OASIS Alert

Medical necessity challenged in most denials.

When your regional home health intermediary denies a single skilled nursing visit, you may get paid nothing for that episode.

A year after beginning edit 5TH74--claims with one SN visit and four therapy visits--regional home health intermediary Cahaba GBA reports it denied 75 percent of the 313 claims reviewed in the January through March quarter. Of the 239 denials, 132 "were related to documentation not supporting the medical necessity of the skilled nursing visit," the RHHI reports.

Second Edit Attacks Single SN Visits

Another ongoing edit focuses on claims with one skilled nursing visit--this time with one or more occupational therapy visits. Cahaba denied 110 of 167 such claims in the January through March quarter, the RHHI reports. In this situation, most often the one-time nursing visit was not covered. And unless there is another qualifying service in the home, the SN visit denial would lead to denial of the OT visits as well, Cahaba notes, because OT is a dependent service.

Scrutinize "Near LUPA" Visits Before Billing

Under the prospective payment system, a low utilization payment adjustment is an episode claim with four or fewer visits. Payments for such episodes are on a per-visit basis, rather than a full episode payment. The difference in payment can be more than a thousand dollars, experts report.

Protect yourself: Because of the high dollar value of the potential cost savings to Medicare, near LUPAs--episodes with just a few more than four visits--will remain a priority review category for all intermediaries, warns senior clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen. 

Cahaba Clarifies Coverage

Before billing for a single nursing visit, be sure you understand that one-time SN visits are rarely billable, experts say. In general, for skilled nursing to qualify a patient for services, visits must be intermittent. "This means there must be a medically predictable recurring need for skilled nursing services," Cahaba clarifies.

Exception: But a single SN visit in a case where therapy is the qualifying service can be covered if it requires the skills of a nurse and is "reasonable and necessary to the treatment of the patient's illness or injury," Cahaba says. This means the service the nurse provides should be consistent with practice standards, the nature and severity of the patient's condition and the patient's medical needs, the intermediary explains. "Generally, if the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba warns.

Once Is Usually Not Enough

Agencies find it hard to accept that a single skilled nursing visit usually won't earn them any money, no matter how long the visit takes or how much they do. But it's true. "Even though an initial OASIS assessment can take 2 to 3 hours to complete, it is an administrative activity and not a skilled service," Adams explains. Also one-time visits for skilled services such as removing a catheter or sutures or assessing a wound when the patient is first admitted are not intermittent.

Tip: A one-time SN visit may be payable when you made the visit with plans--and orders--for additional visits, but unexpected circumstances prevented you from continuing the plan of care, says consultant Rose Kimball with Med-Care Administrative Services in Dallas. For example, the patient may have returned to the hospital, died or moved out of your service area before a second visit occurred.