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Posts tagged ‘medicare compliance’

ADR Checklist

Prissy the Pit Bull available at no charge to review your records. We guarantee they will not be denied for lack of signature. We do not guarantee they will be paid.

Make no mistake that what I am about to say is shameless self promotion.  The safest way to ensure that any medical records requested by a payor source meet standards are to have them reviewed by someone with experience and who does not know the patients or the agency.  This doesn’t always ensure payment but it can alert you to your vulnerabilities so that you can make a plan before the next dance with your MAC.

Short of the the level of security offered by Haydel Consulting Services, you can do your own reviews.  More important than the actual content of the review is the attitude of the person doing the review.  Attacking the charts like a rabid Pit Bull will ensure that most errors are identified but Pit Bulls do not implement action plans.  Your reviewer needs to be cognizant of the fact that any errors or omissions identified are  tools to help cover their coworkers back and they need to be willing to help out their colleagues.  If they can be ethically corrected, they should be.  If they cannot, a team with members from every part of the organization needs to implement a plan to prevent repeat errors.

Here is what I look for:

  1. Orders signed and dated by physician.
  2. Face to face in all charts.
  3. Medications
  4. Diagnoses – note meds came first.  Are there any meds for dx’s not listed.
  5. Frequency – does it correspond to the patients’ needs?
  6. Functional status – if the patient is minimally impaired in the functional domain, are they homebound for psychiatric reasons?
  7. Is teaching original and relevant?
  8. If re-teaching is present, is the reason why re-teaching was necessary explained?
  9. Does teaching require the skills of a nurse?  It does not require the skills of a licensed nurse to tell a patient to take medications timely.
  11. Are therapy re-evals done on schedule?
  12. Is there any lab or other diagnostic tests that support care for the patient even if they were performed in a prior episode?
  13. If subcutaneous injections are given, is there a reason why the patient cannot be taught?
  14. Is there a documented predictable end to daily skilled visits when daily nursing visits exceed 21 days?
  15. If the patient is seen for Management and Evaluation, is an RN performing the visit?
  16. If Observation and Assessment is documented as a skill, are there any clear indications that the patient is likely to become unstable?
  17. Are patient and clinician signatures consistent throughout the record?
  18. Are there any hospital or MD reports that will support services?
  19. Does the clinical note contents support OASIS?
  20. Is the primary diagnosis the focus of care?

Notice again that two questions that are critical to payment are asked last.  It is only after reading the entire episode that you can truly answer these questions.

There are so many other important elements in a chart that are required in order to reflect good clinical care.  This is a payment review only.  So, if the patient had 12 nursing visits scheduled and two were missed, that will not affect payment but I want to go on record as saying that it is unacceptable to find out about two missed visits on ADR review.

If you find egregious mistakes that cannot be ethically corrected, back out the claim.  For instance, if there were no therapy orders after the initial order to evaluate and treat, back out the claim and resubmit it less the therapy.  Print all paperwork and send it with the ADR.  This will not prevent a denial but you won’t look stupid either.  After that, find the therapist culprit and violate your work place violence policy.

I am very interested in knowing who is getting denied for what.   Please email me privately if you have the goods.

And if you are not pleased with what you are finding, do not hesitate to call us.

Difficult Decisions

Be honest with yourself.  Have you ever held on to a patient longer than they technically qualified for home health services because there was nobody else to take care of them?  Have you ever recertified a patient for diabetes because they had an isolated blood sugar of 302 after washing birthday cake down with coke? What about the patient who has achieved stability at rock bottom and the only alternative for the patient is a nursing home?

I can spot patients who do no longer meet Medicare coverage guidelines a mile away because of my superpowers.  Also, I am not emotionally attached to your patients so it is easier for me to be objective.

These are the facts and I do not like them one little bit:

  1. Observation and assessment is a skill for only a short period of time (generally 3 weeks) unless there is documentation to support why the patient remains at increased risk.  This means stuff like actual falls and changes to the plan of care.  Headaches during allergy season that are controlled with Advil do not paint a picture of increased risk.
  2. Teaching is a covered skill.  Re-teaching is only a skill if there is a documented reason why said re-teaching was indicated.  Teaching is NOT a skill when it becomes apparent that the patient cannot or will not learn.  This means that teaching an advanced Alzheimer’s patient new skills will not be deemed reasonable and necessary.  It does not matter how hard you teach someone who is unable to learn.
  3. Homebound status is very poorly defined unless you work for someone with the authority to deny your claims.  Document homebound status.  If the patient meets homebound criteria three ways, document three times.  Everyone is SOB with enough exertion.
  4. There is a space at the lower left corner of each 485 that reads, “Attending physician’s signature and date signed”.  A Nurse Practitioner, physician assistant or love interest of a physician is not a physician.  When you identify actual physicians, try to narrow your choice down to the one who actually attends to the patient’s need and obtain their signature.  A signature is when somebody write their own name in their own handwriting or uses a secure electronic alternative.  Don’t stop yet.  Get the DATE.  If you haven’t heard me rant about dates yet, it is because you haven’t been paying attention.   
  5. Sadly, home health aide services do  not qualify a patient for home health.  In the event that you admit a patient who will likely require services indefinitely, that is the day you should begin searching for an alternative. Call relatives.  Beg churches.  If the patient  has Medicaid, find waived services for the patient.  Anticipate the day you will have to leave your patient alone in the house because there are no more skills to render.

It is heartbreaking to discharge some patients.   Sometimes it helps if another nurse goes to do the dirty work.  I have taken the discharge of patient in need of services not covered by Medicare harder than I ever took a death in all my critical care years.  There’s nothing left to do for a patient at room temperature.  Lonely elderly folks with vital signs are the ones who turn my heart to mush.

Knowing what constitutes skilled care going into the house will guide you in seeking alternatives to what feels like abandoning a patient in need. Remember, the folks who do ADR’s and ZPIC reviews do not know how sweet your patient is.  They have not been seen how happy your patient was to share with you the cookies someone made for them at Christmas.  They have not heard about the way music used to be played when it was good or held your patient’s hand when they lost a spouse.  If you are a good nurse, a patient will touch your life as much as you touch theirs.

But, none of that sappiness, as real as it in our hearts will keep you out of trouble if you do not provide skilled services according to Medicare guidelines.  When you fail to follow guidelines, you put at risk all of your patients, your employees or employers, their families and the agency’s stakeholders.  Better just to start planning your exit strategy on admission, wouldn’t you think?

If you have any questions, please contact us or post below.  If you want to hire Haydel Consulting Services to discharge your lonely patients, we will be glad to do so.  Just take our regular hourly rate and multiply it by 72,761 and plan on a 50 hour minimum for discharge services.

The Ugly Step Sister



Mandy Estes, Haydel Consulting Services LLC

Okay, so it probably wasn’t nice of me to put Mandy’s photo near the Ugly Step Sister title.  It is a coincidence, I promise.  I was going to introduce Mandy to you as I published her first post for our blog but I think she did a pretty good job of that herself.  Mandy can be reached via email any time you have a question or comment.  I hope you appreciate her unique take on things as much as we do.


For those of you who don’t know me, I am Mandy Estes. I have gotten a chance to meet some of you lovely nurses out there when I visit, and the best part of my job is meeting new people and getting to “visit” as we like to say here in south Louisiana. I have worked in homecare for a while now for a LARGE company and a small company and now I am blessed to be employed at Haydel Consulting. Can I say I love my job? Who wouldn’t love their job, if it sometimes consisted of writing a blog about the results of a Medicare 101 quiz? Regulations and tests make me giddy.

Throughout my home health career I have familiarized myself with state minimum standards, but I had not sat down and actually read the federal guidelines from front to back until recently. If you haven’t either, you should at least get started. Below is a link to them, it contains very valuable information and will only make your agency more successful. So, let’s get back to the subject at hand.

Observation and assessment. I want to call it the ugly step-sister to teaching and training.  Overuse of observation and assessment is like sending and engraved invitation to Medicare that reads,  “Hey, Medicare send the contractor to look at my charts!”

I don’t think anyone was too sure what to do with question 46, because the guidelines are somewhat vague when it comes to continued observation and assessment after the golden 3 week time frame. I could quote the guidelines verbatim but I don’t want to bore you all so much that you unsubscribe to Julianne’s funny and informative blog on my first attempt.

In a nutshell, the guidelines say this is justified as a skill when there is a risk for complication or exacerbation, but in addition the nurse is evaluating for modifications in the treatment plan. This means they actually want us to do something about the problems we are observing and assessing, not just stand around and write a detailed nurse’s note of our findings. We have all done it; even me.

Make a plan then take action by writing a case conference or calling the doctor’s office. In order to meet criteria, the plan of care must change.

The guidelines specifically address that a longstanding pattern of watching and waiting is not reasonable and necessary.

Let’s all make a pact to read section 40.1 of the federal guidelines focused on skilled services. If you will learn something you didn’t already know and maybe you can share it with the rest of us.  Experience tells that if one person missed something, chances are a lot of people did.   Education is a powerful tool and in our industry education is a must! Stay tuned, there is more to come.

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 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.

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