Skip to content

Posts tagged ‘documentation’

Dec 11

7 Comments

Medicare 101

We have a lot of challenges in Home Health next year.   No savior came to our rescue.  Congress has absolutely no reason whatsoever to overlook home health when cutting the budget.  They also  have every reason in the world to come after home health for fraud and abuse and they have with a vengeance.  They show no signs of stopping now and if you have been paying attention, nobody is safe.  I have clients with as few as 100 patients undergoing a ZPIC audit and we know that the larger companies are not excused from scrutiny, either.

So before you get serious about implementing new programs and creating new ways to improve care while reducing costs, spend a little to make sure that you as a nurse or you as agency are building upon a sound foundation that protects you if you find yourself under scrutiny.

Take the Medicare Quiz and when you are through, you will see your results immediately.  Let me know what you think of it.

Good Luck.

//

Jul 12

Homebound Documentation

Last week, I wrote about homebound status and I am assuming that all my readers have mastered the nuances of homebound status (even though I am still on the fence about some). But knowing your patient is homebound isn’t enough to warrant payment from Medicare and other payor sources that insist your patients be homebound. You must document it.

Bad Documentation Good Documentation
Patient SOB with exertion (Hint: even triathletes get short winded in their fifth hour.) Patient is unable to walk greater than twenty feet without rest period
Patient requires assist devices to leave home. (Does my car count as assist device?) Patient unable to ambulate without walker and requires assistance to place walker in daughters car. Cannot use public transportation.
Leaving home medically contraindicated. Patient at great risk for infection due to compromised immune system secondary to chemotherapy.
Patient unsafe to leave home due to psychiatric reasons. Patient has history of wandering into oncoming traffic. OR, patient oriented times 2.
Patient unable to drive. Physically unable to drive due to arthritis pain in hands.
Homebound due to pain in joints Patient cannot stand for greater than ten minutes due to pain in hips/knees.
Homebound due to no car Can’t help you there
Homebound due to wounds Wounds to lower extremities at great risk for infection when patient leaves home.

Reading carefully, skillful documentation of homebound status is generally speaking much longer than a simple statement. While the statements in the ‘bad’ column may actually state the homebound reason, they do not offer enough information for a third party reviewer to make an independent determination of homebound status.

As someone who reviews clinical records, I become very interested in homebound status when the following findings are evident on the clinical record:

  • Multiple missed visit reports
  • Any missed visit reports without explanation
  • A functional score of F1 or F2. If a patient can bathe, toilet, and dress themselves and require little or no assistance ambulating and transferring, why can’t they leave the house?
  • Multiple documented absences from the home regardless of where the patient went.

Again, if you look at the jobs of RACs, PSCs, and ZPICs, it is far easier to deny an entire clinical record because the patient isn’t homebound rather than read each and every note and determine if the skills are billable in the context of the patient record. If I were paid for each time homebound status was questionable, I wouldn’t be writing this blog. I would be retired and playing bingo somewhere.

May 20

1 Comment

What Were They Thinking

That is the question that runs through my mind when I review charts at agencies that do not have good quality review processes.

For instance, does the nurse who is teaching on Lortab know that the patient really doesn’t have an order for it on the plan of care?

What about the nurse teaching on Lasix for the sixth consecutive visit? How concerned is a nurse about her patient files a missed visit report but no follow up? Is the patient just laying there on the floor unable to answer the door? These are the questions that go through my mind when I read charts.

Then there is the documentation that is supposed to work as a catchall but actually serves as a ‘catch nothing’. Imagine reading on a chart of a patient with 22 medications that the nurse ‘taught side effects of meds’. That’s a lot of teaching for a single home health visit. It may have been a better use of time to choose one or two high risk medications and teach on those.

So are these just really crummy nurses? No. Does their documentation truly reflect the quality of the care they provide? I think not.

And it isn’t that these nurses are unable to learn. The problem is that it is difficult to teach an adult a skill that they have no use for. In the current regulatory environment, we are paid mainly because we send a bill to Medicare. No one is currently looking at the documentation to support claims. As such, documentation falls off on our priority list.

Can we say with any confidence that this will always be the case? Of course not. Too much attention is being placed on health care reform and how we are spending our Medicare dollar for us to expect the current level of scrutiny to continue.

And when the feds do come looking, it will likely be for clinical records that have long since been closed. In other words, the work you are doing now could be the subject of future reviews. Is your agency ready for that?

I hope so. If not, give us a call and we will get you ready. On the other hand, once the feds arrive, it may be too late!

Newer Entries »