Home Health & Hospice Week

Make sure you have these 3 bases covered for daily insulin injection coverage.

Don’t get sloppy with your assessments and coding for diabetes patients, because they are smack in the middle of reviewers’ radar.

Remember: Coverage for visits that are for the sole purpose of insulin injections is limited to:

•  Patients who are physically or mentally unable to self-inject and

•  When there is no other person who is able and willing to inject the patient.

These patients are also exempt from the requirement for intermittent care because they have a daily need for the injections, said nurse consultant Judy Adams with Adams Home Care Consulting in Asheville, N.C.

To support your claims for daily insulin injections you’ll need to do three things: assess your patient’s ability to self-inject, document the findings of your assessment, and code for the conditions that support your patient’s need for skilled care to provide the injections.

Assess Ability: Incorporating an assessment tool that checks for the ability to self-inject will help you to both weed out inappropriate patients and back up the need for this service for those patients who truly require the assistance.

There are several reliable and validated assessment tools that can measure a patient’s ability to self-inject, Adams said during the recent Eli-sponsored AudioEducator audioconference Are You Ready for the 2015 Home Health PPS Changes? These tools assess the individual’s:

• Cognitive status

• Functional status

• Behavioral status

• Ability to perform activities of daily living

• Ability to inject independently

• Ability to recognize and deal with hypoglycemia

• Ability to recognize the possibility of dosing errors

Document the findings of your assessment: That step is vital to protecting your claims. The old saying “if it’s not documented, it didn’t happen” goes double when you’re only providing a single service. If the record doesn’t show the need for a skilled service, it’s doubtful you’ll get paid for providing it.

Code thoroughly: In an analysis of 2012 claims data, CMS looked at claims and OASIS assessments likely to be associated with insulin injection assistance. It studied episodes with a diabetic condition as the principal diagnosis on the claim, Medicare Part A or Part B enrollment for at least three months prior to the episode and during the episode, and three episodes with at least 45 skilled visits. It found that more than half of the 49,100 episodes that met these parameters had a principal diagnosis of 250.0x (Diabetes mellitus without mention of complication).

“Clinically, this code generally means that the diabetes is being well-controlled and there are no apparent complications or symptoms resulting from the diabetes. Diabetes that is controlled and without complications does not warrant intensive intervention or daily skilled nursing visits; rather, it warrants knowledge of the condition and routine monitoring,” CMS said in the 2015 Home Health PPS final rule.

Do this: A diabetes code alone won’t support your patient’s need for help with injections. Be sure to include the diagnosis codes that best describe the conditions that make your patient eligible for this service. In the 2015 PPS final rule, CMS lists codes it thinks show patients who should be eligible to receive visits for daily insulin injections (see box, this page).

Note: Order a recording or transcript of Are You Ready for the 2015 Home Health PPS Changes? at www.audioeducator.com/home-health/home-health-pps-coding-updates-01-15-2015.html. Read the details about CMS’s concerns in the final rule, starting on page 64 at www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014-26057.pdf. For tips on supporting insulin injection claims with your OASIS, see Eli’s Home Health and Coding OASIS Expert, Vol. 12, No. 5.