OASIS Alert

Be especially cautious when episodes fit these three edit categories.

Your intermediary's goal is to pay only the claims it has to. Don't give it any excuse to deny your deserved reimbursement.

Beware of episodes with V58.6x as the primary diagnosis; with one nursing visit ac-companied by five therapy visits; or with five visits, one of which is a social worker visit.

Widespread edits capture episodes fitting specific criteria and subject them to medical review. Home health agencies under regional home health intermediary Cahaba GBA definitely will face these three edits, but other intermediaries can easily get the same results. Use caution when you see episodes with:

1. V58.6x as a primary diagnosis. RHHI Cahaba GBA is continuing its widespread review (edit 5THCL) of claims in a second or later episode, with no therapies and with a primary diagnosis of V58.61 (Long term use of anticoagulants -- excluding aspirin). From Jan. 1 to Mar. 31, the RHHI denied more than 82 percent of the claims reviewed. The intermediary advises providers:

• As of Dec. 1, 2005, use the V58.6x category of codes only as secondary diagnoses.

• Documentation must show medical necessity. If the patient is stable and the nurse visits just to draw blood for testing, there is no medical necessity for Medicare home health services.

• Qualifying for the medical home health benefit requires use of a skilled service. Venipuncture by itself "no longer is a qualifying skilled service for home health," Cahaba says.

Expert tips: Use V58.6x codes as secondary codes to identify the type of long-term drug that is involved when your agency is monitoring the therapeutic effect of that drug, says consultant Judy Adams, with Charlotte, NC-based LarsonAllen. Monitor-ing the therapeutic effect of a drug can be accomplished through lab results or through observing and assessing a patient's signs and symptoms, she says.

Also, this code series in particular indicates that the patient is taking a drug, not necessarily that the provider is doing anything with the drug, adds Lisa Selman-Hol-man, consultant and principal of Selman-Holman & Associates in Denton, TX.

2. One nursing and five therapy visits. Another edit (5TH74) with high denial rates is for episodes where there are five visits, with only one being a skilled nursing visit and the rest any combination of physical, occupational and speech therapy visits. In the first quarter of 2008, Cahaba denied nearly 81 percent of these episodes, primarily because documentation did not support the medical necessity of the nursing visit. "Generally, if the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba asserts.

Problem: The RHHI instructs that to be covered, services must require the skills of a nurse and be reasonable and necessary, taking into account the patient's overall condition. "Routine nursing evaluations post-hospitalization to check medication management, home safety, etc., or nursing visits to complete the OASIS are an administrative cost, and are not billable," Cahaba warns.

Don't miss: If PT or SLP therapy is the primary reason for skilled care, a one-time nursing visit can be covered, Cahaba instructs. The RHHI's examples cover a visit for venipuncture or Foley catheter removal (for more information on single nursing visits, see OASIS Alert, Vol. 7, No. 8, p. 73).

3. Five visits, with one being a medical social worker. This edit (5TH67), which started in 2003, still tripped up 87 percent of the 170 claims reviewed in the first quarter of 2008, Cahaba reports. MSW visits are covered under certain specific conditions outlined in the Medicare Benefit Policy Manual, the RHHI says. The services must be necessary to "resolve social or emotional problems that are, or are expected to be, an impediment to the effective treatment of the patient's medical condition." In addition, the plan of care must "indicate how the services which are required necessitate the skills of a qualified social worker ... to be performed safely and effectively," Cahaba emphasizes.

Examine nursing visits: Remember, you must document the skilled services provided on each visit and why they were necessary. If the RHHI can deny only one visit, your reimbursement drops from a full episode payment to a low utilization payment adjusted (LUPA) per diem amount with no non-routine supply reimbursement.

Note: The edit information is at http://www.cahabagba.com/rhhi/news/newsletter/200806_rhhi.pdf on p. 33.