Home Health & Hospice Week

If you're furnishing episodes that skirt the LUPA line, you'd better brush up on your Medicare coverage basics or face denials.

That's what home health agencies whose claims fell into two edits from regional home health intermediary Cahaba GBA have found out the hard way. Cahaba has two widespread edits in place for episodes with five visits -- one for claims containing one skilled nursing visit and four therapy visits,and one for claims containing a single medical social worker (MSW) visit.

In the latest period, Cahaba medical reviewers denied 88 percent of the claims with one nursing visit and four visits of any kind of therapy. And they denied 76 percent of claims with one MSW visit making up one of the five visits, Cahaba says in its March newsletter for providers.

For the nursing-therapy claims, "the top denial reason ... was related to medical necessity of the one-time skilled nurse visit," Cahaba explains. For the MSW claims, reviewers also made many denials based on medical necessity for the MSW visit.

These are typical problems for HHAs, says Chicago-based regulatory consultant Rebecca Friedman Zuber.

And they can have a significant impact on agencies' reimbursement, warns consultant and physical therapist Cindy Krafft with Fazzi Associates in Northampton, Mass. Getting just one visit denied in a five-visit episode will knock it down to low utilization payment adjustment (LUPA) status,where Medicare payment is per visit.

The cost: The knock-down from five to four visits can cost you $1,500 to $2,000 per episode,estimates billing expert M. Aaron Little with BKD in Springfield, Mo.

Or it could be even more. The average episode payment in 2008 was about $2,685 while the average payment for four-visit LUPAs was $400 -- a $2,285 difference, Little points out.

"You can see the motivation to remove the nurse visit," Krafft says.

All nursing visits, including single ones,need to meet Medicare coverage criteria, Cahaba notes in its article. "To be considered as skilled nursing services under Medicare regulations, the services must require the skills of a nurse, and must be reasonable and necessary to the treatment of the patient's illness or injury."

A stand-alone visit to perform the OASIS assessment does not meet that criteria, Cahaba warns. "If an agency chooses to have the nurse perform the SOC assessment, the admission visit would be non-billable when there is no 'skilled nursing need' associated with the patient's condition."

Reasonable and necessary services are those that are "consistent with the nature and severity of the illness or injury, the patient's particular medical needs, and accepted standards of medical and nursing practice," Cahaba explains.

This requirement often trips up agencies because under the prospective payment system, they don't think of billing on a visit-by-visit basis, Krafft tells Eli.

"With PPS, folks have forgotten about the coverage requirements," Friedman Zuber adds.

And clinicians have a hard time understanding how a SOC visit isn't billable when the OASIS assessment takes so long to complete, says consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C.

What qualifies: One-time skilled services like venipuncture, removing a catheter, and removing sutures will ensure the visit is billable, Adams notes.

What doesn't: Like OASIS, doing a home safety assessment or post-hospital medication management check are administrative issues and not billable skilled services, Cahaba says.

And be careful with trying to use teaching or observation and assessment as your skilled service. "Generally, if the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba tells agencies.

With teaching, it's hard to convincingly show all necessary teaching was completed in one visit. To help keep your five-visit claims bulletproof, consider these five tips from the experts:

1. Have therapists open cases. You can bypass the one-nursing-visit denial problem altogether by having therapists open therapy-only cases, Krafft suggests. "Revisit why nurses are admitting therapy cases to determine if the practice is still sound from an operational/cost perspective." "Therapists may perform the SOC assessment when there are no nursing orders," Cahaba reminds HHAs.

2. Spread teaching to two visits. If teaching is your skilled service, you'll probably need to spread it out over at least two visits. "Questions of medical necessity are raised when another discipline is added just for one visit to do teaching that potentially could have been provided by the staff already visiting the patient," Adams points out.

"Consider an additional nursing visit for follow up on any teaching done on the first visit," Krafft suggests.

3. Beef up documentation. Especially for episodes that barely exceed the LUPA threshold, your clinicians' visit notes need to be able to stand alone. "The clinician must clearly document what the patient need is and what skill was provided,"Adams advises. "The clinician must show why the service is needed and why it requires the skills of nurse, therapist, or social worker."

"Basic education about a disease or disorder can be provided by many different types of clinicians," Adams notes. Your staff's notes must showwhat skilled need was present.

4. Train staff on the basics. Clinicians will have a hard time documenting the skilled need if they don't really understand its definition under Medicare. "Conduct internal education simply by using the Medicare Benefits Policy Manual," advises clinical consultant Pam Warmack with Clinic Connections in Ruston, La.

"We need to do intensive training of what is considered to be a billable skilled nursing visit," Friedman Zuber urges.

And don't just conduct training once and consider the problem taken care of. "Remember to repeat training several times each year as staff changes are common," Warmack says.

5. Put near-LUPAs in your own crosshairs.Intermediary medical reviewers aren't the only ones who should be going over five-visit episodes with a fine-tooth comb. "Always select low utilizationepisodes as a target for review by [your Quality Assurance] department," Warmack recommends.