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Posts tagged ‘Home Health Nursing’

Jul 29

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 Chris@gachassin.com.   If nothing else, he is good for disturbing visuals you can share with your staff to drive a point home.

Jul 15

Billing Questions

In order to bill Medicare for home health services, all notes, orders and clinical documentation for the episode must be signed and in the medical record prior to dropping claims. Sounds simple, right? Homecare 101. And yet, our whole industry is plagued by rumors. Like old wives’ tales some of these false beliefs become so embedded within an organization that nobody has a clue that they might be doing anything inappropriate. Here are two of the billing myths I have heard lately:

  • Since agencies are paid per episode, it doesn’t matter if all visit notes are in the chart prior to billing. Only therapy notes are required to be in the chart prior to billing. And yet, here is what the OIG suggests as part of a plan to ensure that agencies comply with Medicare billing guidelines:

Provide for sufficient and timely documentation of all nursing and other home health services, including subcontracted services, prior to billing to ensure that only accurate and properly documented services are billed; Emphasize that a claim should be submitted only when appropriate documentation supports the claim and only when such documentation is maintained, appropriately organized in a legible form, and available for audit and review.

  • If an order is written after an episode ends such as when auditing clinical records, it is not necessary to wait for signatures because the order was not written during the duration of the episode. Here is how Palmetto GBA tells us to avoid denials:

When responding to an ADR, verify orders for all services billed are included with the medical records. Ensure physician orders, for all services billed, are obtained prior to providing the service and prior to billing Medicare, and are submitted for review. Ensure all oral/verbal orders are countersigned and dated by the physician before the final claim is billed to Medicare. In the event the physician fails to date his/her signature, write or date stamp the date the order was received back from the physician. The stamp date must include the word “received” and should be in black ink, as red and blue ink will not photocopy.

Even though it is not mandatory that agencies have a compliance plan, there are many good reasons to implement one. Chief among them is a promise by the Office of the Inspector General that sentencing guidelines are influenced by the presence of a compliance plan. Regardless of whether your agency chooses to implement a formal plan or not, these billing guidelines are mandates and must be followed. To do otherwise is to put your agency in serious regulatory or financial risk.

We always welcome your comments and questions below or if you choose, you may email us at haydelconsulting@bellsouth.net. As always we are available to assist agencies in implementing a corporate compliance plan. If you choose to go it alone, please refer to the OIG sample compliance plan.

Jul 14

5 Comments

OASIS-C Version 12.4

The OASIS-C revised version 12.4 can now be accessed by clicking on the link to your left under the Blogroll. The 12.2 dataset has been removed from our site to avoid confusion. Changes are minimal and we look forward to telling you more about this important change in our industry.

Also, it is time to think about compliance with the Red Flags Rule. Please click the link for more information on how to become compliant.

As always, if you have any questions, please comment below or send email to haydelconsulting@bellsouth.net.

Jul 9

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 haydelconsulting@bellsouth.net.

Jun 4

1 Comment

Front Loading Visits

Everyone seems to be familiar with the concept of front loading visits and yet, during clinical record reviews at a variety of clients’ offices, I do not see it being used routinely. Too often, the same old tired weekly frequencies are ordered. And yet, we know that most hospitalizations occur within the first weeks of home health care. Patients coming out of the hospital are at higher risk for re-hospitalization during the first month post hospitalization.

Financial considerations may be seen as a barrier to some agencies and yet, when done with care consideration, it does not necessarily add to the overall episode costs. In fact, overall episode costs may be lowered while improving outcomes. Consider the following patient post hospitalization for congestive heart failure. A ‘generous’ schedule might be 18 visits which would be translated into 2W9.

What if we took those 18 visits and divided them as follows:

3W1 with two additional phone calls to verify weight and medication compliance

2W1 with three additional phone calls to verify weight and medication compliance

1W7 with 2 PRN visits for weight gain greater than three pounds AND twice weekly phone calls to monitor weight and medication compliance.

This comes to only 14 visits if the PRN visits are both used. Now, if the patient puts on five pounds and orders are obtained to increase diuretics, additional visits can be ordered in the interim to monitory symptoms.

And, if the patient does well, the agency saves the cost of 4 visits – roughly $400.00 – while at the same time delivering care of a higher quality to the patient.

That sounds like a plan to me.

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