OASIS Alert

Published on Thu Jul 07, 2005 PDF

Medicare pays for a single SN visit - but not often.

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.

That's because for skilled nursing to qualify a patient for the Medicare home health benefit, the nursing visits must be needed intermittently. "This means there must be a medically predictable recurring need for skilled nursing services," regional home health intermediary Cahaba GBA explains in its June provider newsletter.

Providers refer many patients to home health agencies with an order for only one visit, clinicians report. The patient may need sutures removed, a single injection or a one-time assessment. 
 
In other cases, the nurse makes only one visit because the patient is not admitted to home care. For example, the patient may not be homebound, there may not be an available caregiver to be there between nursing visits, or the patient may already be in an open episode with another agency.
 
Problem: Providers continue to submit claims for one-time skilled nursing visits, Cahaba reports. This may be because one-time therapy visits are reimbursed, causing agency confusion, suggests consultant Rose Kimball with Dallas, TX-based Med-Care Adminis-trative Services.
 
Solution:  Review with your staff the few situations in which you can submit a claim for a single SN visit, Cahaba suggests:

1. You expected more. If you expected to make more than one visit when you admitted the patient, but something unforeseen happened to prevent the subsequent visits, you can submit a claim. It will be processed as a low utilization payment adjustment (LUPA), the RHHI explains. This situation may arise if the patient died or was hospitalized after the first visit or if the patient refused further care or transferred to another agency.
 
Watch out: If you planned more visits but later found the patient is already under care with another agency, you can't submit a claim, Cahaba says. "Two HHAs cannot bill for services during the same episode period," the RHHI explains.

2. You're not alone. When there is a medically necessary skilled therapy service in the home already, a single SN visit may be covered if it is medically necessary, Cahaba instructs. For example, your agency may be providing therapy for a patient with a joint replacement. In this case, a single SN visit to remove sutures would be a covered visit, the RHHI says.

Caution: A single SN visit to complete the OASIS assessment does not qualify for coverage unless the nurse furnishes another medically necessary skilled service during the visit, Cahaba warns.

Note: Cahaba's instructions are at www.iamedicare.com/Provider/newsroom/newslines/0605.pdf.