OASIS Alert

Document medical necessity or don't make the visit.

If your clinicians are routinely visiting COPD patients -- recert after recert -- for observation and assessment, prepare to see routine denials. You may need to review the recertification OASIS assessment with your staff.
 
Watch for: A widespread edit selecting recert claims with a primary diagnosis of chronic obstructive pulmonary disease and a length of stay greater than 120 days will address major problems in this area, fiscal intermediary Cahaba GBA says. Of the 169 claims reviewed in the January through March quarter, Cahaba denied 45 percent, the FI reports.

Key flaw: In more than half the denials the claims lacked documentation to support ongoing skilled nursing services, Cahaba says. Your OASIS answers and the record must support your visits.
 
But the big issue in this edit is that it targets claims in the third certification period, says senior consultant Judy Adams with Charlotte, NC-based LarsonAllen. Clinicians need to remember the Medicare coverage rules didn't change with the introduction of the prospective payment system. Just because a patient is homebound doesn't mean you "can go in forever," she warns.

Solution: Go Back To Basics

Know the rules and document carefully when caring for COPD patients. Observation and assessment visits have two essential components:.
 
1. Changes in the patient's condition. Document abnormal or fluctuating vital signs, weight changes, edema and respiratory changes in these patients, Cahaba instructs.
 
2. Changes in orders or plan of care. Document what actions you took in response to the changes in the patient's condition, Adams advises.
 
Know when observation and assessment of the patient's condition are reasonable and necessary. Ask if "the likelihood of change in a patient's condition requires a skilled nurse to identify and evaluate the patient's need for possible modification in the patient's plan of care until the patient's treatment regimen is essentially stabilized," Cahaba says.

Reimbursement essentials: For Medicare coverage, clinicians caring for the patient with COPD must clearly document changes in medications, teaching related to energy conservation, teaching related to pursed lip breathing, etc. to deal with the patient's changing medical condition, Adams advises. Merely documenting that the patient is weak, has increased dyspnea and limited energy demonstrates a change in the COPD, but is just a description of a patient with a deteriorating medical condition. In addition, document actions taken to modify the treatment plan, she stresses.
 
Example: Did you get new doctor's orders, instruct the patient on using a nebulizer or arrange a therapy consult for teaching energy conservation measures? Be sure the intermediary can see what you did. 
 
Note: Information about the edit is at www.cahabagba.com/part_a/whats_new/news_copd_errors_20060424.htm.