Home Health & Hospice Week

You're courting claims denials if you don't guard against these common problems.

Medical reviewers are going over home health agency claims and records with a fine-tooth comb--will yours hold up to the examination?

Regional home health intermediary National Government Services conducted recent probe reviews on different groups of claims, yet came up with the same problems causing denials, according to a message NGS sent to providers.

In addition to diagnosis coding problems, NGS reviewers found these three reasons topped the denial and downcode list:

1. OASIS downcoding. "The medical record documentation does not support the OASIS M0 item response," says NGS, formerly United Government Services and Associated Hospital Service of Maine. Reviewers most commonly downcoded claims for M0 items in the clinical severity domain.

Example: The provider chose response #2 for M0420 on pain. That response indicates that the patient has pain "daily, but not constantly" that interferes with her activity or movement. "However, there is no mention of pain, medication adjustments and response in the [plan of care] or the medical record," NGS says. "We would be unable to validate that the patient had pain 'daily, but not constant.'"

"The problem with validating the OASIS scores is again a result of coding for reimbursement," believes regulatory consultant Rebecca Friedman Zuber in Chicago. Home health agencies must encourage staff to choose the most appropriate OASIS item response based on the patient's condition, not on reimbursement considerations.

Tip: Review OASIS answers against clinical documentation, Zuber suggests. Then take those case studies and use them as a teaching tool for your staff.

Also try having staff do their own mock medical reviews of their records. Let them "see if they can verify the OASIS scores," Zuber counsels.

Watch out: Your staff may be marking inaccurate OASIS responses in response to your urgings to claim higher reimbursement, Zuber cautions. "Agencies need to examine the messages they are sending their staff to see if they are in fact encouraging this type of thing," she instructs. "If they are, they need to quit."

If you aren't pressuring staff to claim more reimbursement, then you need to train and supervise them more closely to ensure OASIS compliance, she suggests.

2. Lack of skilled services. Another top denial reason across claims is that "skilled services were not reasonable and necessary or no longer required," NGS found in the reviews.

"HHA personnel seem to understand less about the coverage rules than they did prior to PPS," Zuber laments. "Many home health clinicians don't understand what Medicare considers to be a skilled service anymore as training hasn't focused on this since PPS came in."

It's not just field staff who are missing Medi-care coverage knowledge, Zuber tells Eli. Agency clinical supervisors also need to brush up on coverage basics. "We need to revisit this material," she urges.

Don't forget: "It is necessary to document skilled interventions on each visit," emphasizes consultant Sharon Litwin with 5 Star Consultants in Ballwin, MO.

Problems often arise when teaching is the skill at issue. First, the disciplines must have a coordinated plan so they know what each is teaching. Then documentation of those teaching efforts must be detailed and precise. Often, "I see little or no documentation," Litwin says. And, like other visit notes, documentation frequently lacks specifics such as showing patient response to teaching and failing to show how the teaching progresses as the episode progresses.

"If the patient stays the same, teaching is done, and the patient and caregiver know how to do any procedures, then there is no further skilled need," Litwin remarks. "This must be monitored by the management of the agency."

3. Ignoring ADRs. Non-response to additional development requests (ADRs) continues to rank in the top denial reasons, NGS notes. The intermediary listed it as fourth in the most common denials.

"At least it isn't the first reason anymore," Zuber says. "It was for a while."

Providers have 30 days from the ADR date to respond to the request by submitting documentation, NGS explains. "Documentation must be received within 45 days to avoid an automatic full claim denial."

Get savvy: You should be tracking your claims online, Zuber urges. "Agencies don't have much time to respond to ADRs, so they need to find out about them as soon as they can."

Monitor your electronic remittance advices for any claims that are being held and the reason, Zuber advises. This will give you "much earlier notice that an ADR is going to be requested." Then you can start assembling and checking the record much earlier.

How to know: If the claim is moved to SB6001 Status/location, an ADR is being requested, NGS ex-plains. "Begin tracking the 30 day deadline and submit your medical record," the intermediary instructs.

Tip: Submit a response to each request separately with its own cover letter, NGS advises. And don't forget to allow for mailing time.