Home Health & Hospice Week

Patients’ testing requirement will rely heavily on treatment goals.

If you haven’t been paying much attention to Palmetto GBA’s LCD on diabetes testing, you could pay a big price.

Home health agencies and industry reps haven’t reported many denials based on the Local Coverage Determination addressing HbA1c testing so far, but that may not last long. “Palmetto is so busy with the [Probe & Educate face-to-face] audit, we have not seen denials for this yet,” says consultant Patti Zabell with McBee Associates. “But I am sure they are coming our way,” Zabell warns.

And HHAs served by other Medicare Administrative Contractors can’t afford to ignore the quarterly testing requirement for unstable patients either. The other MACs have yet to adopt the LCD, experts acknowledge. In a March 2015 meeting of its Home Health Advisory Group, CGS specified that “at this time, CGS has no plans to implement a similar LCD per our [Medical Review] Manager.” But they could take up the policy at any time, especially if urged to do so by the Centers for Medicare & Medicaid Services. That may be more likely now that Palmetto is working out the kinks in the LCD, experts predict.

To safeguard your claims for patients with diabetes in light of this LCD and other medical review scrutiny, consider these steps:

1. Read Palmetto’s LCD. Especially now that the policy has gotten more complicated, go straight to the source and read up on the standards the MAC will hold you to. You can access the LCD by going to www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx, entering the LCD number (L35132) in the Quick Search box that says “Document ID,” entering a date after May 5 on the next page, and clicking on the LCD title listed on the next page.

Highlight: The LCD lists the ICD-10 codes in the E11 category affected by the policy.

2. Identify category for patients. Stable patients require HbA1c testing every six months while those who are not stable still will require quarterly testing under the revised LCD (see story, p. 163). Identify which category your patient falls into and apply the correct timeframe.

Pointer: Things that may qualify patients for required quarterly testing are therapy changes such as sliding scale, dose change, or insulin-type change, offers Beth Noyce with Noyce Consulting in Salt Lake City. Patients may not be meeting glycemic goals when their HbA1c targets are out of reach, Noyce adds on her blog.

Remember: To qualify for every-sixmonths testing, “stable glycemic control is defined as two consecutive HbA1c results meeting the treatment goals specific in the plan of care,” reminds Lisa Selman-Holman with Selman-Holman & Associates and CoDR — Coding Done Right.

Tip: Deciding which category the patient falls into rests heavily on what goals the physician sets for them. “Rather than showing that the DM II home health patient’s blood glucose is tightly controlled with ongoing treatment changes and repeated proof of instability, documentation of nursing visits to administer insulin to a patient with DM II should show that the treatment is effectively meeting reasonable, achievable, patient-specific goals,” Noyce argues. “If the patient’s insulin injections do this, Palmetto requires HbA1c tests only twice a year.”

3. Educate referring physicians. HHAs have encountered resistance from physicians to order “HbA1c testing on Palmetto-dictated schedules,” Noyce reports. Use this new LCD, and particularly the American Diabetes Association standards cited in it, to help bring reluctant docs around to the policy, Noyce advises.

4. Secure test results at admission. When admitting a patient with diabetes, “you must have information regarding the last results,” Selman- Holman urges. “You either need to get an order for venipuncture or you need to ensure you get the physician’s results on your chart.”

5. Address diabetes in POC. “You must communicate with the physician regarding treatment goals for the patient and expected HgbA1c results,” Selman-Holman advises. Then, “you must have a plan to attempt to stabilize the patient and monitor.”

Bottom line: The LCD will “require coordination with the physician to define the desired level of diabetes control the physician wishes for each patient,” emphasizes Judy Adams with Adams Home Care Consulting in Durham, N.C. That should include stable diabetic patients too (see story, p. 164).

6. Tailor POC to the patient. Julianne Haydel with Haydel Consulting Services sees scenarios documented such as advising the patient to have a drink of juice and snack when blood sugar is low, but the patient has mobility and cognitive problems; pursuing tight blood glucose control for a hospice patient who needs a comfort regimen; and teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.

Make sure your education matches your patients’ conditions and needs.

7. Avoid pitfalls. Rumors have circulated that this LCD applies only when diabetes is the primary diagnosis, or only if diabetes is in the top six diagnoses list on the claim. That’s wrong, Selman-Holman stresses on her blog. “If type 2 diabetes is listed on the claim, the policy applies,” she says.

Agencies should also resist the urge to drop diabetes as a code altogether. “Diabetes is one of those conditions that has the potential to affect the PoC and rehab potential,” Selman-Holman says. “In addition, the coding guidelines indicate that we should code what the physician states. It’s a difficult argument to make that diabetes does not have the potential to affect the PoC, being a chronic disease that affects multiple body systems.”

8. Train your staff. Education and reinforcement will be necessary to help your staff with these steps, experts urge. Add diabetic training to your in-service topic list.

9. Keep an eye out. Enforcement of this LCD could start any day, taking a big bite out of HHA reimbursement for diabetes patients, experts warn.

Documentation focus: But an even bigger consequence could be just over the horizon. Palmetto may be setting the stage to deny visits for insulin injections when “the nurse-injected insulin doesn’t prevent treatment changes and/or doesn’t result in model HbA1c values,” Noyce suspects. This is where your documentation showing that the treatment is meeting the patient’s goals will be very important, she says.