Big Teddy Bear nor is he the go-to guy for small talk or casual conversation.

You need to know this about Dr. Quaid to understand the kind of day I had when I was working in CCU a few years ago.  A patient who happened to be a relative of one of Dr. Quaid’s partners had an urgent need for a pacemaker.  Dr. Quaid drew the short straw and had to install the unit and I was the only nurse with an empty bed.

He was not happy and I was not happy and the entire unit was not real happy but off we went to conquer another case of nagging bradycardia.

With marginal cooperation from the patient, Dr. Quaid began injecting the area with Lidocaine and began in earnest to float the weapon of dysrhythmia destruction down some large vessel towards the heart – I believe they call it a subclavian but then again, I wasn’t the one steering.  As he was doing so, the patient‘expressed some discomfort’ (screamed at Dr. Quaid to stop) and a decision was made to give him more lidocaine.

It was probably one of those cost reducing measures that resulted in the Central Line kit having only syringe in it.  That one, lonely syringe had long been knocked on the floor but I had another syringe Dr. Quaid could use if he did not touch the cap.  I told him this.  “Do NOT touch the cap,” I said loudly and clearly.

He touched the cap which meant I had to tell Dr. Cheerful that he was contaminated.  Worse, there were no size 8 gloves in the cart and he wouldn’t even try on the 7.5’s.

So I went to fetch another pair of  gloves out of the supply room and somehow caught the corner of the sterile field, knocked the clipboard off the sink causing papers to fly everywhere and tripped and fell through the curtain that was affording the patient (but not me) a small measure of dignity.  I got Dr. HugeHands his gloves and then stopped for a brief second to emotionally prepare for my imminent death or worse; that moment when I wished I had assumed room temperature but didn’t.

So, I can’t say I stepped lightly back into the room where  Dr. Quaid was putting my mess in order. I handed him the gloves and waited for that first caustic word but it never came.  Silence.  Utterly loud, screaming silence.

He quietly returned to his task of electrical wiring but I knew he was unhappy.  I’m intuitive that way.   I pretended not to notice and watched the monitor to see when the pacer wire found its way to its final destination.

The silence grew louder until I couldn’t stand it and I blurted out that I had  endured 14 years of ballet lessons in three countries because my Mom thought it would make me more graceful but she was wrong.  I did not tell him about the ballroom dancing taught by nuns, the tennis partners who refuse to play with me unless an ambulance is on standby or the fact that I have been voted most like to die of a closed head injury in yoga during Savasana.  Still not a word from Dr. Quaid.

After three hours or maybe it was only three endlessly long minutes, he stopped in the middle of a tying a suture, made direct and intimidating eye contact with me and said quite simply, “I hate to imagine what your life would have been like without those dance lessons.”

There is a reason why I am telling you this ridiculously long and utterly humiliating account of an incident that happened long ago.

Keep in mind that on more than one occasion, seizure precautions have been implemented as I attempted to dance when I tell you that many of you cannot write for beans.

Remember that I have been described as an arthritic swan by ballet teachers when I point out that some of you cannot string together a grammatically correct sentence to save your life. Its downright sad to see some of you go through your entire vocabulary in one clinical visit note.

That I have twerked by accident during a Waltz should you make you feel better about visit notes that could be used as a poster for an Adult Literacy campaign were it not for the HIPAA Privacy Rule.

The fact is…. some of you simply do not write well and that’s okay.  Apparently, I do not dance very well.  Much to the dismay of others – a whole lot of others – it doesn’t stop me from trying.

If I hurt your feelings and you are ready to quit, don’t.  If you think your computer documentation will solve your problems, get over it.  If you have lived more than three decades and find yourself correcting more than half of your visit notes after review, give up on trying to be a literary presence.  All you really need to do is accurately convey your thoughts on paper and I am going to teach you how.  Remember, Medicare does not pay for grammar and spelling.  There are no Pulitzer prizes for visit note narratives.

Instead of trying harder, working more, adding more drivil to your notes, simply document the following on each and every visit:

  1. A short description of the patient and what they were doing when you got to the home.
  2. A complete assessment including weights.  Note:  in other health care environments, patients with aortic stenosis have very loud heart murmurs and patients with COPD wheeze.  In other words, document your findings – don’t just check the same old boxes you normally check.
  3. A review of all medications against orders.  Document any discrepancies.
  4. Problems assessed on the visit and any events reported since the last visit.
  5. What you did about the problems.


Patient at table making holiday plans with f’ly member upon arrival.  Med planner reviewed and noted all medications present.  Pill bottles examined and called MD for refills for Metoprolol.  MD office nurse stated meds would be called to Walgreens.  Pt has loud murmur which has been there since admit.  MD verified that pt always has murmur on admission.  Diabetic foot care done by patient while SN watched.  Pt performed foot care with just a little coaching from nurse.  Pts daughter present during visit and she agreed to pick up medications.  Will follow up.

Then write yourself an email or put a note to follow up on your calendar.  Call the daughter who picked up the meds to verify they are in the home and write a case conference that says:  ‘Daughter said she picked up meds from Walgreens.  See visit note of 09/13.’

Compare that to:

Pt was instructed on the significance of attempting to remember if he took medications before taking other meds.

I read that in a chart of a patient with Alzheimer’s Disease.  Medicare paid for a nurse to instruct a patient with Alzheimer’s on the significance of attempting to remember if he took medications before taking other meds.  And you wonder why I am so brutal in my assessment of your documentation.

The truth is that I know you guys.  You work hard, keep patients out of the hospital, make them well and happy and you deserve to be paid – not arrested.  I’ve heard some of the documentation classes.  I’ve read the examples.  Please don’t bore me with those cold, clinical assessments that tell me nothing about the person you are visiting.

Go practice.   Keep it simple.


Face to Face Documentation Guidance

I have received several denials on face to face documents because the signature was not dated.  Would somebody please tell Palmetto GBA to lighten up a minute and read the regulations?   I would do it myself but I am busy trying to get y’all paid.

The Benefit Integrity Manual Section reads as follows:

For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the MACs, CERT and ZPICs shall ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ ordered.

If you read carefully the actual face-to-face guidance, it is, in fact, silent on the whether the signature must be dated.  Here is what I cut and pasted from the Benefit manual. 

The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen 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 a signed addendum to the certification. It may be written or typed.

It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.

It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

Not only is the regulation silent about dating the signature on the face-to-face document, it references the signed and dated certification which for most agencies is the 485.  I am unable to infer that the regulations imply that the signature on the face-to-face document must be dated because it is illogical for the guidance to reference one mandated date and not the other. 

Does anyone disagree with me?  If the face-to-face document is sent after the 485, it would be difficult to prove that it was received prior to billing if it was not dated.  That is not my problem.  My problem lies in trying to figure out why Palmetto is playing so dirty with providers and working around their attitude to get my clients paid.

Let’s move on, shall we?  If they can play dirty, so can I.  Louisiana is home to swamps and New Orleans.  I know dirty.

The following are some examples of what Palmetto GBA considers to be inadequate documentation.

  • Diagnosis alone, such as osteoarthritis
  • Recent procedures alone, such as total knee replacement
  • Recent injuries alone, such as hip fracture
  • Statement, ‘taxing effort to leave home’ without specific clinical findings to indicate what makes the beneficiary homebound
  • ‘Gait abnormality’ without specific clinical findings
  • ‘Weakness’ without specific clinical findings

In the first three bullets, note the word, ‘alone’.  I wholeheartedly concur with them.  But, what if the diagnosis is accompanied by the procedure and the injury.  Suddenly, they are not alone.

The Medicare Benefit Manual defines homebound status for us as such:

An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.

I am fairly certain many of you have read that before.  If the definition suits Medicare, why is Palmetto above accepting it.  I understand that I can cut and paste those words anywhere.  If I saw a face-to-face with a single diagnosis of hypertension and the Medicare language for homebound, I would think twice about the validity of the document but that’s not what is happening.

I just finished with an appeal for a patient who was admitted post discharge from the hospital for pneumonia, sepsis, COPD and CHF.  The physician wrote that it was a taxing effort for this 85 year old to leave the home.  Well, I guess so.  Evidently, Palmetto GBA needs more information to arrive at the same conclusion.

Would a reviewer who could not understand why a patient with Sepsis, pneumonia, COPD and CHF would be short of breath, could they possibly distinguish between the eight different types of gait abnormalities related to neurologic conditions alone.   See 5th bullet.  (hemiplegic, spastic diplegic, neuropathic, myopathic, Parkinsonian, choreiform, ataxic (cerebellar) and sensory.)

Weakness – last bullet – is a good reason to stay home.  I don’t see the issue here.  Obviously, there should be something wrong with the patient that causes weakness but what specific clinical findings go with weakness?  “Patient was unable to complete ten reps with 20 pound bar?”

If I wrote a face to face, I would put something like:

Ms. Jane Deaux was seen by me on September 16, 2013 on the last day of her hospitalization for sepsis, pneumonia, COPD and CHF.  She spent 9 days in the ICU in a condition that is generally considered to be incompatible with life.   Without any regard to the rising cost of health care, the old woman refused to die.

She continues to complain about being short of breath and tired and refuses to accept that this is part of the aging process.    She has also called the office complaining of falls.  Reluctantly, I ordered physical therapy even though it is an expensive treatment modality for someone who might very well end up dying in less than a year.

She is confined to the home because she cannot breath very well when ambulating and getting to her car requires her to walk a short distance.  This ‘shortness of breath’ is caused by the inability oxygen to cross the alveolar membranes in the lung tissue resulting in a very low partial pressure of oxygen in her arterial blood.  The low PO2 manifests itself in a bluish cyanotic pallor which causes the patient to be self conscious as it draws unwanted attention from strangers.  Because carbon dioxide is not blown off in normal respiratory effort, her pH decreases causing her to become acidotic which leads to extreme electrolyte imbalances resulting in cardiac dysrhythmias expressed outwardly by symptoms of lightheadedness, falling, loss of consciousness, broken bones on impact and death.  As such I certify that it requires a considerable and taxing effort for this patient to leave the home.

I dare you.  I double dare you.  Find a doc and let him use this as a template.  Have the physician edit to fit the patient and see if it gets paid.  Just sayin…

Face to Face–Your Results

A few weeks ago, you were invited to take a quiz on the home health requirement for face – to – face encounter documentation.  If you haven’t already done so, please go take the quiz now.

The results were interesting to say the least.  You know when a face to face encounter must be done and you are very clear about your (non) role in the creation of the document.  Where you fell off was in the questions regarding who signs the face-to-face document.  If your overall score was not what you hoped, rest assured that your colleagues are right there with you.

Here are some of the more interesting responses.

Less than 50 percent of you knew that if a patient died prior to the 30th day and a good faith effort was made for the patient to have a face-to-face encounter, you may still bill.  This is not a suggestion regarding how to get around those pesky MD’s who refuse to sign, by the way.


The question that was particularly disturbing was a true/false question inquiring if it was true that the same physician who signed the 485 must also sign the face-to-face encounter document.  If you answered that question correctly, you are among a 35 percent minority.  A full 65 percent of you answered it incorrectly. (Green is good, pink is bad – I did not choose the color scheme.)


Similarly, less than half of you knew that if the hospital documentation was used as the face-t0-face encounter it had to be labeled as such and the date of the encounter had to be included.  When you consider many of the discharge summaries, they often apply to the entire hospital stay.  A visit date must be identified and declared as THE day the encounter occurred.  image

Rest assured, other than these very three common reasons for denial, y’all knew your stuff very well. 

So what do these results mean? If I was paid by your agency to come in and teach y’all about the face to face encounter and after I left, you continued to get denied, would you consider me to be an effective teacher?

The truth is that Palmetto GBA is responsible for educating you on the face-to-face to requirements.  This is part of their contract with CMS. 

Here’s the part that keeps up at night.  If all of you were to learn exactly what a perfect face to face documents looks like and then you all taught ten people who in turn taught ten people, by the end of next week literally billions of people would know everything there is to know about the face to face document. 

And not one patient would receive better care because the physician forgot to label the hospital documents as the face-to-face document. 

Just sayin…  Palmetto GBA, take it for what it is worth but I respectfully suggest you might have a little more work to do in the realm of face-to-face document denials. 

The Checkbox Patient

You say the pain feels like an elephant sitting on your chest?  I'm sorry but that's not an option.  Let's move on.

You say the pain feels like an elephant sitting on your chest? I’m sorry but that’s not an option. Let’s move on.

I get frustrated when I see people try to squeeze an entire person into a series of checkboxes.  This has gotten under my skin for a long time.  Apparently, Medicare agrees with me.  Keep the following paragraph from the Program Integrity Manual in mind when you are shopping for software.

The Program Integrity Manual – the PIM – is the guidance CMS offers to the contractors including RACs, Zone, and MACs. It was updated in December. If you want the full document, google Medicare PIM chapter 3. Chapters 3 and 4 are where I spend a lot of time.  I provided the bold text.

The review contractor shall consider all medical record entries made by physicians and LCMPs. See PIM regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation.

The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service. See the Local Coverage Determination for further details.

CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/LCMP may choose any template to assist in documenting medical information.

Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.

Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.

If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.

So, be wary of programs that do too much for the nurses.  If a program doesn’t require at least a short narrative, it likely will not get done.  If a nurse has scrolled through 50 checkbox questions, said nurse is not going to want to double chart that which has already been documented.

Don’t let some software vendor sell you the moon when what you really need is a clean, consistently reliable system that helps nurses understand and communicate their information.  You need reports and communication.  You need support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.

You do not need any more denials.  I assure you.

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