Home Health & Hospice Week

Consider a referral for PT or OT evaluation.

Palmetto GBA’s new LCD addressing diabetes patients is one manifestation of the Centers for Medicare & Medicaid Services’ extra scrutiny to claims for insulin injections. Another is CMS’s list of diagnoses that could show a patient is unable to self-inject (see Eli’s HCW, Vol. XXIII, No. 38 & No. 39).

The increased focus follows a 2013 report from the HHS Office of Inspector General that found fraud and abuse problems related to claims containing diabetes diagnoses and outlier payments for insulin injections — as well as years of outlier abuse for insulin injection patients in the Miami area. That abuse led to the 10 percent outlier cap’s imposition in 2010.

Try this: A thorough, documented assessment can back up the need for your patient to receive skilled visits for insulin injection. But before a skilled nurse assesses for ability, you may want to consider a referral for an occupational therapy or physical therapy evaluation, says nurse consultant Judy Adams with Adams Home Care Consulting in Asheville, N.C. “These disciplines have access to a large box of tools that they can use in assessing and treating patients in areas such as manual dexterity, vision, mobility and general activities of daily living,” she says.

(For a list of some specific tools that can be used with diabetic patients, see Eli’s Home Health and Coding OASIS Expert, Vol. 12, No. 5).

Use CMS Code List To Your Advantage

In addition to documenting the patient’s cognitive and functional assessments, ensure that you verify those issues found with the physician and code for them as part of the OASIS, POC, and claim. You can use CMS’s proposed list of diagnoses that substantiate the need for the nurse to inject the insulin and include on these patients’ claims, suggests coding expert Lisa Selman-Holman of Selman-Holman & Associates, Code Pro University and CoDR — Coding Done Right in Denton, Texas.

CMS worked with a contractor to come up with the list of 165 diagnoses that would help prove a patient’s eligibility for insulin injections. Ironically, many of the diagnoses are among those recently removed from the case mix list.

“It’s almost like CMS was saying ‘If you didn’t identify this diagnosis as a need for resources, we’re going to take resources away from it. We know you’ll start using these diagnoses to support coverage, but we’re not going to give you extra coverage for them,” Adams said during the recent Eli-sponsored AudioEducator audioconference, Are You Ready for the 2015 Home Health PPS Changes?

Note: Order a recording or transcript of Are You Ready for the 2015 Home Health PPS Changes? at www.audioeducator.com/home-health/home-health-pps-coding-updates-01-15-2015.html.