Homecare Q&A No-nonsense solutions that clear the Medicare fog

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Antony Morton
6 years ago
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1 pril 3, 2015 Homecare & No-nonsense solutions that clear the Medicare fog Service of the Beacon Institute Face-to-face When responding to home health services provided January 1, 2015, and beyond, and we receive an DR [additional development request] related to LUP or 5 7 visits, do we need to include face-to-face documents with the DR information? ll Medicare patients for whom you bill, regardless of whether they are LUP, require a face-to-face document with DRs. Recertifications Please provide direction on the following scenario: RN primary discipline, HC [homecare aide] secondary discipline The RN recerts a patient, and the new cert begins on Thursday, March 19th. The RN writes orders for the HC to continue services. Does the start of the VFOs for the HC need to begin on the day of the new cert period, or can it begin the following week? For example, the new cert begins Thursday, March 19th. The HC can t get in until the following week. Is it okay to start VFOs the beginning of next week? Or should they be listed as once every two weeks for the first string? Please advise. You can write orders for when the services begin. In other words, if the recert date starts on Thursday, March 19, but HC visits start the week of March 23, and RN visits start the week of March 30, then you would write your frequency as follows: RN OW9 first visit to begin week of 3/30/15 HC 2w9 to begin week of 3/23/15 ppeals We have an DR that got denied due to 5T080 absence of short-term and longterm goals within the initial therapy evaluation. I was wondering if you can give us your professional expertise on how to appeal this. Where in the CMS guidelines does it indicate that there should be short-term and longterm goals for therapy? The PT evaluation has goals, but all were stated in seven weeks. Due to the nature and complex medical condition of the patient, the therapist determined that the seven-week goal was a realistic and appropriate time frame for this particular patient. Do we have a case to appeal on this? Palmetto and CGS have specific local coverage determinations (LCD) regarding shortand long-term therapy goals. The Medicare Policy Manual, Chapter 15, p. 162 also addresses shortand long-term goals, stating: Long term treatment goals should be developed for the entire episode of care in the current setting. When the episode is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified. Goals should be measurable and pertain to identified functional impairments. Therapists typically also establish short term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of 2015 HCPro, a division of BLR. ll rights reserved. Page 1 of 4

2 pril 3, 2015 care. If the expected episode of care is short, for example therapy is expected to be completed in 4 to 6 treatment days, the long term and short term goals may be the same. If you felt you demonstrated the care in good faith, I would appeal the DR and state that education has been provided to the clinical staff in standards of care. OSIS Some of my staff seem unclear about the parameters of the resumption-of-care (ROC) assessment. Can you shed some light on the specific circumstances that warrant one, and what kind of information is required? The ROC assessment is completed any time a patient has returned home following an inpatient stay of more than 24 hours that was triggered by reasons other than diagnostic testing. The ROC assessment should be completed within 48 hours of the patient s return to the home. However, before executing this assessment, staff should have completed the transfer to an inpatient facility form (not to be mistaken with the discharged from agency form). Errors should occur when encoding the ROC assessment if this requisite documentation hasn t been completed. The following Mxxxx items are included on the ROC assessment: M0032 and other PTS items reviewed from original completion M0080 M0110: Clinical Record Items M1000 M1036: Patient History & Diagnoses M1100 M1242: Living rrangements & Sensory Status M1300 M1302, M1306, M1308 M1324, M1330 M1350: Integumentary Status M1400, M1410: Respiratory Status M1600 M1630: Elimination Status M1700 M1750: Neuro/Emotional/Behavioral Status M1800 M1910: DL/IDLs M2000, M2002, M2010, M2020 M2040: Medications M2102, M2110: Care Management M2200, M2250: Therapy Need and Plan of Care Hospice eligibility Our organization has recently experienced spikes in claim denials due to various issues with justifying hospice eligibility on certifications and recertifications. How can we ensure we re meeting and documenting eligibility requirements effectively? Before offering the Medicare Hospice Benefit (MHB) to a beneficiary, the hospice must first verify that the patient qualifies for hospice services. LCDs identify the information regional home health intermediaries use when determining medical necessity and eligibility for hospice services. The hospice program s medical director and the patient s attending physician should use the LCD found on the hospice s Regional Home Health and Hospice Intermediary website as a resource in the analysis of a patient s clinical status to determine eligibility for hospice. LCDs for hospice focus on noncancer diagnoses, which are harder to prognosticate than cancer diagnoses. Certification of terminal illness n accurate and complete certification of terminal illness supports payment, provides the hospice program with a sound foundation for delivering care, and vets the admitted patient s eligibility. Verifying a prognosis of six months or less (assuming the disease progresses normally) is a judicious process focused on ensuring that the patient s clinical status reflects the prognosis. Predicting life expectancy is not an exact science, so when a beneficiary lives longer than expected, it is not just cause to discharge the patient from the MHB. The clinical judgment of the medical director or the physician member of the interdisciplinary 2015 HCPro, a division of BLR. ll rights reserved. Page 2 of 4

3 pril 3, 2015 group (IDG) and the patient s attending physician serves as the basis for the certification of terminal illness for hospice benefits. Prior to certification, these physicians review the patient s clinical history and current status to determine whether hospice care is reasonable and necessary for the palliation or management of the patient s terminal illness. dditional supporting information, including the identification of any related comorbid conditions, is beneficial in validating a patient s prognosis. In hospice, the patient has two initial 90-day certification periods and an indefinite number of 60-day periods. patient admitted to hospice moves from one certification period to the next only after the IDG reevaluates the patient s clinical status and determines that he or she remains eligible for hospice. For recertification of services under the MHB, only the signature of the hospice medical director or physician member of the IDG is required. Effective January 1, 2010, a face-to-face physician encounter is required for Medicare beneficiaries who are poised to enter a third hospice benefit period or any period thereafter. physician involved with the hospice or a hospice-employed nurse practitioner must perform the face-to-face encounter. This encounter must occur within 30 calendar days prior to the start of the third benefit period and all subsequent recertifications. The documentation requirements related to the face-to-face physician encounter encompass the sharing of clinical findings used to determine continued hospice eligibility and a written certification, including a narrative explanation and other required encounter documentation, signed prior to billing the claim. Election form Medicare does not have a standard MHB election form, so each hospice must develop its own. This form must supply details about hospice services, allowing the patient and his or her family to provide informed consent about the benefits. The election statement must include: Identification of the particular hospice that will provide care to the patient The patient s or patient representative s acknowledgement that he or she has been given a full understanding of the palliative rather than curative nature of hospice care as it relates to the patient s terminal illness cknowledgement that certain Medicare services are waived by the election, such as any that are related to the treatment of the terminal condition for which hospice care was elected or a related condition (some exceptions apply) The effective date of election, which may be the first day of hospice care or a later date but may be no earlier than the date of election The signature of the patient or representative To promote informed consent, the hospice may also choose to include the following information on the MHB election form: Hospice hours of operation Emergency contact information Description of covered and noncovered services Information about prescriptions and biologicals coverage and a list of contracted pharmacies Types of services and levels of care available Information about revoking hospice cknowledgment of potential financial obligations to the patient Information about patient rights and advance directives Disclosure of confidential and HIP information DNR orders and cardiopulmonary resuscitation policies Primary caregiver policies Tube-feeding policies list of facilities contracted with the hospice for inpatient and residential care Reasons for revocation and discharge Nondiscrimination policy 2015 HCPro, a division of BLR. ll rights reserved. Page 3 of 4

4 pril 3, 2015 The MHB election form is a legal agreement between a hospice and a patient or the patient s responsible representative. patient who elects hospice must sign the form on the day of election. The patient may sign the form prior to the day of admission to hospice, if the actual date of admission is noted on the form. Legal landscape We re a small agency with a very tight budget, so we re particularly disturbed by the horror stories we hear about the types of lawsuits filed against home health providers these days. In addition, we recently had a scare with an angry family after a patient fell during a physical therapy visit. ny tips for preventing future legal fallout in such cases? Unfortunately, when a fall occurs in the presence of agency staff, people assume that it could and should have been prevented. Considering this often-unfair logic, James Newfield s revelation in the 2006 article, Fall- Related Injuries, that fall-related injuries make up a disproportionate percentage of home health liability claims is disturbing, yet unsurprising. Despite these legal obstacles, an aggressive fall prevention program, thorough assessments, accurate documentation, and a performance improvement plan can help an agency argue its commitment to safe patient care. ccording to Newfield, an agency must take proactive steps to head off misperceptions of negligence if a patient falls in the presence of a staff member, including: Setting reasonable expectations for falls. Discuss the risk of falls and potential consequences with each patient, as well as his or her family. Underscore that fall risks can be reduced but not completely eliminated. Performing fall prevention at the start of care and reassessing throughout the course of care. Establish an evaluation strategy that promotes independence while limiting fall risks. ssessing each patient as an individual. Consider his or her attitude toward assistance, assistive devices, and ambulation to tailor care accordingly. Emphasizing the integral role each patient and his or her family plays in the success of the agency s fall prevention program. ll of these clinical approaches should also be documented in the patient s record. Establishing a paper trail of each involved party s expectations, understanding, and commitment regarding the fall prevention program may be crucial at a later time. Homecare & is distributed via 24 times per year to Beacon Institute members. Please submit questions for editorial consideration either by fax (to Homecare & at ) or (askanexpert@beaconhealth.org). Include name, agency, and telephone and fax numbers. lthough a reasonable effort is made to provide accurate information and interpretation, circumstances may vary depending on the individual case and state and regional regulations. Consequently, the publisher assumes no liability whatsoever in connection with its use. Copyright Warning: Unauthorized photocopying, forwarding, or sharing of online viewing password is punishable by law. We share 50% of net proceeds of settlements or jury awards with individuals who provide essential evidence of illegal copyright infringement. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or For customer service, please call or write to HCPro, 100 Winners Circle, Suite 300, Brentwood, TN HCPro, a division of BLR. ll rights reserved. Page 4 of 4

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Homecare Q&A No-nonsense solutions that clear the Medicare fog

Homecare Q&A No-nonsense solutions that clear the Medicare fog Homecare & No-nonsense solutions that clear the Medicare fog Service of the Beacon Institute Medicare clinician arrives at the home, where skilled services are provided. Based on the assessment/observation