Home Health ICD-9/ICD-10 Alert

Do you know which OASIS data items can help you prevent HTN denials?

If you're listing an unspecified hypertension diagnosis in M1020a for a patient in her third or later episode, you'd better make sure your documentation is superlative or you'll risk your Medicare payment.

HHH Medicare Administrative Contractor CGS has been conducting a widespread edit of claims with hypertension as the primary diagnosis and a length of stay greater than two episodes, the MAC notes on its website. In the last quarter, CGS denied a whopping 97 percent of the claims reviewed under this edit. That's up from an 88 percent denial rate a year ago, the MAC points out.

This has been an ongoing problem for home health agencies, experts say. "I am not in the least surprised at the denial rate for the hypertension recertifications," says clinical consultant Pam Warmack with Clinic Connections in Ruston, La.

The problem: The top denial reason under the edit "is related to documentation of medical necessity of the skilled services, primarily for skilled nurse visits for observation and assessment," CGS explains on its website. "For a skilled service of observation and assessment to be covered by Medicare, there must be clear documentation of the patient's condition that warrants this service."

To show medical necessity for O&A, agencies typically need "documentation of changes in diagnosis, exacerbations, medication or treatment changes that continue to put the beneficiary at risk for further plan of care changes," CGS says. "Nursing may continue observation and assessment when there have been continued changes and risks for further need to change the plan of care."

Monitoring an essentially stable blood pressure and redundant teaching on the same anti-hypertensive medications does not meet the criteria for medical necessity, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. Even if the hypertension is somewhat unstable, the actions taken in response must be documented.

"What makes skilled nursing 'skilled' is our ability to react to changes in the patient's condition, not just calling the physician when the BP is outside parameters but also implementing nursing interventions," Selman-Holman says. "There are so many times when auditing charts I see documentation of a change and then I'm disappointed when the nurse doesn't even address the change but goes on to provide some 'skill' unrelated."

The observation and assessment of the patient's condition by a nurse are reasonable and necessary skilled services, Section 40.2.2.1 of the Home Health Benefits Manual advises. But only when there is a reasonable potential for change in the patient's condition that will require skilled nursing personnel to identify and evaluate the need for modification of treatment or initiation of additional medical procedures. "Where a patient was admitted to home health care for skilled observation because there was a reasonable potential of a complication or further acute episode, but did not develop a further acute episode or complication, the skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential for such a complication or further acute episode."

"The primary intent of the Medicare home health care program is to cover short-term exacerbations of illness in a patient's home," explains consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. Therefore, Medicare won't cover endless O&A, especially of a stable patient.

To track patients with a long length of stay and a principal diagnosis of 401.9 (Essential hypertension, unspecified), you can turn to M0030 -- Start of care date and M1020a -- Primary diagnosis. Using these two items you can single out HTN patients who have been recertified multiple times.

Caution: Make sure you're not using HTN as a "fall back" diagnosis to support ongoing care for a patient who perhaps has had a HTN issue at some point but is currently stable, Laff cautions. Trying to "find" a reasonable diagnosis to keep a patient on service for PT/INR monitoring isn't wise, she says.

You can also track long-term HTN patients by looking at OASIS outcomes data to see if a patient has been hospitalized or had emergent care related to HTN during the current episode, whether there were any medication changes relevant to HTN, and whether the vital sign trend (not one or two aberrant blood pressure readings) identified that the patient's blood pressure was out of control, Laff says. These occurrences can help support the need for ongoing care.

"To use HTN as a primary diagnosis, it must be the focus of care and there must be substantial evidence of aberration, order changes and signs and symptoms of HTN," Laff says. Don't try to argue that the patient's blood pressure "might" spike, she cautions. "If it hasn't changed substantially enough for the physician to increase or change a medication dose in five to seven weeks -- the patient should be discharged."

Bottom line: "Ongoing monitoring is nice and may be appropriate but it is not a Medicare-billable service unless there is substantial medical necessity," Laff says.

Note: See CGS's article at www.cgsmedicare.com/hhh/pubs/mb_hhh/2012/03_2012/index.html#006.