Home Health & Hospice Week

Beware of recycling diagnoses for recertifications.

RACs and other Medicare contractors are zeroing in on medical necessity in medical review. Use this expert advice to dodge denials in this area.

You can head off problems by making certain that the patient qualifies for recertification by performing routine one-on-one case conferences, advises consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. In the conference, ask these diagnosis code-related questions to help determine whether medical necessity exists — before the Recovery Audit Contractors do:

1. What is the patient’s primary diagnosis for this episode?

• This would include asking the right questions during the case conference — has the patient had any signs and/or symptoms of exacerbation of diagnosis, or has the patient’s condition been completely stable?
• Has the physician ordered new medications or changed dosages? (This does not include over the counter “simple” meds like Tylenol etc.)
• Was the symptom isolated or sustained over a period of days?

2. Is the diagnosis the same as the prior episode?

• Is there evidence of adequate clinical case management (how many visits, telephone contacts, etc.)?
• Was teaching adequate? “If there is documentation in the record that the ‘patient and/or caregiver verbalized understanding’ of the teaching — then you are on very thin ice if you are recertifying a patient for the same diagnosis only for teaching,” Laff stresses.

3. Are you “recycling” diagnoses? Make sure you’re not switching to a secondary diagnosis, where there may be no evidence of exacerbation of that problem, Laff cautions.