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Medicare Compliance & Reimbursement

Compliance:

Know When Your Patients Qualify For Home Care -- And When They Don't

Published on Mon Jan 16, 2012

Use this checklist from one HHH MAC to guide your eligibility assessments.

Medical review from Medicare contractors has been somewhat lax under the prospective payment system, but that's all changing now that numerous government bodies and contractors are looking over your records. As review continues to ramp up in the coming months, it will be more important to be able to identify situations when patients qualify for home care, and when they don't.

Use these reasons for skilled service need and tips on documenting them from HHH Medicare Administrative Contractor Palmetto GBA to help inform your identification process and strengthen your documentation:

1) New onset or acute exacerbation of diagnosis (include documentation to support signs and symptoms and the date of the new onset or acute exacerbation).

2) New and/or changed prescription medications. Palmetto defines new medications as those the beneficiary has not taken recently, i.e., within the last 30 days. Changed medications are those which have a change in dosage, frequency, or route of administration within the last 60 days.

3) Hospitalizations (include date and reason).

4) Acute change in condition (be specific and include changes in treatment plan as a result of changes in medical condition, e.g., physician contact, medication changes).

5) Changes in caregiver status or an UNSTABLE CAREGIVING situation (e.g., involvement of many services or community resources, unsafe or unclean environment which interferes with putting the plan into action).

6) Complicating factors (i.e., simple wound care on lower extremity for a beneficiary with diabetic peripheral angiopathy).

7) Inherent complexity of services. You must show why the services can be safely and effectively provided only by a skilled professional.

8) Lack of knowledge or understanding of the beneficiary's care, which requires initial skilled teaching and training of a beneficiary, the beneficiary's family or caregiver on how to manage the beneficiary's treatment regime.

9) Reinforcement of previous teaching when there is a change in the beneficiary's physical location (i.e., discharged from hospital to home).

10) Any type of re-teaching due to a significant change in a procedure, the beneficiary's medical condition, when the beneficiary's caregiver is not properly carrying out the task, or other reasons which may require skilled re-teaching and training activities.

11) The need for a nurse to administer an injection of a self-injectable medication such as insulin or Calcimar. Clinical documentation needs to indicate: (a) the beneficiary's inability to self-inject and the non-availability of a willing/able caregiver, (b) the appropriate diagnosis to warrant administration of the medication, (c) laboratory results (if required to meet Medicare criteria), and (d) dosage of the medication.

12) The need for Foley/suprapubic catheter changes and/or assessment/instruction regarding complications.

13) The need for gastrostomy tube changes and/or assessment or instruction about complications.

14) The need for administration of IM/IV medications based on medical necessity, supporting diagnosis, and accepted standards of medical practice.

15) Dressing changes for complicated wound care including documentation (at least weekly) of wound location, size, depth, drainage, and complaints of pain.

16) The need for management and evaluation of a complex care plan. Answering "yes" to the following questions may be helpful in determining this need:

Is the patient at HIGH RISK for hospitalization or exacerbation of a health problem if the plan of care is not implemented properly (e.g., multiple medical problems or diagnosis, limitations in activities of daily living or mental status, cultural barriers, history of repeated hospitalizations)?

Does the patient have a COMPLEX, UNSKILLED care plan (e.g., many medications, treatments, use of complex or multiple pieces of equipment, unusual variety of supplies)?

Is there an UNSTABLE CAREGIVING situation (e.g., involvement of many services or community resources, unsafe or unclean environment) that interferes with putting the plan of care into action)?

Does it require the skills of a registered nurse or a qualified therapist to ensure safe and appropriate implementation of the plan of care?

4 Steps To Avoid, Appeal Denials

Use these tips for avoiding and appealing homebound and medical necessity denials:

"Thoroughly audit the patient record without 'reading between the lines' and considering anything verbalized about the patient -- only considering what is documented," says consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. The documentation alone must support the claim.

The bene can leave the home if she is homebound. You just must "submit documentation that reflects that it is a taxing effort for the beneficiary to leave the home," Palmetto advises.

Conduct an interview of the primary clinician if you decide to appeal. This will help you write a succinct summary for the appeal that highlights reasons for medical necessity and homebound status. Your appeal summary should also include the total number of visits for each discipline provided, Laff adds.

Don't neglect one requirement if the other is fulfilled. If the patient is homebound, they still must require skilled services and vice versa, Laff stresses.

Focus on changes. Medicare is not a long term care benefit, and Medicare contractors are on the look-out for patients who don't have skilled needs. One reason Palmetto cites for medical necessity denials is "the submitted documentation ... indicated there was no longer a reasonable potential for change in the medical condition."

"Look for documented evidence in the patient record reflecting changes in condition affecting the plan of care," Laff advises. "Do not rely on the addition of a simple over the counter medication -- i.e. ibuprofen, vitamins, etc. -- to support a significant clinical change in condition."

In particular, when the skilled need is observation and assessment, be sure to document those changes carefully. "If the patient has remained stable and all medical conditions are well controlled, it may be determined that the patient's condition is not volatile and therefore continued skilled services were not reasonable or medically necessary," Laff cautions.

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