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Posts tagged ‘home health’

New Automated Denials Coming Soon

Today’s post is written by John M. Reisinger, CPA (TN Licensed) of Innovative Financial Solutions for Home Health Publisher of the Home Health Care Resource Planner.  His contact information follows this post.

John sent the following out in an email this morning so some of you may have already seen it but it is important enough that reading it twice is a good idea.  It speaks to a new way that agencies can be denied without a lot of trouble.  There are links to supporting information an this needs to be shared with your entire agency.

Dear Clients:

 The CMS Medicare Learning Network (MLN) released a new article on March 24 regarding the denial of payment when a Claim is submitted when there is no (required) corresponding assessment in their system.  This will have an effective date of April 1, 2017; so this is something that you want all your billers to be on top of, as well as those that manage the OASIS submission process.  (Julianne’s note:  often the OASIS is submitted but not included with ADR information when a recertification falls in the prior episode.  Be sure that the person compiling the ADR knows to go back and retrieve the recert OASIS.)

Title:  Denial of Home Health Payments When  Required Patient Assessment Is Not Received – Additional Information


This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries.


In Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, 2017. This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change.


Don’t cost yourself money by not paying attention to the details.  This has always been a requirement under PPS, just a loosely (if at all) enforced regulation.  That is changing effective April 1st.  Now is not the time to worry about the ‘way we have always done it’, now is the time to start doing it ‘the way it should be done’.  Hopefully your software has systems in place to identify these instances when they occur, and your billers have an understanding of how to verify what is appropriate to be billed and what is not yet ready and why (and have processes in place to share that information with you immediately).

In fact, everyone should now be moving to and focusing on ‘the way it should be done’ in all aspects of their operations instead of the‘way we have always done it’, because if things we did in the past were so good, we wouldn’t be having the troubling relationship that we currently have with CMS, MedPac, Congress, et al, that we do have.


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More Conditions of Participation

484.55 Condition of participation: Comprehensive assessment of patients.

Most agencies will not find it difficult to comply with the requirements in the Comprehensive Assessment because they are already assessing these areas.  The fact that ‘Cognitive Status’ which is already included in the OASIS data set and ‘Patient Goals’ are now mentioned in the Conditions of Participation may be an indicator of exactly how serious Medicare is about changing their focus to a patient centered approach to care and outcomes as opposed to the more punitive approach of hunting for agencies that disregard regulations.

The biggest change regarding the Initial Assessment that I see is that the Occupational Therapist is now able to complete the initial visit if OT is the only service ordered by the MD and if the need for OT establishes Medicare Eligibility.  Welcome to the world of Admits, OT’s.

Content of Comprehensive Assessment

  • Current health; functional and cognitive status
  • strengths, goals and care preferences
  • Continuing need for home care
  • Review of all medications (Identify potential adverse reactions, ineffective drug therapy, side effects, significant drug reactions, duplication and noncompliance with meds.
  • Patients primary caregiver and other available support
    • Willingness to provide care
    • Availability and schedules
    • Patients representative if any
  • Incorporation of OASIS data

Recertification visits are still done within the same time frame (days 56 through 60 of episode).  Resumption of care visits are done within 48 hours of the patient’s return to home OR on physician ordered ROC date.

Plan of Care

Patients are accepted for treatment on the reasonable expectation that the agency can meet medical, nursing, rehab and social needs in the home.  Care plan must specify the care and services to meet specific needs identified in the comprehensive assessment.

Plan of Care contents

  • All pertinent diagnoses
  • Mental, psychosocial and cognitive status
  • Types of services, supplies and equipment required
  • Frequency and duration of visits to be made
  • Prognosis
  • Rehab potential
  • Functional limitations
  • Activities permitted
  • Nutritional requirements
  • All Medications and Treatments
  • Safety Measures
  • Risk for Emergency dept visits and rehospitalizations
  • Measures to mitigate risk of above
  • Patient and caregiver education
  • Specific interventions and education
  • Measurable outcomes and goals mutually identified by the patient and agency
  • Advance directives
  • All orders

Each patient must receive a copy of their plan of care.

Additionally, each patient is to receive written instructions that include:

  • Visit schedule
  • Med list with names, dosages and any meds to be administered by agency
  • Any treatments including those administered by agency or persons acting on behalf of agency including therapy.
  • Any other pertinent instructions specific to the patient’s care needs
  • Name and contact information of the agency clinical manager.

Revision of POC

There is nothing new here but something has been removed.  There is no requirement that a 60 day summary be sent to the physician.  It shouldn’t be needed if agencies abide by the following.

  • The plan of care must be reviewed and revised by the physician responsible for the home health plan of care at least every 60 days .
  • Agency MUST promptly alert relevant physicians to any changes in the patient condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  • Revised plan must reflect current information from updated OASIS and contain information about progress to goals.
  • Revisions must be communicated to the patient, representative (if any), caregiver and all physicians issuing orders for the plan of care.
  • Revisions related to discharge planning must be communicated with all of the above plus the patient’s primary care practitioner or other healthcare professional who be providing care for the patient in the community.

Conformance with MD Orders

  • Drugs, services and treatments are administered only upon the order of a physician.
  • Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after assessing for contraindications.


  • Review the way your agency handles plans of care and ensure your process includes a mechanism for dissemination of information to all physicians writing orders for a patient.  Review or develop a vaccine policy that allows for administration of flu and pneumonia vaccines according to a well-written protocol developed in conjunction with a physician.
  • Most agencies will have to expand the collection of information related to caregivers and availability.
  • Begin now to audit admissions for the requirements set forth in the CoPs.
  • Begin reviewing admissions using a tool based on the new requirements.  admission-review-tool.pdf  Modify to fit the needs of your agency.
  • Educate your staff.

More Later.  And to think, we haven’t even looked at Quality Assurance, yet.

Above is a very basic quiz on home health documentation.  It focuses on the type of errors that will result in claims being denied.  Is there a greater insult to a nurse than telling him or her that they do not deserve to be paid after going above and beyond to care for their patients?

Don’t let this happen to you.  Click the ‘Start Quiz’ link and find out how well your documentation measures up.  And call us if your agency might benefit from training from Haydel Consulting Services.


Episodes and Flu

In today’s lively discussion we will discuss the subtle differences between periods of time referred to as episodes and drive home the reason it matters.

It’s that time again. Most patients who were admitted or recertified to home healthcare this month and for the next several months will have some part of their care delivered after October 1. This is really important to note because any patient who is discharged or transferred to an inpatient facility on or after October 1 will receive some part of their care in the ‘Influenza Vaccine Data Period’. The specific questions about vaccines can be found in the OASIS transfer and discharge assessments beginning with M1041.

M1041 is a trick question. It asks if any part of the ‘episode of care’ include any dates on or between October 1 and March 31. Most veteran home health nurses understand that an episode of care is quite different from an episode which is a 60 day period of time. Newer nurses and therapists may not pick up on the nuances differentiating an Episode of Care from a generic 60 day episode.

An Episode of Care begins at admission OR Resumption of Care and ends at the time of Transfer or Discharge. Got that? As such, an Episode of Care can be equal to a 60 day episode but it could also be longer or shorter than a plan episode.

Let’s take a look, shall we? In the illustrations below, the grey arrows represent generic 60 day episodes. The white boxes will show various events that might occur creating an Episode of Care that is different from a plain episode.

Episode of Care equals generic episode

In the next example, an Episode of Care equals two regular episodes.

2 episodes – 1 Episode of Care

The last example shows how multiple Episodes of Care can occur within one episode. The white squares are one episode of care while the black squares represent the second Episode of Care.

2 Episodes of Care in 60 day episode

Since the actual questions are not asked until transfer or discharge, the challenge is to make the information readily available for the clinician who completes the transfer or discharge OASIS. It is also your challenge if you perform transfers and discharge assessments to make sure you have the information available.

Why is this important?

  1. Many agencies have outcomes posted on Home Health Compare indicating that you really don’t care if your patients get the flu. Or worse – you really want the patient’s to get flu.
  2. Value Based purchasing will likely include information about vaccines. ‘Value Based Purchasing’ means agencies with good numbers will make more money and that money will come from poorly performing agencies. If that doesn’t alarm you, break it down. Do you really want to fund an increase in revenue to your largest competitor who knows how to distinguish between Episodes of Care and generic 60 day episodes?
  3. The flu kills a whole lot of people every year and our elderly are the most vulnerable. While there is concern about the validity of the published numbers, nobody doubts that the flu can take a senior citizen with heart failure out of the game permanently. In 2013, the CDC reports that over 50,000 people died from the flu but last year the number was likely under 5,000. The flu varies wildly and waiting to see how bad it will be does not work.

Most assessment tools in computer software or handwritten, include questions about vaccinations on admission and resumption of care. The problem is getting the information right. The checkboxes are not completely trustworthy without dates.

So, M1041 researches patients on service from Oct. 1 through March 31. It isn’t until M1046 which strangely directly follows M1041 with no mention of 1042, etc. that the clinician is asked if the patient had a flu shot. There are 8 possible responses.

  1. Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)
  2. Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)
  3. Yes; received from another health care provider (for example: physician, pharmacist)
  4. No; patient offered and declined
  5. No; patient assessed and determined to have medical contraindication(s)
  6. No; not indicated – patient does not meet age/condition guidelines for influenza vaccine
  7. No; inability to obtain vaccine due to declared shortage
  8. No; patient did not receive the vaccine due to reasons other than those listed in Responses 4 – 7.

Going back to the second diagram showing how one Episode of Care can go on through discharge over multiple episodes, it is easy to see how the correct response might be hard to find. If you’re really not fond of your coworkers, imagine that it could be you out there doing the discharge and having to click through 200 or so screens to find where a nurse offered the vaccine.

The information reported on Home Health Compare reflects only the number of patients who have received the flu vaccine. If they received it from you during another Episode of care, their physician or any other provider, they obviously go into the mix. What does not get counted are the patients who have been offered and declined the vaccine.

Your numbers should be very close to 75 percent on home health compare. If they are not, there is a really good chance somebody does not understand the differences between an Episode of Care and a 60 day episode.

There it is. Three pages, three unskilled illustrations and almost 100 words so your clinicians will be able to correctly assess whether or not your patients have been vaccinated against the flu. It shouldn’t be this hard, folks. And guess what? We haven’t even touched on Pneumonia or Shingles. Let’s see what washes out in the final regs, first.

Good Luck

Patient Dissatisfaction

What do HHCAHPS surveys really mean? Are they useful in home health and hospice? Read yet another controversial viewpoint from Haydel Consulting Services.

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