Home Health & Hospice Week

Medical necessity can be hard to prove for hypertension patients.

If you're treating a patient for hypertension in her third or later episode, your documentation must be superlative or you'll risk your Medicare payment.

HHH Medicare Administrative Contractor CGS has been conducting a widespread edit of claims with hypertension as the primary diagnosis and length of stay greater than two episodes, the MAC notes on its website. In the last quarter, CGS denied a whopping 97 percent of the claims reviewed under this edit. That's up from an 88 percent denial rate a year ago, the MAC points out.

This has been an ongoing problem for home health agencies, experts say. "I am not in the least surprised at the denial rate for the hypertension recertifications," says clinical consultant Pam Warmack with Clinic Connections in Ruston, La.

The problem: The top denial reason under the edit "is related to documentation of medical necessity of the skilled services, primarily for skilled nurse visits for observation and assessment," CGS explains on its website. "For a skilled service of observation and assessment to be covered by Medicare, there must be clear documentation of the patient's condition that warrants this service."

To show medical necessity for O&A, agencies typically need "documentation of changes in diagnosis, exacerbations, medication or treatment changes that continue to put the beneficiary at risk for further plan of care changes," CGS says. "Nursing may continue observation and assessment when there have been continued changes and risks for further need to change the plan of care."

Important: Look to this statement from the Medicare Benefit Policy Manual to help understand O&A coverage, CGS suggests: O&A "of the patient's condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient's condition that requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment or initiation of additional medical procedures until the patient's treatment regimen is essentially stabilized."

The patient's condition isn't the only factor, however. Treatment changes also must be present to justify the skilled service need. CGS points to this section of the Manual: "Observation and assessment by a nurse is not reasonable and necessary to the treatment of the illness or injury where these indications are part of a longstanding pattern of the patient's condition which itself does not require skilled services and there is no attempt to change the treatment to resolve them."

Some HHAs seem to have difficulty grasping Medicare coverage criteria. "The primary intent of the Medicare home health care program is to cover short-term exacerbations of illness in a patient's home," explains consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. Therefore, Medicare won't cover endless O&A, especially of a stable patient.

Note: See CGS's article at www.cgsmedicare.com/hhh/pubs/mb_hhh/2012/03_2012/index.