Home Health & Hospice Week

Get ready for a higher level of scrutiny for patients you've had on service for years. Regional home health intermediary Cahaba GBA is putting the medical review spotlight on claims for patients with a length of stay greater than 999 days. A new widespread review edit will select these claims and review them for medical necessity, Cahaba says in its July provider newsletter.

Cahaba initiated the probe as a result of data analysis, it points out. The topic code for this review will be 5008W.

A length of stay of 999 days is almost three years, says consultant Betty Gordon with Simione Consultants in Westboro, Mass. "These patients should be few and far between," not regulars on your roster, she adds.

Patients who need such long-term services include those with foley catheters, pernicious anemia that requires B12 injections, and sometimes blind diabetics who can't self-inject if there is no one else to do so, Gordon observes.

Unstable patients who have constantly changing care plans and medications would also require management and evaluation for such periods, although M&E services have also been highlighted for scrutiny.

To protect your long-stay patients' claims from medical review crackdowns, Gordon suggests taking these steps:

1. Conduct frequent reviews. You need to make sure long-stay patients still meet the definition of homebound and still require skilled care, Gordon advises. To determine this, conduct a full patient review and case conference frequently.

You must make sure that supervisory oversight before each recertification is part of the review, she suggests.

2. Document your reviews. It's not enough to review the case for home care eligibility, Gordon reminds agencies. You must document your review process and your findings thoroughly. Then evaluate your findings to ensure that no crucial elements fall through the cracks.

Gordon recommends instituting this type of review for any patient on service longer than three episodes (six months).

3. Document the skilled care. In the patient's ongoing clinical notes, your staff must document the skilled services they are furnishing.

For example: If the patient has anemia, be sure to include the bloodwork results in your documentation. If the patient requires M&E services, document carefully that she is not stable and why.

"It has to be a justified reason, a real skilled need," Gordon says of the qualifying service.

4. Don't stop looking for discharge. Don't make the mistake of getting lazy about discharge opportunities. Be sure to document why the patient can't be discharged.

For example: When the patient is a blind diabetic, document your ongoing efforts to find someone to inject for her and explain why a person can't be found.

If intermediaries are picking up on long-stay patient claims today, Recovery Audit Contractors (RACs) may take action on the topic later this year, when they swing into full home care gear (see Eli's HCW, Vol. XVIII, No. 19, p. 146). Be sure your charts are up to snuff by then.

Medical review of long-stay patients are only an issue if you haven't "documented well," Gordon reassures agencies.

Note: Cahaba's probe notice is at www.cahabagba.com/rhhi/news/newsletter/200907_rhhi.pdf.