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Posts tagged ‘denials’

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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Physical Therapy Goals


The following is from a denial a client sent last week.  The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document.  That denial was overturned in favor of my client but the claim was denied again for a new reason.  You have to see this in order to believe it:

Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.

So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals. 

Did you happen to notice that the entire course of therapy was three weeks? 

Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted?  That really gets under my skin.

In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document.  They agency lost a full round of appeals before the reviewers found something else wrong with the chart.  Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met.  I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal.  In actuality, there were five of these I worked last week.

You have two choices.  First, you can write a short term goal or you can write a very long term goal.   The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged.   I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed.  Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?

An alternative solution would be to write a goal or two for the first visit or first week of therapy.  Some examples that come to mind from who knows where because I am not a therapist are:

  • The patient will agree to participate in their course of therapy by the end of the first visit.  (Chances are this is pretty accurate if the patient allows you in for a second visit).
  • The patient will have all prescriptions for pain filled prior to next visit.  (I do not like the way it sounds when therapists work with un-medicated patients.)
  • The patient will have DME delivered by end of day 4 of episode.  (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.

I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh.  I assure you that is not the case.  All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation.  Be bold about it.  Include page numbers.

I would be interested to hear what is happening in your offices.  Has anyone else seen denials like these?  If so, what contractor?  (Palmetto, NGS, CGS, etc.)  Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below. 

Confined to the Home


Here’s the point of this entire post.  Medicare knows the definition of ‘homebound’.   Medicare states that patients don’t have to be bedridden but there must exist a normal inability to leave the home and that when the patient does leave the home it requires a taxing effort.

As it turns out, most of us and quite a few physicians also know the definition and write it verbatim on visit notes, care plans and face-to-face documents.  When Medicare documentation calls for ‘reason homebound’, they are not asking for their own definition.

So, here’s my way of avoiding those pesky denials related to homebound status and overturning the ones that do get denied.  At the time of admission or recertification document all of the reasons why the patient can’t just up and go and all contributing factors.

These are very incomplete lists but I always try to support homebound status with as many factors as are applicable to the patient.

Absolutes Supporting Reasons
Severe pain with ambulation multiple medications that can impair balance
Safety concerns due to recent hx of multiple falls. multiple meds that can impair judgment
Disoriented to person and place and must be supervised at all times urinary incontinence
Short of breath while talking, eating or repositioning in bed cumbersome assist devices
SaO2 drops to 87 with activity apprehension about leaving home
Unable to ambulate safely s/p hip replacement moderate pain after standing for extended periods
Impaired judgment secondary to psychiatric illness cannot open some doors, drive or use left arm to balance due to splint
High risk of infection due to open wound and compromised immune system. requires considerable effort communicate needs clearly due to residual aphasia and paralysis of dominant hand.

 

Note the difference between the Absolutes and Supporting reasons.  People are not considered confined to the home because of apprehension alone but it adds depth to a complete picture of a patient with severe pain when ambulating.

Patients short of breath while talking or eating who are also incontinent and rely upon an assist device to get to the restroom are at very high risk for falls.

Documenting all assessment findings that contribute to homebound status at least once an episode and then continuing to support these reasons in your visit notes may very well get you paid.

486 Summary Example:  Patient homebound due to hip replacement two weeks ago and cannot walk without another person assisting him with his walker.  He is taking narcotic pain medications which increases his risk for falls and there are steps without a bannister leading to the front door.

The truth is that we all meet Medicare’s definition of homebound status at times.  Isn’t it hard for you to leave the house in the morning?  Surely it is a taxing effort for you to make sure all the kids have their lunch and homework, find your keys, retrieve your cell phone from the litter box where the toddler put it and somehow make it to the car.  If a normal inability does not include four trips to the car and back to house to retrieve forgotten items including the baby, then crazy is the new normal.

Medicare doesn’t care about any of that. They want to know, from a clinical perspective, how the patients meet the criteria they set forth for us in the conditions of participation.  We need to paint a crystal clear picture and not just write enough to meet guidelines.  When you are finished documenting homebound status, there should be no question that the patient cannot and does not leave the home.

If there is a question, go take a second look.  If you cannot elaborate on ‘SOB with exertion’ (as I am after climbing 6 flights of stairs), your patient may very well not be homebound.

Of all the wild excuses for denials lately, this one is not so unreasonable.  We can do this without changing the law, involving physicians, and praying that the grammar police don’t get us.

Good luck.  I am very confident we can take this denial off the table.

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 3.3.2.4 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…

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