Home Health & Hospice Week

Make patient, treatment changes the cornerstone of your documentation for hypertension patients.

Don't write off your long-stay hypertension patients who are in legitimate need of skilled services. Follow these expert tips to head off denials for this group of patients.

1. Understand Medicare coverage criteria. You can avoid denials by doing your best to furnish only care that will be covered by Medicare. To do this, you need to understand the underlying coverage criteria, urges consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C.

Read through the Medicare Benefit Policy Manual chapter on home health services (Chapter 7) for the details your care must comply with. The manual chapter is at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//bp102c07.pdf.

Even if your patient has a skilled need, Medicare won't cover it endlessly (see related story, this page). For observation and assessment, which was the top denial reason in HHH MAC CGS's edit, when the patient "did not develop a further acute episode or complication, the skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential for such a complication or further acute episode," the Manual says.

2. Focus on patient changes. To prove your long- stay patient with a primary diagnosis of 401.9 (Essential hypertension, unspecified) needed O&A, you must show how the patient's condition exacerbated or changed. "The coverage criteria clearly indicate there must be evidence that the patient's condition is not stable," Laff points out. "Continued 'monitoring' of hypertension is not skilled unless the patient's [blood pressure] is erratic and out of control."

3. Show treatment changes. Having the patient's condition change is only half the documentation job. You also need to chart how the treatment is developing in response to the patient's condition.

"The question I would ask myself is whether active treatment of the hypertension is taking place," advises Chicago-based regulatory consultant Rebec-ca Friedman Zuber. "If the patient's blood pressure is labile or isn't coming down in response to treatment, then there should be evidence in the record of medication changes and other treatments designed to lower the blood pressure."

Not covered: If the patient's blood pressure "is troublesome but there is no evidence of efforts to control it, then the question is what is actually taking place that justifies the visits," Zuber tells Eli.

Pay special attention to the Manual's instru-ction that O&A isn't covered when the patient's condition is "part of a longstanding pattern ... and there is no attempt to change the treatment to resolve" problems, says clinical consultant Pam Warmack with Clinic Connections in Ruston, La.

Bottom line: For coverage, the chart needs "documented evidence that the MD is changing medications in response to this condition," Laff counsels.

4. Flesh out documentation. It's not enough for the patient to meet the coverage criteria -- your chart has to show she met them. "Every patient must be approached as an individual and the documentation of their needs and how home care can improve their recovery and ensure medical safety must be prominent," Warmack urges. "You must paint a picture of the patient's situation with your words and then prove in words how home care is going to make a difference."

5. Avoid pitfalls. Don't expect to have visits covered because you say you're teaching the patient about the condition or medications. "I often see this when performing record audits," Laff relates. "The [nurse] will 'teach' about signs and symptoms of HTN on one visit, one med per visit for five visits, and then start over."

Likewise, arbitrarily changing the patient's primary diagnosis to avoid edits such as the one CGS runs isn't a valid strategy for securing Medicare coverage. "The agency should not recertify the patient with a different primary diagnosis in an effort to reduce Centers for Medicare & Medi-care Services scrutiny," Laff charges. "I call it 'ro-tating diagnoses.'"

6. Don't overlook telemonitoring. Medi-care's coverage rules don't change just because you are using telemedicine equipment, Laff reminds agencies. Say you have a documented tracking system to monitor the BP. "If there has been no incident or series of incidents where the B/P has been out of control and the MD has not changed the medication, it is no longer considered to be a skilled service," she explains.

Option: "The agency could then provide monitoring under a private pay situation if the pa-tient agreed," Laff suggests.

7. Educate your staff. Don't let your education efforts end with yourself or other top management. "It is imperative to provide adequate orientation and ongoing education for clinicians," Laff urges.

You can't personally look over every visit note, so you need to teach staff how to spot patients whose Medicare coverage is at an end. That way you can avoid furnishing uncovered care, and getting claims denials for that care.

For example: "So many clinicians still be-lieve that anytime they simply assess and observe a patient that they are conducting the reimbursable skill of O&A," Warmack relates. "I try to train my clinicians that it is always the reasonable duty of a home care clinician to assess and observe a patient, regardless of the reason for the visit. Even if your reimbursement is captured from teaching activities or perhaps a task like wound care, the clinician begins every visit with an assessment of the patient and observing the patient. But as a reimbursable skill, O&A is a whole different animal."

8. Provide oversight. Still, frontline clinicians won't be able to make coverage calls all on their own. HHAs must "ensure continued oversight of the patient care delivery process," Laff advises.

Laff recommends ongoing case management by RNs, including routine one-on-one case conferences with the case manager. Ideally, conferences would occur every two weeks, and before discharges and recertifications. "All patients being recertified must be discussed with a manager prior to that recertification," she stresses.

End result: Say an agency mandates that no patient is recertified without a case conference with a manager. "The manager reviews the patient information with the SN to determine whether or not the patient is stable and has not had repeated exacerbations of HTN out of control (not one isolated incident not addressed by a med change)," Laff says. If the patient is stable, she should be discharged, Laff concludes.