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OASIS Alert

Medical Review:

Avoid Therapy CERT Errors Or Risk Denials

Published on Tue Apr 03, 2012

Report only therapies the patient receives at home in M1030.

It's no surprise that inadequate documentation was a leading reason for denials according to a recent report from one home health MAC. Make sure you're not missing the boat with your OASIS responses to these often-missed items.

Home health agencies' number-one denial reason in the Comprehensive Error Rate Testing program was "Documentation does not support OASIS responses/HIPPS code billed," Home Health & Hospice Medicare

Administrator Contractor CGS says in its March newsletter for providers.

Watch Your M1030 response

One common error was in answering M1030 -- Therapies the patient receives at home, CGS says. In these cases, "the OASIS response did not reflect the therapies the patient received, such as a PEG tube, or a PICC line," CGS explains.

This item is one of the most confusing on the OASIS, experts say. Remember that M1030 looks at only therapies the patient receives at home -- not those administered in outpatient facilities or elsewhere outside the home.

This item may be turning up on the CERT report when the OASIS includes diagnoses such as V55.1 (Attention to artificial openings; gastrostomy) or V44.1 (Gastrostomy status) but the coding isn't supported in M1030, says Arlynn Hansell, PT, HCS-D, HCS-O, COS-C clinical excellence program manager at American Mercy Home Care in Cincinnati, Ohio.

"Or perhaps you are indicating enteral/parenteral nutrition in M1030, but not backing it up with coding, documentation, or appropriate responses in M1870 (Feeding)," Hansell says.

Tricky: A frequent M1030 mistake is taking credit for therapies in the home when you're actually just flushing an abandoned site. If you have orders to flush an abandoned site with water, you can't mark that in M1030, Hansell says. You can only list response 3 -- Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal) when you're providing nutrition.

Don't think you can rely on scrubber software to prevent this error. While a scrubber might clue you into a lost opportunity in M1030 if you have V55.1 or V44.1 listed in M1020/M1022, it's less likely to point out the mistake of taking credit for nutrition in M1030 when you're only flushing an abandoned site with water, Hansell cautions.

Don't Sell Your Agency Short with M1030

Remember, your agency doesn't have to be administering the therapy for you to report it in M1030. For example, if your patient has a PEG tube that her husband hooks up for night-time feedings, you can take credit for this by answering "3" for enteral nutrition because the therapy is taking place at home.

However, if your patient has a PRN order for IV therapy or enteral nutrition, and the guidelines for administration are not met on the day of the assessment, you can't report this as a therapy in M1030. But if the patient will receive the therapy as a result of the assessment, or if you have orders to provide the therapy on a specific future date, you can mark it in M1030.

Example: Suppose you have an order to flush your patient's PICC line. She just came home from the hospital and had her PICC line flushed yesterday. You have orders to flush it again in five days. Which response to M1030 should you list?

Answer: List 1 -- Intravenous or infusion therapy (excludes TPN) in M1030 for this patient. You can take credit for your patient's therapy even though you will not be flushing that PICC line on the day of your assessment because you have a definite order to flush the PICC line in five days.

Mind These Medication Errors

"Another common error was with medications" and OASIS item M2030, CGS reports. As with the M1030 errors, the documentation submitted to the CERT review contractor did not support the OASIS responses.

When answering M2030 -- Management of injectable medications, you're indicating your patient's ability to take his prescribed injectable medications reliably and safely.

If you report 2 -- Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection or 3 -- Unable to take injectable medication unless administered by another person, you need to make sure the documentation backs up your selection. "You must show why the patient needs assistance," Hansell says. "What is the caregiver doing?"

Mistake: If your patient lives alone, it might be appropriate to list response "2" or "3" at start of care. But these answers aren't appropriate at discharge. It's not acceptable for a patient who lives alone to remain unable to take his injectable medication without an alternative plan in place, Hansell says.

Another common mistake is saying that a patient can't perform injectable medications when she doesn't currently have any injectable medications prescribed, Hansell says. You can't answer M1030 based on a prediction of the patient's ability if she were prescribed an injectable medication.

You also can't report injectable medications given in the doctor's office in M1030. The injection must be occurring in the home.

Example: If your patient goes to the doctor for a monthly B12 injection, you can't take credit for it in M1030.

Get the Physician's Signature Before Billing

According to CGS, the number-two denial reason CERT found was the agency failing to secure the physician's signature on orders/the POC before billing. "Your agency should have an internal review process in place to ensure that a claim is not submitted until the signed POC/orders have been received and meet the signature guidelines," CGS instructs. That goes for verbal orders too.

Tools: Bone up on signature guidelines with CGS's quick resource tool, "Signature Guidelines for Home Health and Hospice Medical Review," at www.cgsmedicare.com/hhh/medreview/sig_guidelines.pdf. CGS's March newsletter is at www.cgsmedicare.com/hhh/pubs/mb_hhh/2012/03_2012/index.html.

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