8. Select Data Medicare Chapter 7 Training-Final

Information about 8. Select Data Medicare Chapter 7 Training-Final

Published on July 24, 2014

Author: SelectDataInc

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The Basics of Medicare Home Health Documentation Compliance Reasonable & Necessary Services: The Basics of Medicare Home Health Documentation Compliance Reasonable & Necessary Services Laura Montalvo, BSN, RN, COS-C, HCS-D, Chief Clinical Officer at Select Data Goal/Objective:: Goal/Objective: Increase clinician understanding of Medicare-required clinical documentation PowerPoint Presentation: According a recent study, “ Documentation is the key to increasing and verifying reimbursement in homecare…complete and clear documentation is certainly best for patient care, communication among providers, and to justify proper billing”. 2,304,606: 2,304,606 This was the number of patient’s over a 6 month period whose name on claim didn’t match what was on his/her card—all these claims were RTP’D (returned to provider). This is the most common reason for claims being returned or rejected. Overview of Documentation: Overview of Documentation Use descriptive, objective language Remember that the patient is in front of admitting/recertifying clinician, but not in front of the medical chart reviewer Follow legal standards for documentation in your state of service If it is not documented, then it is not done Documentation to Support Homebound Status: Documentation to Support Homebound Status Confined to the home – Describe why the patient is homebound. An individual is considered “confined to the home” if both of the following two criteria are met: Criteria 1--The patient must either: Because of illness or injury, need supportive devices such as crutches, canes, wheelchairs, and walkers; special transportation; or another person’s help to leave his or her residence, OR Have a condition such that leaving his or her home is medically contraindicated Criteria 2--There must exist: A normal inability to leave home; AND Exertion of a considerable and taxing effort needed to leave the home Documentation to Support Homebound Status: Documentation to Support Homebound Status Example #1: GAIT/SOB/FALLS/CV DISEASE EXAC. “Patient is homebound due to inability to ambulate for more than a few minutes or few feet without falling due to poor balance and extreme fatigue/weakness; very SOB with minimal exertion and patient must stop to sit and rest every few minutes or he/she cannot go on. Patient has had multiple falls with injury in recent past and also requires the assistance of another person to ambulate at all times due to unsafe gait pattern and cardiopulmonary disease exacerbation.” Documentation to Support Homebound Status: Documentation to Support Homebound Status Example #2: DEMENTIA/SAFETY/FALLS “Patient is homebound due to end-stage dementia and cannot be left unattended due to wandering behaviors and extremely poor cognition. Patient has wandered away from home and been lost in the past resulting in injury. The patient is now too disoriented to safely leave home alone and requires frequent prompting and redirection of another person to keep the patient from harm. The patient also exhibits poor balance and falls easily if not supported by another person during all attempts at ambulation.” Documentation Continued…: Documentation Continued… Explain situations where leaving the home are medically contraindicated. Explain absences from the home including reason, frequency, and duration. Examples of homebound explanations when leaving home for medical reasons:: Examples of homebound explanations when leaving home for medical reasons: Patient stated when she returned home she was very tired, short of breath, and had to lie down for about an hour. Pt stated upon returning home he had to take additional pain med due to increased pain from walking. He rated his pain at a 6 and his normal is a 2. Examples Continued: Examples Continued Pt stated he uses a walker in the home, but must use a wheelchair when he goes to the doctor due to inability to walk more than 10 minutes before resting. Pt stated she occasionally goes to church with her daughter, but it tires her out so much she has to go to bed the rest of the day. Health-Care Related Absences: Health-Care Related Absences Visits to physicians office Visits to a wound care center for treatment Dialysis, chemotherapy or radiation as an outpatient. Health-Care Related Absences Continued: Health-Care Related Absences Continued When some services cannot be provided at the patient’s home due to unavailability of special equipment, the home health agency may make arrangements with a hospital, SNF, or rehab center to provide these services as outpatient services. Pt must still meet the Medicare homebound criteria and documentation should include the condition of the patient upon return from the outing. Documentation Example of Absence Related To Health Care: Documentation Example of Absence Related To Health Care The clinician would document: Patient stated she goes to the wound care center once a week. She takes pain medication prior to going and upon return home due to severe pain when ambulating with the assistance of another person at all times due to poor balance and falls. She states the trip is very stressful and requires her to go to bed and rest. A.Smith RN What is Skilled Teaching & Training?: What is Skilled Teaching & Training? Requires the skills of the nurse to teach. Reasonable and necessary for patient’s condition. Covered for a reasonable period of time (not indefinitely). Not covered if patient or caregiver not willing or able to be trained. Always document why the training was unsuccessful. When is Re-teaching or Re-training Covered?: When is Re-teaching or Re-training Covered? Re-teaching may be considered reasonable and necessary for an appropriate period of time when there is a change in the patient’s condition or when the pt/cg is not properly carrying out the task/procedure. The medical record should document the reason that the re-teaching or re-training was required. Skilled Therapy Documentation: Skilled Therapy Documentation Goals of Therapy Current versus prior status Progress toward goals Medical necessity of services to include: Diagnoses Functional level and impairments Activity limitations Orders: Orders Orders must specify each discipline and type of service to be rendered by each discipline. Orders should also include specific frequency and duration of service. PRN visits must be quantified and qualified. PRN Orders: PRN Orders Orders for services to be furnished “as needed” or “PRN” must be accompanied by a description of the patient’s medical signs and symptoms that would require a visit and a specific limit on the number of those visits to be made under the order before an additional physician order would have to be obtained. Handwriting Requirements: Handwriting Requirements Medicare requires the individual who ordered or provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the individual’s first and last name and credentials. What if a Doctor’s Signature is Illegible?: What if a Doctor’s Signature is Illegible? If a physician’s handwritten signature is illegible, a printed name must be used under his/her signature and a physician signature attestation statement is required. What About the Date?: What About the Date? If the physician fails to date his signature, the agency must send the order back to have the physician date or be at risk for technical denial and payment loss. Endpoint/End in Sight: Endpoint/End in Sight MUST BE A FINITE, PREDICTABLE, AND REASONABLE ENDPOINT TO DAILY SKILLED NURSE VISITS WHEN: Skilled nurse is the qualifying skill, and Skilled nursing is being provided daily (7days/week), and Daily skilled nursing visits are expected to last more than a short period of time (3 weeks or less) So How Do you Document Endpoint?: So How Do you Document Endpoint? Can be stated in days, weeks, months, or a specific date. It’s the nurse’s ‘best estimate’ as to when daily skilled nursing services will decrease to less than daily. Skilled nursing is the only discipline that requires an endpoint to daily visits. Are there any exceptions to the endpoint rule?: Are there any exceptions to the endpoint rule? Daily insulin injections are the only exception to the endpoint requirement! Medical Social Services: Medical Social Services Appropriate when social concerns impede effective implementation of the POC. Social problems seen in home health include finances, housing, and caregiver concerns. Medical Social Worker Services Documentation: Medical Social Worker Services Documentation Substantiate that the services require the MSW Support that the patient’s social/emotional problems impact the overall medical condition of the patient. Key To Prevent Payment Denials: Key To Prevent Payment Denials Must “paint a picture” for the nurses/therapists that are reviewing your claims. How good an artist are you? What Are These ‘Reviewers’ Looking for in Your Documentation?: What Are These ‘Reviewers’ Looking for in Your Documentation? Patient’s health status and medical needs should be reflected in the plan of care (485), OASIS, and clinical documentation. The length of time services are covered is determined by the needs of each individual beneficiary. There should be no contradications between the information on the plan of care, OASIS, and clinical documentation. What does Medicare specifically want you to avoid?: What does Medicare specifically want you to avoid? Words like “stable”, “same as last visit”, “norm”, “normal” “independent with supervision” (because it contradicts itself) % of meal eaten (also need to put what they ate because it can vary greatly) For example—100% of an apple is very different than 100% of a Fried Seafood Platter Also Avoid:: Also Avoid: Relying on memory Using liquid eraser Crossing out words beyond recognition Making assumptions, drawing conclusions, or blaming. Using abbreviations unless they are clear and appear on your agency’s list of approved abbreviations. Medicare’s Most (Un)Wanted List: Medicare’s Most (Un)Wanted List Non Response to ADR Lack of Medical Necessity of Services Denials Related to Orders Endpoint Denials Plan of Care/Certification Denials Lack of Medical Necessity of Services—What does it mean?: Lack of Medical Necessity of Services—What does it mean? Submitted documentation does not establish the medical necessity of the services rendered, or The beneficiary no longer meets the need for skilled services. How to Prevent this Problem!: How to Prevent this Problem! Document: New onset or exacerbation of diagnosis New or changed medications Recent Hospitalizations Acute changes in condition Changes or instability in caregiver status Complicating factors Teaching performed-support need for re-teaching Top Denials Related to Orders: Top Denials Related to Orders No physician’s orders for services or more than ordered Verbal orders not signed and/or dated timely Incomplete physician’s orders How to Prevent this Problem!: How to Prevent this Problem! Adequate physician’s orders to cover all services billed. All orders must include: Specific services to be provided Specific discipline to render the services Specific frequency and duration of services Denials R/T Endpoint: Denials R/T Endpoint Endpoint statement given, but is not valid. No documentation to support exemption from endpoint requirement. How to prevent this problem!: How to prevent this problem! Work closely with MD to determine estimated endpoint to daily SNV. Ensure documentation includes a specified endpoint. Include documentation to support that endpoint is realistic and progress toward meeting that endpoint. Include documentation to support exception to endpoint requirement for insulin injections. Tips when charting routine/progress notes:: Tips when charting routine/progress notes: Include on every note: Any changes in the patient’s condition Skilled interventions performed related to the 485 or POC The patient’s responses to the services provided Any event or incident in the home that would affect the treatment plan Vital Signs Tips for notes continued…: Tips for notes continued… Include on every note: Communication with other team members since the previous visit Patient/Caregiver education (includes written instructional materials and brochures as well as the pt’s response to the instruction and any return demonstrations). Discharge Plans Chart all events in chronological order. 60 Day Summary Tips:: 60 Day Summary Tips: Include: Current problems, treatments, interventions, and instructions Home health care provided by other health care professionals, such as PT,ST,OT,MSW, and HH Aides Reason for any change in services Patient outcomes and responses—both physical and emotional—to services provided. Hospitalizations Goals attained or not attained and why not. D/C Summary Include:: D/C Summary Include: The time frame covered The services provided The clinical and psychosocial conditions of the patient at discharge Recommendations for further care Caregiver involvement in care Interruptions in homecare such as readmission to the hospital Referral to community agencies Patient’s response to and comprehension of patient-teaching efforts Goals attained Care Supported By Documentation….: Care Supported By Documentation…. Is supported by your assessment Is ordered in the plan of care Is reasonable and necessary according to the patient’s medical diagnoses Is helping the patient make progress Medicare Payment Terminology Defined: Medicare Payment Terminology Defined Focused Medical Review (FMR): This is the targeting or directing of medical review efforts by the Medicare Administrative Contractor (MAC) in an attempt to identify providers who may be providing inappropriate or noncovered care. Often this review takes place long after the care has been provided; hence a paid claim is not necessarily a covered claim. This is why the documentation must be accurate and complete and support covered care! Medicare Terms Defined : Medicare Terms Defined The Centers for Medicare and Medicaid Services (CMS): An agency of the US government responsible for the Medicare and Medicaid programs. Outlier : An addition to a full episode payment in cases where costs of services delivered are estimated to exceed a fixed loss threshold. Medicare Terms Continued: Medicare Terms Continued Partial Episode Payment (PEP) (adjustment): A reduced episode payment that may be made based on the number of service days in an episode (always less than 60 days, employed in cases of transfers or d/c’s with readmissions). UB-04 : The claim or bill form. LUPA : Low utilization payment adjustment RAP : Request for anticipated payment. ADR : Additional development or documentation request. PowerPoint Presentation: Remember that documenting effectively is a learned skill, and, as with any skill, improvement comes only with practice and effort! References-The Basics Of Medicare: References-The Basics Of Medicare http://www.palmettogba.com www.cms.gov www.nubc.org www.who.int/classifications/icf/en Lippincott, Williams, & Wilkins: Complete Guide to Documentation www.mosby.com/homecare HOME HEALTH DOCUMENTATION COMPLIANCE TRAINING: HOME HEALTH DOCUMENTATION COMPLIANCE TRAINING Developed by: Laura Montalvo, BSN, RN, COS-C, HCS-D Chief Clinical Officer Select Data Audit Trends: Audit Trends “ Home health agencies should expect to be scrutinized like never before. The government is committed to minimizing waste, fraud and abuse in Medicare and Medicaid. As a result, Medicare, Medicaid and their contractors are ramping up their efforts to audit providers and ferret out billing mistakes, improper coding, lack of medical necessity and the like. Private payers are also on the bandwagon, conducting their own audits of participating providers.” -Quote from Decision Health, Audit Toolkit for Home Health Providers, Second Edition Audit Trends: Audit Trends Failure to document the MD verbally approved implementation of the proposed plan of care prior to initiation . Failure to document the MD verbally approved the implementation of the proposed therapy plan prior to initiation . Dependence on check boxes. Dependence on pre-determined “canned” care plans/goals. Little to no documentation that skilled care was actually performed. Failure to write PRN orders per Medicare requirements. Documentation of homebound status not specific. Failure to follow ordered frequencies. More Audit Trends: More Audit Trends Non-specific orders for disease process teaching. Failure to notify MD of changes in patient condition. Over utilization. Multiple non-visit discharge OASIS (this practice is not recommended by Medicare and the practice negatively impacts patient outcomes). Therapy goals are not based on the use of objective measures and tools to evaluate the patient. General non-patient specific interventions on 485. Therapists not performing temperature/VS checks. Missed visits (failing to notify MD of missed visits). Lack of coordination of care between the disciplines/MD. Documenting the Verbal SOC: Documenting the Verbal SOC Per Chapter 7, Home Health Medicare Benefit Policy Manual, Use of Oral (Verbal) Orders, Section 30.2.5: “Services which are provided from the beginning of the 60-day episode certification period based on a request for anticipated payment and before the physician signs the plan of care are considered to be provided under a plan of care established and approved by the physician where there is an oral order for the care prior to rendering the services which is documented in the medical record and where the services are included in a signed plan of care .” Examples of non-billable Verbal SOC: Examples of non-billable Verbal SOC “Called MD office and notified of admission.” “Called Dr. Smith and left message that patient has been admitted.” “Called MD office and left message with medical assistant. “Called Dr. Johnson and no answer; left message with answering service.” No documentation that the MD or MD office was ever contacted after SOC, Recert assessment or Therapy eval visit has taken place for the verbal approval to initiate the proposed plan of care/therapy plan. Examples of billable Verbal SOC: Examples of billable Verbal SOC “Called Dr. Smith and received verbal approval to initiate the proposed plan of care as communicated.” “Called Dr. Jones office and received verbal approval to initiate the proposed plan of care from Lisa Langton, Medical Assistant (physician representative) after she communicated plan to Dr. Jones.” “Follow-up call placed to Dr. Smith office after leaving message yesterday, but not receiving return call. Communicated proposed plan of care to office coordinator, Jane Doe, who states she will communicate plan to MD and call me back. Received return call approving the proposed plan of care from Jane Doe,(physician representative) on behalf of Dr. Smith. Examples of Poor Homebound Documentation: Examples of Poor Homebound Documentation “Taxing effort to leave home.” “Patient cannot drive.” “Patient remains homebound.” “Patient is independent at home and with all care.” “Patient has no trouble getting around at home.” “Unable to leave home safely alone.” (Must state why) “Patient states she walks to bus stop to go to MD visits.” “Residual weakness.” (Must state how this makes pt. homebound as many people are weak, but not homebound) “Patient is progressing well without limitations.” (Homebound status is considered a limitation) Failing to document any narrative description regarding homebound status on each visit note. CMS Homebound Narrative Example: CMS Homebound Narrative Example Narrative Example “The patient is temporarily homebound secondary to status post total knee replacement and currently walker dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for signs of decomposition or adverse events from the new COPD medical regimen.” Excerpt from the CMS Physician Home Health Face-to-Face Requirement Power Point. Documentation Examples that Support Homebound status: Documentation Examples that Support Homebound status “Patient requires one-person assistance to ambulate due to poor balance, morbid obesity, frequent falls, and residual weakness from recent cardiac surgery. “Patient is SOB when ambulating more than 20 ft. with the use of a walker and must sit down and take multiple breaks to rest due to extreme weakness and respiratory problems from COPD.” “Patient has advanced dementia and is unable to leave home unassisted due to confusion and severe memory deficits.” “Patient is medically-restricted to home for 4 weeks due to major GI surgery from diverticulitis complication and also has poor balance, weakness, and frequent falls. “Patient has severe pain from Rheumatoid arthritis flare-up and has unsteady gait even with use of a wheeled walker. Patient now requires one person assistance to ambulate safely on unlevel surfaces.” Examples of Non-Billable Teaching & Training: Examples of Non-Billable Teaching & Training “Taught patient S/S of CHF exacerbation.” (Nonspecific) “Discussed HTN, COPD, UTI dx with patient.” (Nonspecific) “Reviewed S/S to report to MD.” (Nonspecific) “Medication review performed.” (Nonspecific) “Retrained on Lisinopril side effects.” (Nonspecific & without valid reason to support retraining) “Safety measures reviewed.” (Nonspecific) “Disease process taught.” (Nonspecific) “Taught on Leukemia and medications.” (Nonspecific) “Instructed on S/S of infection, GERD, COPD.” (Nonspecific) Examples Billable Teaching & Training: Examples Billable Teaching & Training 1. “Instructed patient and daughter (Rose Brown) on signs and symptoms of CHF to report to agency or MD: weight gain, swelling in extremities, SOB or coughing, increased congestion, fatigue and weakness. Patient and daughter both able to return verbalize teaching given.” 2. “Instructed patient on signs and symptoms of post-operative wound infection to report to agency or MD: temperature > 99.1, increased drainage, foul smelling odor, pus, increased pain, swelling, or redness. Patient was able to repeat instructions given with prompting by this RN.” 3. “Taught patient and caregiver (Rick Smith) on prevention of asthma attacks: identify and know asthma triggers as well as early warning signs of an attack—chest tightness, coughing, wheezing, increased resp. rate/trouble breathing. If patient experiences an attack, immediately utilize rescue inhaler of Albuterol 2 puffs every 4-6 hrs as needed. Patient and caregiver both verbalized full understanding.” Examples of Non-Billable Observation & Assessment: Examples of Non-Billable Observation & Assessment “SN eval done.” “Observation and assessment performed.” “Head-to-toe assessment performed as ordered.” “Review of body systems done.” “VS assess.” “Assessment done.” “Evaluation WNL.” “Patient with +2 bilateral edema to ankles.” “Patient with scattered crackles to lungs bilaterally.” “Patient with green sputum and cough. Told patient to make MD appt.” Examples Billable Observation & Assessment: Examples Billable Observation & Assessment 1. “Skilled head-to-toe assessment with focus on cardiopulmonary system due to recent hospitalization due to CHF exacerbation. Bilateral +2 edema noted to ankles and patient has gained two pounds in 3 days (187 lb. on 2/2/12 and is now 189 lb.). Call placed to Dr. Smith with report of deviations and received orders to instruct patient to take an additional dose of Lasix 20 mg today and SNV tomorrow.” 2. “Full body system assessment with focus on respiratory system due to recent hospitalization with COPD exacerbation. Patient is noted to have coughing and upper congestion which remains consistent with baseline respiratory status. Continued observation and assessment is needed due to likelihood that cough/congestion may increase and result in COPD exacerbation and/or return to hospital.” SN Wound Care Not Complex: SN Wound Care Not Complex No depth to wound (closed suture line) Cleaning with SNS or wound cleanser and applying a gauze or band-aide repeatedly No signs and symptoms of infection noted/documented Cleaning with betadine and leaving open to air No clinical explanation in documentation of why the patient required continued skilled nursing when no signs or symptoms of infection were present and the wound care being performed was simple. Typically, only 2-3 visits will be covered by most MACs Order Requirements: Order Requirements Per Chapter 7, Home Health Medicare Benefit Policy Manual, Specificity of Orders, Section 30.2.2: All orders must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services. (Cannot write frequency only orders as they are invalid without a corresponding treatment plan) PRN orders must also be accompanied by a description of the patient’s medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician order would have to be obtained. References-Home Health Documentation Compliance: References-Home Health Documentation Compliance Medicare Benefit Policy Manual, Chapter 7 – Home Health Services; http://www.cms.gov/manuals/Downloads/bp102c07.pdf State Operations Manual, Appendix B – Guidance to Surveyors: Home Heath Agencies Reasonable and Necessary Services: Reasonable and Necessary Services Covered Services under the Medicare Home Health Benefit Select Data Objectives: Objectives To gain a basic understanding of what services are covered under the Medicare Home Health Benefit Conditions That Must Be Met: Conditions That Must Be Met To qualify for Medicare Home Health: Be confined to the home; Under the care of the physician; Receiving services under a plan of care established and periodically reviewed by a physician; Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or Have a continuing need for occupational therapy Recovery Audit Contractors (RACs): Recovery Audit Contractors (RACs) Recovery Audit Contractors (RACs) base denials on specific language and examples cited in the Medicare Benefit Policy Manuals such as in Chapter 7 (Chapter 10 Claims Processing can be cited as well) Clinicians must thoroughly understand and display application knowledge of billable skills versus non-billable skills and coverage criteria in clinical documentation based on Chapter 7 guidance. Failure to understand the rules regarding billing O&A, Teaching/Training, Direct Skill, M&E for SN and Therapy general principles governing reasonable & necessary/maintenance therapy as covered services, will result in RAC denials and financial take backs. Observation and Assessment: Observation and Assessment O & A is reasonable and necessary “ when the likelihood of change in a patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures until the patient’s treatment regimen is essentially stabilized. ” O & A: O & A How long is O & A covered after a patient is discharged from the hospital and admitted to home care if there is no further acute episode or complication? O & A : O & A Answer Three weeks. Medicare allows this because there is a reasonable potential of a complication or further acute episode (think rehospitalization) O & A: O & A O & A is no longer covered when the treatment of the illness or injury is part of a longstanding pattern of the patient’s condition, and there is no attempt to change the treatment to resolve them. Management and Eval: Management and Eval M & E is covered when the underlying conditions or complications require that only a registered nurse can ensure that essential nonskilled care is achieving its purpose. RN performs M & E of the patient’s plan of care and the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the patient’s recovery and medical safety in view of the patient’s overall condition. Teaching & Training: Teaching & Training Teaching & 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. Teaching & Training: Teaching & Training 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. Teaching & Training: Teaching & Training When is teaching & training no longer covered? 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. Actual Skilled Care: Actual Skilled Care Injections—B12 allowed for DX of pernicious anemia Insulin injections is customarily self-injected by patients or is injected by their families—however can be exception (outlier) The pre-filling of insulin (or any other med) does not require the skills of a licensed nurse and, therefore, is not covered Oral med admin and eye drop admin are not covered in most circumstances. Actual Skilled Care: Actual Skilled Care Tube feedings are covered as long as the feedings are required to treat the patient’s illness or injury Nasopharyngeal and Tracheostomy Aspiration are covered Catheters—insertion, sterile irrigation, and replacement are all covered Wound care (not simple) would be covered Ostomy care covered Venipuncture: Venipuncture Effective February 5, 1998, venipuncture for the purposes of obtaining a blood sample can no longer be the sole reason for Medicare home health eligibility. Can only be covered if patient has another qualifying skill AND meets all home health eligibility criteria. For Prothrombin—covered when the documentation shows that the dosage is being adjusted Therapy Not Reasonable or Necessary: Therapy Not Reasonable or Necessary Denial Trend: failure to document both short and long-term goals on 485 or therapy plan. Note: this includes all therapy patients no matter how short their duration of care. Per Palmetto appeal letter findings: “Even though the documentation supports the beneficiary was homebound and in need of home health services, the physical therapy plans of care/evaluations/visit notes do not contain measurable short and long term goals which are a requirement for Medicare. All goals are established to be completed by ‘4 weeks’.” Therapy Not Reasonable or Necessary: Therapy Not Reasonable or Necessary The Home Health LCD for Physical Therapy (latest version) L 31542 requires: “Both short and long term goals stated in measurable terms, and their expected date of accomplishment.” Therapy Not Reasonable or Necessary: Therapy Not Reasonable or Necessary Denial trends: repetitive therapy notes documenting the performance of therapeutic exercises and gait training with patient (sometimes only change was in reps), but lacking documentation as to why the skills of a therapist were needed to perform the nonskilled care. Denial trends: Copying and pasting of exact therapy notes over and over with little editing made it appear that the patient did not have any real changes with the therapy services and billable skills were not being performed. Therapy Not Reasonable or Necessary: Therapy Not Reasonable or Necessary Per CMS Medicare Benefit Policy Manual, Chapter 7: “A service that is ordinarily considered nonskilled could be considered a skilled therapy service in cases in which there is clear documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform the service . However, the importance of a particular service to a patient or the frequency with which it must be performed does not, by itself, make a nonskilled service into a skilled service. Therapy Not Reasonable or Necessary: Therapy Not Reasonable or Necessary Denial patterns: records where therapist performed only one skilled evaluation visit did not perform a billable skill on that visit. An evaluation alone is not an automatic billable skill. This pattern continued on discharge notes where therapists would document all goals were met with specific measurements, but no billable skill was performed on the discharge visit. Denial patterns: records that once the therapist documented the patient could ambulate on level and unlevel surfaces with an assistive device, that homebound criteria was no longer met (in many cases) and the patient became ineligible for the home health benefit. Therapists continued working on other goals that were not met (strength, ADL, ROM, etc ) despite not documenting specifically how/why the patient was still homebound note to note. Therapy Documentation : Therapy Documentation Be alert when treating upper extremity injury/condition that homebound is truly met and is documented note to note. Once patient is able to ambulate with AD on level and unlevel surfaces, question homebound status (even if there are still other goals not met). Either discharge or explain thoroughly how/why the patient remains homebound note to note. Ensure all therapy patients have short and long term goals documented despite the duration of care. Document why the skills of a therapist are needed to perform the nonskilled care of ambulating and exercising, etc , on each note (think complications, risk for hospitalization, improper form placing patient at risk for falls/injury, etc ). Perform a billable skill on every note (be on heightened alert for one time evaluation visits where the patient is deemed not appropriate for continued therapy and also on discharge visits were goals are all met). References-Reasonable & Necessary Services: References-Reasonable & Necessary Services Medicare Benefit Policy Manual, Chapter 7-Home Health Services Should you have any questions regarding any information on this presentation, please contact Laura Montalvo, Chief Clinical Officer at Select Data at (714)287-0997.

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