OASIS Alert

Being too embarrassed to ask costs $200.

If a high percentage of your patients don't score a "1" on M0520, you may need to retrain your clinicians.

Your challenge in "Mission Inconti-nence"and you don't have much choice about accepting it--involves two parts. First you need to determine if the patient is incontinent and then you need to decide what you can do about it.

The basics: M0520 asks if the patient has urinary incontinence or if a urinary catheter is present. If you mark "1 - Patient is incontinent," the skip pattern directs you to M0530 to indicate when incontinence occurs.

If incontinence occurs at any time, M0530 adds six points to the clinical severity domain of the home health resource group that determines reimbursement.

Bottom line: These points can add about $200 to an episode payment.

Incontinence Also Affects Outcomes

Just as important as its influence on payment is the effect of incontinence on outcomes, says clinical consultant Lynn Yetman with St. Petersburg, FL-based Reingruber & Co.

"Percentage of patients whose bladder control improves" is one of the newest additions to the Home Health Compare publicly reported outcomes. The national average for this measure has remained at 49 percent since it was added to Home Health Compare in September 2005. At that time, 24 states had averages for this measure that were below the national average, with averages ranging from 31 percent to 65 percent as of March 2005, the Centers for Medicare & Medicaid Services said.

Heads up: And with incontinence a primary reason families admit patients to nursing homes, addressing this issue is likely to become a part of pay for performance, experts say.

Expect 'Yes' On M0520

Urinary incontinence--loss of bladder control--is a symptom, not a disease, and can result from a broad range of conditions and disorders, says the Charleston, SC-based National Association For Continence. Thirteen million Americans--85 percent of them women--are incontinent, including more than half of all nursing home patients, NAFC reports.
 
The incidence of at least occasional incontinence may reach 60 percent in women over 50, according to recent studies. And ex-perts estimate that about 50 percent of homebound elderly patients are incontinent. If you follow the OASIS manual instructions carefully, "just about every patient you see will have urinary incontinence," notes Chicago-based consultant Rebecca Friedman Zuber.

Prevent Downcoding

Once you identify incontinence on an assessment, be sure to document it to support payment, experts warn. Staff expectations that the elderly often are incontinent may be the reason this problem is inadequately documented, they say.

Strategy: Generally, you should include incontinence in the treatment plan and document it in the record, counsels OASIS expert Linda Krulish, with Redmond, WA-based OASIS Answers Inc. You might need to address chronic incontinence only once, perhaps documenting the length of time it has existed, information about its cause, supplies being used and preventive education to avoid skin breakdown, she suggests.

But document new problems--such as recent incontinence of unknown origin or incontinence related to mobility issues--more frequently as part of the treatment plan. "Show what you're doing to address the issue," she adds.

Address Incontinence, Don't Ignore It

Depending on the cause of the incontinence, one home health episode may not give agencies time to show improvement.

But if a patient is working to recover function and return to her previous lifestyle in the community, evidence supports a short window of opportunity--about the length of one episode--notes Winston-Salem, NC-based consultant Sandra Lentz with Dixon Hughes.

Best bet: Agencies should focus on using the whole episode, rather than on decreasing lengths of stay, she says.

By treating even mild stress incontinence, you may be able to prevent more debilitating problems in the future, says Vienna, VA-based clinical consultant Mary Curry Narayan with Visiting Nurse Services.

Approaches to treating incontinence include behavioral techniques (for cognitively intact patients), bladder training (such as timed voiding), prompted voiding (often used for cognitively impaired patients) and physical function training (such as exercise programs), according to the Medicare Quality Improvement Community Web site.

Don't Overlook Physical Therapy

Physical therapy may be covered to develop a home exercise program to address incontinence, says regional home health intermediary Cahaba GBA in its May 1 Medicare A Newsline. While two to four visits often are considered medically necessary to complete and instruct a patient in a home exercise program, one visit may be enough for an incontinence program, Cahaba suggests. "These are not exercises that can be visually demonstrated and the outcomes of reduced incontinence from the exercise program will not be immediately identified."

Caution: Biofeedback to treat incontinence is not covered in the home, Cahaba says.

But focusing just on a home exercise program underestimates what PTs can do to address incontinence. Some PTs specialize in treating incontinence, because it involves so many related aspects of PTs' practice, such as access to and use of toileting facilities, improving dressing skills and using assistive devices, says physical therapist Cindy Krafft, director of rehabilitation for OSF Home Care based in Peoria, IL. And with this M0 item now a publicly reported outcome, agencies need to get the whole team working on this issue, experts say.

Note: For incontinence tools go to www.medqic.org, click on "browse by topic" and then on "incontinence." For the National Association For Continence, go to www.nafc.org.