Medicare Compliance & Reimbursement

Look to your MAC for guidance on medical necessity.

Don’t let slipshod observation and assessment documentation impede your bottom line. Detailed notes can help you garner the reimbursement you deserve. Careless charting may be the culprit of a recent rash of O&A-related denials for many home health agencies that underwent a recent, medical review probe.

HHH Medicare Administrative Contractor (MAC) Palmetto GBA announced a service-specific probe for claims with the CH** HIPPS code back in November. The probe reviewed claims for early or late episodes, with a Clinical Severity Level of 3 and Functional Severity Level of 3 — the highest possible.

In its first round of results from nine states, Palmetto fully or partially denied 106 of 886 claims reviewed — 12 percent. In its second round of results covering six more states, the MAC reports that it denied even more — 88 of 594 claims, a 15 percent denial rate. Louisiana ranked the highest, with 23 of 99 claims denied for a 19 percent charge denial rate. Claims from South Carolina fared the best, with six of 95 claims denied for a 5 percent charge denial rate.

Palmetto cites a laundry list of reasons for the denials, ranging from agencies failing to respond to Additional Development Requests to missing short- or long-term goals for therapy to documentation contradicting OASIS M0 items.

One frequent reason for denials or downcodes was “5F041/5A041 — Information Provided Does Not Support the Medical Necessity for All or Part of This Service.” In other words, skilled nursing visits were not covered “because the documentation submitted in response to the [ADR] did not support medical necessity for continuation of skilled services,” particularly regarding observation and assessment, Palmetto explains in the articles. Skilled observation and assessment beyond a three-week period may be justified only “when documentation supports the likelihood of further complications or an acute episode. However, observation and assessment are not reasonable and necessary when the documentation indicated that the abnormal findings are part of a longstanding pattern of the patient’s condition and there is no attempt to change the treatment to resolve them.”

Important: “The key to Medicare coverage is for the documentation to ‘paint a picture’ of the beneficiary’s overall medical condition indicating the need for skilled service,” Palmetto stresses.

The MAC offers examples of valid reasons for services that you can list in your documentation and tips on how to support them, including:

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. New medications are 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; therefore, 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/instruction regarding 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: 

     a) 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)?
     b) 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)?
     c) 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 into action)?
     d) Does it require the skills of a registered nurse or a qualified therapist to ensure safe and appropriate implementation of the plan of care?

Note: See more documentation advice from Palmetto in the probe results articles at www.palmettogba.com/palmetto/providers.nsf/Docs/Providers~JM Home Health and Hospice~Medical Review~Results.>