Home Health & Hospice Week

Sole nursing visit denials may be more common, but sole medical social worker visit problems can cost you a pretty penny too when they result in LUPAs.

Medical reviewers for regional home health intermediary Cahaba GBA denied 76 percent of claims with one MSW visit making up one of five visits on the claim, Cahaba says in its March newsletter for providers (see related story, p. 82).

The Medicare Benefit Policy Manual says MSW visits may be covered if "the services of these professionals are necessary to resolve social or emotional problems that are, or expected to be an impediment to the effective treatment of the patient's medical condition" and "the plan of care indicates how the services which are required necessitate the skills of a qualified social worker ... to be performed safely and effectively," Cahaba explains.

Pitfall: "Routine evaluations for community resources where no needs were previously identified would not be considered a covered MSW service," Cahaba warns.

As with skilled nursing, the documentation has to show why the MSW visit meets the coverage criteria, says consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. Otherwise, it's too easy for reviewers to downgrade your five-visit claim to a low utilization payment adjustment (LUPA).

"When there is an identified barrier to the patient's recovery or rate of recovery that MSW skills can be used to help assess, plan and overcome this barrier, the documentation must be supportive of the medical necessity of the MSW," Cahaba instructs agencies.