Home Health ICD-9/ICD-10 Alert

An internal audit can help prevent future denials.

Your hypertension claims are under fire. But it’s nothing a little documentation improvement and self-auditing can’t solve. Safeguard your reimbursement for these patients with this expert advice.

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 acknowledged that the denial rate of the claims reviewed under this edit is down from 97 percent to 85 Percent. But that still leaves home health agencies with a long way to go in addressing the issue.

The problem: The top denial reason under the edit remains “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.”

Solution 1: Check your documentation. When the documentation shows that your HTN patient’s blood pressure is essentially stable and there are no medication changes, your claim is on shaky ground. This patient’s condition doesn’t meet the requirements for medical necessity. “It doesn’t take a nurse to take a blood pressure,” says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR—Coding Done Right and Code Pro University in Denton, Texas. “It does take a nurse to act appropriately on unstable blood pressures, so there has to be evidence of a potentially unstable condition and that the nurse is taking appropriate action.”

Even documentation for patients with unstable blood pressure may need bolstering. Make certain the record includes details about the interventions your agency provides. “So many times when responding to medical review requests, I’m reading the chart and think ‘finally something is happening’ and then the nurse misses the opportunity for skilled intervention,” Selman-Holman adds.

What can agencies do to prevent denials under this edit?

When you report hypertension as a primary diagnosis, the documentation in the record must reflect actual instability, says Lynda Laff with Hilton Head, S.C.-based Laff Associates. “Do not admit or recert a patient for HTN that is controlled by medication.”

Documentation that supports medical necessity for a hypertension patient will show a patient’s blood pressures falling out of physician-ordered parameters and being actively managed by the physician with adjusted or new medication, Laff says.

Solution 2: Track HTN Patients.

To be proactive in heading off denials as a result of this edit, you can track your patients with a long length of stay and a principal diagnosis of 401.9 (Essential hypertension, unspecified). Look to OASIS items M0030 — Start of care date and M1020a — Primary diagnosis to find patients who could fall under increased scrutiny. Monitor these two items to find HTN patients who have been recertified multiple times. If you find patients with blood pressure that’s in control/stable for three or more weeks, you’re in danger of being caught in this edit.

You can also look at OASIS outcomes data to find patients who have been hospitalized or had emergent care related to HTN during the current episode, patients with medication changes relevant to HTN, and patients with vital sign trends (not one or two aberrant blood pressure readings) that indicate out of control blood pressure. These occurrences can help support the need for ongoing care.