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Posts tagged ‘home health’

Jul 9

Secret Codes

Do you remember hoping for a magical decoder ring at the bottom of a cereal box?  I do and to this day, I haven’t found one.  The good news is that you don’t need one even though it would be fun.

I have a stack of denials on my desk and nobody was more surprised than me when I realized  that the denial reasons were related to the Face-to-Face documentation.  The reviewers noted  that the visit documentation was within the time frame, signed and dated by the correct provider, but the claim remained denied because the agency plan of care was  not related to the reason the patient was receiving services.  I hate it when someone goes to the trouble of telling me how close we were but missed by an inch.

Here are some of the reasons given.

  1. Diagnoses from the initial plan of care are static regardless of how long a patient is on service.  Well controlled hypertension after a couple of weeks will not get you paid even if it’s your blood pressure that’s high.  Be careful not to change diagnoses just to change them.  Some diagnoses such as wounds may remain primary.
  2. Similarly, some patients are readmitted after being discharged in the past and the plan of care from the prior admission is pulled up and copied without attention to the coding.   
  3. Sometimes, the wrong primary diagnosis is chosen. Remember that nurses do not learn diagnosis coding in school. The tendency is to choose the worst diagnosis suffered by the patient but it may not be the reason the patient is admitted to home health. Consider the patient who is paralyzed and has pressure wounds because they are confined to a wheelchair. Paralysis is a very troublesome condition but you can’t do much about it.  Wound care may be a more appropriate diagnosis.  Other diagnoses like diabetes and hypertension have so many options that it can be difficult to discern the correct diagnosis as well as the sequence.
  4. Often patients are discharged from the hospital and the reason for the hospitalization is resolved or the physician or biller at a clinic does not code like home health does.  Remember that we are instructed that the primary reason for home health must be related to the Face to Face document.  The diagnoses need not be identical and often, copying the clinic or hospital diagnoses results in a poorly coded plan of care.   Diagnoses like Diabetic Coma in an awake and alert patient are often questioned.  In order to ensure that the Face-to-Face document relates to the reason for care, the document must be read thoroughly.  Call the MD if there is any doubt if a patient has a certain diagnosis.  

Regardless of whether your agency does the coding or it is outsourced, coding is an expense to the agency.  Agencies with a corporate entity may decide to have in house coders. Agencies with one or two locations might consider outsourcing coding.  Like everyone else, coders go on vacation, get sick and sometimes quit.  That usually happens right after you pay for annual training which is necessary for your coders to keep up with changes to the codes.   We are happy to help anyone with their coding.  We can cover you when your coder gets sick or if you don’t know coding, review your coder’s work to ensure it meets standards.  We don’t want you to be denied hard earned money for care given to patients who need it.  Call 225-253-4876 or email us.

May 1

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Denied?

If you saw the list of UPIC denials a client recently received you’d probably want their license pulled. I would have stopped working for them to be honest if I hadn’t already read the charts.  

The first red flag was that there were multiple denials for each chart.  The second red flag was that many denials repeated themselves in essentially every claim on the list.  There were approximately 60 clinical records and after my initial horror subsided, I started pulling charts one by one.  

I know we all forget to add pertinent things to the plan of care from time to time.  But did my client neglect to include wound care orders on almost 60 patients?  Truthfully they did not include wound care orders on about 45 – 50 patients.  But that’s understandable when you consider that these patients did not have wounds. The patients with wounds had orders.

The reviewers recognized the physical limitations of patients who were confined to the home but determined that the patients were not homebound because there was no documentation that it was medically contraindicated for the patient to leave home. Let’s review.  The patient has to meet certain criteria to be considered confined to the home.  They can be found in section 30.1 of the Medicare Benefit Policy Manual.  The patient must meet two criteria.  There are two ways to meet Criteria One.  The word ‘OR’ in all caps indicates that this is an either/or situation.

  • The patient must because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence 

OR

  • Have a condition such that leaving his or her home is medically contraindicated. 

If they meet Criteria 1, they must also meet criteria 2 which has two components and both of these must be met.  

  • There must exist a normal inability to leave home; 

AND

  • Leaving home must require a considerable and taxing effort. 

The patient who relies on a walker with human assistance and is short winded after 10 feet does not need to have documentation that it is medically contraindicated that they leave the home (assuming that they do not leave the home often).

I’d like to assume that you know this but if the contractors who are ensuring your compliance to Medicare coverage regulations don’t know it, I can’t very well expect you to know it.

More than one chart noted that a patient had a caregiver in the Medical Necessity section of the reasons for denial.  Please note that the presence of a caregiver does not disqualify a patient from receiving home health services.  That would found in section 20.2 of the Medicare Benefit policy manual.  If the caregiver is willing and able to meet all the patient needs, then home health would not be necessary.  It is rare that a caregiver knows all of the medications, can give injections, perform wound care (if the patient has a wound) and know what out of range parameters need to be reported and to whom they should be reported.  

All of the denials included the fact that there was no measurable level of understanding by the patient of teaching. Let’s assume that the caregiver is included.  On every single note by the agencies in question, the nurse documented that the patient understood or partially understood the teaching provided.  But just for fun, let’s go back to our Medicare Benefit Policy Manual.  It lists those services that are usually considered covered and the circumstances under which they are covered.  It can be found in section 40.1.2.3 See if you can find anything about documentation of a measurable level of understanding of the patient’s understanding.

Teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family, or caregivers how to manage the treatment regimen would constitute skilled nursing services.  Where the teaching or training is reasonable and necessary to the treatment of the illness or injury, skilled nursing visits for teaching would be covered.  The test of whether a nursing service is skilled relates to the skill required to teach and not to the nature of what is being taught.  Therefore, where skilled nursing services are necessary to teach an unskilled service, the teaching may be covered.  Skilled nursing visits for teaching and training activities are reasonable and necessary where the teaching or training is appropriate to the patient’s functional loss, illness, or injury. 

Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary.  The reason why the training was unsuccessful should be documented in the record.  Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient’s illness, functional loss, or injury. 

In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction.  Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered.  Where the teaching constitutes reinforcement, an analysis of the patient’s retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits.  Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home.  Where the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered. 

Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient’s condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task.  The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education. 

I know this is a lot but should your agency ever have records requested, you must be familiar with these (and all) the coverage guidelines.  It is reasonable to believe that the contractors are authorities on the coverage guidelines.  Although they have made mistakes before and been overly tedious in my opinion, I have never seen such creative writing in denials.  Worse, all of the stated reasons for denial should be addressed because the assumption might be that you agree with the reason for denial if you don’t.  That’s a lot of time, folks and your deadline is 30 days.

You work hard for your money.  More importantly, you work hard for your patients.  That’s where your focus needs to be.  If anyone else has dealt with a UPIC audit like this, please email or call me at 225-253-4876.

Sep 12

Five Things 5 Days at Memorial gets Right

Seven of the eight episodes of 5 Days at Memorial have aired and thus far it stays true to Sheri Fink’s book of the same name. So far, the Apple TV series has gotten five things that may be relevant to us absolutely correct.  I recommend that you all watch the series or read the book and then talk about it in your next Emergency Preparedness table meeting.

  1. A strong leader from your organization must be chosen before a life threatening emergency occurs because regardless of what you have done, a strong leader will assume authority.  It would be in everyone’s best interest if you approved of the person. At Memorial, Anna Pou, an EMT assumed control for both Memorial and Life Care which was an LTAC leasing space from Memorial hospital. Do you really want a doctor you don’t  know or who has no affiliation with your agency running your show?  
  2. If you are fortunate to have ample warning of a natural disaster, encourage your patients to move.  Move them out of your service area if that’s what it takes.  Lose money if necessary.  For the sake of comparison, I had an LTAC client that leased space on the top floor of a building across the street from Memorial.  Prior to the storm, they moved patients to Baton Rouge. It was expensive and most inconvenient but everyone was safe.
  3. Communication sucks before, during and after a disaster.  There is no other way to state that in a ladylike or professional manner. As soon as there is an inkling of a possibility of a disaster on its way, the employees need to call the patients and families and find out where they might be should they evacuate.  Although this information is part of the admission process, things change.  For weeks after Katrina, we were getting emails from people looking for relatives and loved ones.
  4. Plans fail.  Katrina was likely a category two storm when it hit New Orleans down from Category 4 or 5 while it churned in the Gulf.  Everyone was fine the next day.  It was around mid morning when the first trickles of water from a breached levee started to flood the street.  A city prepared for a storm ended up suffering from some of the worst flooding in history.  The generators in place to maintain power were under water. Focus on keeping your patients foremost in your plan and don’t try to anticipate how a disaster will evolve.
  5. Even though plans fail, it is important to have one.  If you work for an agency or hospice provider, be available if there’s any way possible.  Know what the plan is and if you are knocked off course by an unforeseeable event, at least you will know where you should be and can work to get back on track.  

Many of you are wondering why I am stating the obvious.  It’s because many people don’t learn.  Last year, Hurricane Ida hit and one nursing home owner, Bob Dean, thought it would be a good idea to warehouse almost 800 people in a warehouse.  It flooded and the patients were moved to a dryer area.  Most patients were side by side on wet mattresses that were touching with no room for nurses to get through.  Eight people died as a direct result and more died in the following weeks.  It is impossible to care for 800 elderly patients in a dark warehouse with no electricity or running water. Bob Dean felt he was treated unfairly when his licenses were revoked.  When that was largely rejected by the public he went on to say that he suffered from temporary Dementia.  He thinks his licenses should be restored.  Maybe if he hadn’t been visiting friends in the cool dry climate of Connecticut and been out to the unsanitary (to be kind) warehouse, he would have a different opinion.

When we live through a once in a lifetime event, we tend to believe that it is just that – once in a lifetime.  These unimaginable events are exactly that – beyond the scope of our imaginations.  All we need to keep in mind is that bad things happen and our patients come first.

Jul 27

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Save The Date

Your comments are needed on the 2023 proposed regulations

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Aug 15

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The Real Reason your Claim was Denied

A good mystery is a delight but they should be reserved for leisure time reading. It should not be an element of Requests for Additional Information (ADRs) from Palmetto GBA or any other Medicare contractor. And yet, they are. Below are some examples that have come across my desk in recent months as the Targeted Probe and Educate (TPE) process marches forward. I admit that at times I am truly challenged.

There are two denial codes in particular that keep showing up and really, they could mean anything. The first is:

5F023 – No Plan of Care or Certification

Believe it not, there are some people who think this means that no plan of care or certification was included with the submission of documents. If it is found when the biller is checking claims status, he or she may simply fax over the plan of care thinking they are helping the agency get paid faster. There goes one round of appeals.

If they had taken the time to look up this reason for denial on Palmetto GBA’s website they may have found an explanation that confirmed their initial impression. It is prefaced by the following:

The services billed were not covered because the home health agency (HHA) did not have the plan of care (POC) established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.

So, when a letter arrives in the mail two days after the resubmission of the plan of care, agencies may be surprised to find out their claim was denied because the physician’s Face-to-Face encounter did not support homebound status in his clinic note. Maybe because it is not a requirement for their patients to be homebound so they don’t think about it.

You would think they would make a code just for homebound status so that the reason codes for denials would correspond with the reasons for denial. That’s what I would do.

To be fair, nobody is doubting homebound status. Rather, they are saying that the physician did not fully support homebound status.

Another claim denied for having no certification or plan of care was explained the same way. The Face-to-Face encounter documentation did not support homebound status. The physician documented that the beneficiary was having recurrent dizziness, continued incisional pain, low back pain and bilateral knee pain. The medication list included percocet, alprazolam and hydroxyzine. And yet, a reviewer at Palmetto does not understand how dizziness, knee pain, back pain and incisional pain might reduce the ability of a patient to leave the home and tolerate the outing with aplomb.

5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.

As an additional bonus, there is no shortage of claims denied for reason code 5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.

So which is it? Is the Face-to-Face missing or untimely or incomplete? Responding to a denial is not the time for guesswork.

On one appeal, Palmetto GBA asserted:

… The face to face encounter note indicated that the beneficiary required the use of a wheelchair, thus satisfying criterion one of the face to face requirements. However, criterion two was not met. There was no indication of a normal inability to leave the home or how leaving the home would require a considerable or taxing effort.

The physician wrote in the encounter documentation that the patient had a catheter, a prior CVA, dilated cardiomyopathy and he ordered a hospital bed and an alternating pressure mattress for the prevention of skin breakdown.  An overnight pulse oximetry was ordered to determine if the patient qualified for supplemental oxygen. There was a previous stroke resulting in weakness and difficulty with speech. Could anyone (in their 90’s) have this combination of conditions and find it NOT taxing to leave home?

The physician does not follow the patient home and determine how the patient tolerated the outing.  He or she doesn’t call the patient in the morning like the dentist who performed a root canal.  

In all of the denial letters, the Medicare Benefit Policy Manual, Chapter 7, is referenced.  Section 30.5.1.2 of that manual states:

The certifying physician and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s: 

Need for the skilled services; and 
Homebound status; 

The key word here is ‘substantiate’.  According to the Manual, the physician does not need to document specifically how the patient tolerated the outing from home.  Rather, there must be sufficient information to substantiate that a patient can not leave home without a considerable or taxing effort. 

Don’t get angry.  I’m mad enough for us all and it isn’t healthy.

Call a consultant if you need help.  (My number, 225-253-4876, is a good start.)

Meanwhile, I’m trying to figure out how they will handle Medical Review in PDGM.  Could it be we get a break the way we did when PPS was first implemented?

Questions and comments are always welcome.  Look for the comments section or email me at your convenience.


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