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Thanks for the Visual

A friend of mine who practices health care law politely pointed out to me today that nowhere in CMS regs does it state that Physical Therapy must be rendered by therapists wearing clothes. Yet, try sending a nude therapist to a patient’s home and you will find yourself in regulatory hell. Thanks for the visual, Chris. I will have nightmares tonight.

My wise friend went on to say that at this point in time, the emphasis should be on over documentation as opposed to under documentation. Whether your concern du jour is RAC audits, payment, outcomes or state survey, your clinical records will determine your fate.

And of course attorneys and consultants have the luxury of really focusing on clinical records. We are not trying to schedule three resumptions on an afternoon when two nurses called out sick. We do not have to verify visits to ensure that our staff gets paid. When troubled clients call us we ask them to schedule an appointment. An agency nurse should have her ears boxed for taking that approach with a distraught family member. So when exactly do you look at clinical records?

A quarterly review is better than nothing but you are hard pressed to go back and draw lab that was ordered and missed two months ago. But, a quarterly review will give you the information you need for educating your staff.

Daily review of visit notes as they are submitted to the office will avoid a lot of problems but not all. A note can seem perfect outside of a chart and in the context of the entire record it is lacking important information.

But you have to bill every sixty days. There are requirements that the care provided during an episode meet the standard of being reasonable and necessary and that care be rendered under the orders of a physician. This is the perfect time to read through the last episode to ensure that the documentation is complete and meets guidelines. Certain tasks can be delegated to non-clinical folks such as ensuring that orders are signed and that all visits are in the chart. In doing this, the nurse has to read only an episode worth of notes to ensure that the care plan has been followed and that documentation meets Medicare payment guidelines as well as the guidelines of any other payor source.

When cash is tight and nurses are scarce, it is tempting to omit this last step of a billing audit. Nowhere in CMS does it say that a nurse must audit the chart. But, when your turn comes to be viewed under a regulatory microscope, it would be best if you had all your clothes on or you will find yourself in regulatory hell.

NOTE:  Christopher Johnston, one of my favorite attorney’s is available at the Gachessin Law Firm in Lafayette, LA.  I hope you never need him but if you do, here is his phone number:  337-235-4576 or   If nothing else, he is good for disturbing visuals you can share with your staff to drive a point home.

What are You doing about CHF?

What have you done lately to reduce your acute care hospitalization rate? If you don’t do anything else this year, a campaign to educate your staff about Congestive Heart Failure may make an appreciable difference. In March of this year, the American College of Cardiology published updated research and guidelines on Congestive Heart Failure which can be found here. Found within the paper are common factors precipitating hospitalization. Many of these factors are easily addressed in the course of a home health visit. Please share with your staff.

• Noncompliance with medical regimen, sodium and/or fluid restriction

• Acute myocardial ischemia

• Uncorrected high blood pressure

• Atrial fibrillation and other arrhythmias

• Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers)

• Pulmonary embolus

• Nonsteroidal anti-inflammatory drugs (Note: Ibuprofen worsens the risk of hospitalization in heart failure patients by 43 percent. Other NSAIDS increase risk even more!)

• Excessive alcohol or illicit drug use

• Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)

• Concurrent infections (e.g., pneumonia, viral illnesses)

Knowing that CHF patients have these risk factors prior to hospitalization is not enough.  Addressing these conditions as they arise can prevent a hospitalization.  Many agencies are using phone encounters between visits to assess weight fluctuations, new medications, control of diabetes and comorbidities.   In reviewing charts, it is amazing how many patients with a diagnosis of CHF have NSAIDS ordered that probably can be replaced with other pain relievers.

It is rare that an agency is so large or has a hospitalization rate so high that avoiding even a couple of high risk hospitalizations a month for CHF patients won’t make a difference in reported outcomes.  However, these efforts must be sustained and agencies must be patient to see their efforts reflected on the CMS reported outcomes.

If you have any questions or comments, please leave a comment below or contact us at

Hospitalization in the Five Day Window

In spite of careful planning on the part of nurses, therapists and physicians, it sometimes happens that a patient will go to the hospital after a recertification OASIS was completed and actually stay in the hospital for the duration of the episode and into the following episode. When this happens, it is frequently the case that the patient must be discharged and readmitted, but not always.

If a patient comes out of the hospital after the episode has ended and if (and only if) the patient has the exact same HHRG as the prior episode, only a resumption of care assessment is required. To determine if the HHRG is exactly the same, you may use the CMS toy grouper or Alternately, your software may have the capability or you can painstakingly compare answers with the last assessment while remembering that differing answers do not always result in differing HHRGs.

If the HHRG does differ then the patient must be discharged and readmitted to the agency. In order to accomplish this, most agencies begin a new chart. This is also problematic because often times, the second chart appears to be incomplete. For instance, you may have a situation with unstable caregivers that has previously been addressed by your social workers. In the new chart, all a reviewer may see is the unstable caregiver situation without reference to any intervention. Therefore, our suggestion is that when you must readmit a patient due to intervening hospitalizations to always reference that this is a readmission due to OASIS considerations. This allows your quality assurance department, your surveyors and reviewers and most importantly your consultants to understand that a prior chart with additional information does exist.

A document that addresses OASIS Considerations for PPS has been linked under the Essential Links section in the sidebar to your left. As always, we welcome your comments or your emails at

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