Home Health & Hospice Week

Trying to bill for episodes with a single skilled nursing visit and any number of occupational therapy visits could be a costly mistake.

Regional home health intermediary Cahaba GBA is editing such home health agency claims and issuing widespread denials, it says in its September newsletter for providers. "The primary denial reason was due to the one-time nursing visit not being medically necessary or not intermittent," the RHHI ex-plains in the Newsline. "To be covered as skilled nursing services, the services must be intermittent, require the skills of a nurse, and must be reasonable and necessary to the treatment of the patient's illness or injury."

Toll: The cost of this mistake is great in otherwise OT-only episodes. If medical reviewers can deny the nursing visit, the entire episode will get denied because OT is a dependent service. That means OT is allowed only when another qualifying service -- skilled nursing, physical therapy or speech-language pathology -- is present, notes therapist and consultant Cindy Krafft with Fazzi Associates based in Northampton, MA.

Definition: For Medicare coverage, "intermittent" means "a service ordered generally every 60 days ... and less than daily," Cahaba notes. In special circumstances, that can be 90 days.

In other words, patients must require more than one skilled nursing visit per episode to be eligible for home care under the intermittent criteria, explains consultant Judy Adams with LarsonAllen based in Charlotte, NC.

Exception: There is an exception for when a single SN visit is OK, Krafft points out. "It would be valid if the nurse intended to do more than one [visit] but something stopped that from happening -- like the patient refused further nursing care," she tells Eli.

Pitfall: Some agencies have a hard time understanding that a nurse visit to complete OASIS doesn't qualify the patient for Medicare. Even if the nurse furnishes another qualifying skill on that visit, it still won't be billable in an otherwise OT-only episode due to the intermittent criteria.

By the way: Single SN visits with otherwise physical therapy-only episodes are allowed, Krafft acknowledges. "But it still can raise suspicion," which could land you in the medical reviewers' crosshairs, she warns.

Once a patient does qualify for a home health episode, OT can be the only discipline involved for the rest of the episode and even for a subsequent episode, Adams notes. The hurdle is securing the qualification.

Try this: One strategy is to split the medically necessary nursing services into two visits, Krafft suggests. "Two visits are better to show what the need was -- and to follow up on any teaching done at the first visit," she says.

You can spread out the two visits over a week or two, she offers. But "keep in mind, there still needs to be a skilled reason for the two visits or they will be denied," she adds. Nevertheless, the two visits will decrease risk with the edit.

Skilled reasons for small numbers of visits can include "teaching about a new disease process or medication, doing a procedure like administering an injection, starting an IV, inserting a catheter or doing wound care or some other physician-ordered treatment for the patient," Adams offers.

Tip: "To avoid a denial like this, the nurse must clearly document the provision of a skilled service in addition to the assessment visit and clearly show that the patient will require more than one skilled nursing visit to meet their medical condition needs," Adams counsels.

If you have an episode where you planned more than one SN visit but were unable to deliver them, be sure to document that carefully, Adams advises. "If there are special circumstances and the nurse did plan to see the patient for several visits but something happened to the patient that meant the nurse could not make those visits, the original plan and the circumstances that interrupted that plan must be documented."

Hope for change: The American Occupa-tional Therapy Association and other OT advocates are lobbying for a change to Medicare rules that would allow OT to be a qualifying service, Krafft notes.

Medicare did briefly allow OT as a qualifying service in the 1980s, but quickly rescinded the change, Adams recalls.

But agencies shouldn't hold their breath, since policymakers are reluctant to make changes that could increase spending for the Medicare program, experts say.

Note: Cahaba's September Newsline is on-line at www.cahabagba.com/rhhi/news/newsletter/200809_rhhi.pdf.