Home Health & Hospice Week

Hemoglobin testing poised to torpedo serious amount of claims.

A HHH Medicare Administrative Contractor has eased up on its diabetes testing requirements, but your claims for diabetic patients could still be at major risk.

Background: Last year, MAC Palmetto GBA began requiring HbA1c testing on a quarterly basis for patients with diabetes mellitus on their care plan (see Eli’s HCW, Vol. XXIV, No. 14). The quarterly testing requirement wasn’t just for patients requiring daily home health agency visits for insulin injections, but for any patient with a DM diagnosis, Palmetto confirmed in a question-and-answer set from a January Ask the Contractor Teleconference.

Change: Now Palmetto has revised its LCD, “Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus (L35132),” to require quarterly testing only for “the home health beneficiary population ‘whose therapy has changed or who are not meeting glycemic goals,’” the MAC says in the updated policy that took effect May 5. “For other beneficiaries with stable glycemic control (defined as two consecutive HbA1c results meeting the treatment goals specified in the plan of care) performing the HbA1c test at least two times a year may be considered reasonable and necessary,” according to the revised LCD.

“Performing the HbA1c test quarterly in patients whose therapy has changed or who are not meeting glycemic goals is supported by the American Diabetes Association Standards of Medical Care in Diabetes – 2016 (ADA Standards),” Palmetto points out in the LCD. The policy is “based on Palmetto GBA’s claims data and the increased risk of emergency department (ED) encounters and acute inpatient admissions related to hypoglycemia in this population.”

HHAs “won the battle” on the testing standard, says attorney and coding expert Lisa Selman- Holman on her blog. “Agencies have run into problems getting physicians to order the HbA1c” on the quarterly basis Palmetto requires, notes Selman- Holman with Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas.

“Agencies are always glad to reduce work,” adds consultant Karen Vance with BKD in Springfield, Mo.

“Maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care,” suggests Julianne Haydel with Haydel Consulting Services on her blog.

And the change should “lessen the risk of denial for patients who are provided care by your agency,” Haydel says. Since the quarterly testing requirement applied to all patients with a DM diagnoses, the potential for denials based on missing tests was significant.

On the other hand: Agencies “lost the war” on getting the testing requirements eliminated, Selman- Holman says.

HHAs had hoped to have this LCD eliminated altogether, notes Judy Adams with Adams Home Care Consulting in Durham, N.C. The LCD revision isn’t “much support for agencies simply because it is easier to remember 120 days and track that as compared to twice a year,” judges consultant Patti Zabell with McBee Associates.

Plus, the policy increases the lookback period when you admit a new patient. At admission, “the agency will need to go back to the MD to determine when the last HbA1c was done,” Zabell tells Eli. “This means the MD would have to look back six months or further to determine the last draw or order another lab test.”

And agencies haven’t seen much in the way of denials based on this LCD yet, Vance observes. Right now, they are busy getting socked with denials under the face-to-face physician encounter Probe & Educate campaign.

Treatment Philosophy Underlies Update

Palmetto didn’t change its policy just to make HHAs’ life easier. One of the MAC’s primary motivations for the revision was the argument that tight control of blood glucose in the elderly is unwarranted and may cause more harm than good.

“Hypoglycemia-related emergency department visits and acute inpatient hospitalizations among elderly patients with diabetes mellitus are recognized as potentially preventable adverse drug events,” Palmetto notes in the LCD. “The U.S. Department of Health and Human Services (HHS) Healthy People 2020, a decade-long work plan for improving the health of the U.S. population, contains a specific Medical Product Safety (MPS) objective [MPS-5.2 Reduce emergency department (ED) visits for overdose from injectable antidiabetic agents] aimed at reducing the baseline rate by 10% by 2020,” according to the policy.

“Insulin-related hypoglycemia and errors (IHEs) are especially prevalent in individuals with advanced age, limited life expectancy and frailty,” the LCD says. “This LCD seeks to help reduce these adverse events by promoting evidence-based home health plans of care,” Palmetto notes.

“Elderly people probably should not go on tight control,” maintains Beth Noyce with Noyce Consulting in Salt Lake City. “Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years,” Noyce says on her blog.

Other patients unlikely to benefit from tight control of blood glucose levels are patients with complications such as end-stage kidney disease or severe vision loss, conditions like coronary artery disease or vascular disease, and “hypoglycaemia unawareness (think dementia),” Noyce says.

Opportunity: HHAs have the potential to “show Medicare (and Congress, and private insurers) that DM II patients with home health services avoid hypoglycemic episodes that land them in the ER or the hospital,” Noyce urges. “Better quality of life for beneficiaries, and cost savings for Medicare.”

Note: For a free PDF copy of and link to the revised LCD, email editor Rebecca Johnson at rebeccaj@eliresearch.com with “Palmetto DM LCD” in the subject line.