Home Health Eligibility Requirements

Transcription

1 Presented By: Melinda A. Gaboury, COS-C Chief Executive Officer Healthcare Provider Solutions, Inc. healthcareprovidersolutions.com Home Health Eligibility Requirements Meets eligibility for home health Homebound Under a POC certified by a physician Medicare participating agency Requires intermittent nursing or PT, SLP, or a continuing need for OT Face-to-face encounter for the SOC Medical necessity 1

2 Home Health POC Documentation Requirements All diagnoses Mental status Services, supplies, and equipment needed Frequency of visits to be made Prognosis Rehab potential Functional limitations Home Health POC Documentation Requirements Activities permitted Nutritional requirements All medications and treatments Safety measures to protect against injury Instructions for timely discharge or referral Any additional items needed 2

3 Skilled Nursing Documentation Home Health SN Documentation Requirements Requires skills of a registered nurse Necessary to treat illness Complexity Intermittent Skilled nursing care that is either provided or needed on fewer than seven days each week or less than eight hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable) 3

4 Home Health SN Documentation Requirements Is the patient appropriate for home health nursing? Why does this patient need skilled nursing services now? Records need to support need for beginning or continuing services Has patient received treatment for this same condition previously? Does not disqualify from treatment Home Health SN Observation & Assessment Requirements Reasonable potential for change in a patient s condition Coverage for up to 3 weeks or so long as there remains a reasonable potential for complication or further acute episode Once condition stabilized, must discharge O&A by SN is NOT reasonable and necessary when fluctuating signs and symptoms are chronic and have not required a change in prescribed treatment. 4

5 Medical Necessity for HH SN Teaching The test of whether a nursing service is skilled relates to the skill required to teach and not to the nature of what is being taught. Appropriate to the patient's functional loss, illness, or injury. How to manage the treatment regimen Where after a reasonable period of time, the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record. Medical Necessity for HH SN Teaching Determining the number of visits: Initial teaching: consider the complexity of the activity to be taught and the unique abilities of the patient. Reinforcement: assess the patient's retained knowledge and anticipated learning progress. Re-teaching: change in the procedure or condition, or where the patient, family, or caregiver is not properly carrying out the task. Must document the reason that re-teaching or retraining is required and patient/caregiver response. 5

6 Home Health SN Teaching Activities Examples of SN teaching and training : Medication administration & management New diagnosis, treatment, medication Management of medical gases (Oxygen) Wound care New ostomy care & management Self-catheterization Tube feedings IV care, management, administration Bowel or bladder training Home Health SN Teaching Activities Examples of SN teaching and training activities: Techniques for ADLs, use of adaptive devices Transfer techniques Proper body alignment, positioning, skin care Use of prescribed assistive devices Prosthesis care and gait training Use and care of braces, splints and orthotics Therapeutic diet Medication side effects and contraindications Care and application of special dressings 6

7 Medical Necessity for HH SN Direct Care Wound Care NOTE: While a wound might not require skilled nursing care, the wound may still require skilled monitoring for signs and symptoms of infection or complication or skilled teaching of wound care to the patient or caregiver. Coverage or denial based on all of the documented clinical findings. The plan of care must contain the specific instructions for the treatment of the wound. The size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented. Document to Support the Focus of Care Paint the Picture with the Initial Clinical Summary Can be used for the agency's F2F addendum to support the medical necessity for HH services and homebound status Should be concise and patient-specific Include reason for referral for HH services Give overview of related treatments, new and changed medications, hospitalizations, surgeries, tests, recent emergency care State the primary focus of care (primary diagnosis) for HH services; prioritize secondary diagnoses 7

8 Document to Support the Focus of Care Paint the Picture with the Initial Clinical Summary Support medical necessity Identify patient/caregiver deficits to be addressed, new diagnoses or exacerbation of condition, new or changed medications or treatments, specific needs for teaching, observation, or direct care Include patient and caregiver availability, ability, and willingness to participate and/or perform Identify safety issues, risks, non-compliance, or any other obstacles to care Include assessment findings supporting homebound Required assistance, normal inability to leave home, considerable and taxing effort Document to Support the Focus of Care The 60-day and Recertification Clinical Summary Maintain proof of sending to the physician Synopsis of the care provided Supports necessity for services provided Disciplines remaining active Clinical findings related to reportable vital signs Labs and specimens and overview of results Wound description, measurements, healing status Catheter changes, ostomy care and/or IV needs Includes planned updates to the POC Progress towards reaching prior goals Clinical assessment findings supporting homebound 8

9 Document to Support the Focus of Care Skilled Nursing Visit Documentation Every Skilled Nursing visit note should include: Clinical assessment Response/changes in behavior to previous services Detailed rationale explaining need for services The complexity of the service to be performed Skilled services provided during the current visit Patient/caregiver s response to skilled services Plan for next visit based on rationale of prior results Any other pertinent characteristics of patient/home Specific objective & measurable progress achieved Document to Support the Focus of Care Skilled Nursing Visit Documentation CMS clearly states generalized documentation does not support the need for skilled care. Terminology such as: Patient tolerated treatment well Caregiver instructed in medication management, or Continue with POC are vague or subjective and should not be used. Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services. Guidance/Guidance/Manuals/Downloads/bp102c07.pdf 9

10 Document to Support the Focus of Care Avoid Under or Over-Documentation A descriptive, patient & visit-specific narrative that contains the above mentioned CMS requirements is imperative in each visit note. Cloned or copy-pasted narratives were identified by the OIG as targeted areas of concern in EMR records. Denials are likely when only check-boxes are utilized. Fraud charges could result if the electronic record is over-documented and misrepresents services that were actually provided. F2F FINAL RULE 2015 Update Final Decision: We are finalizing our proposal to eliminate the face-to-face encounter narrative as part of the certification of patient eligibility for the Medicare home health benefit, effective for episodes beginning on or after January 1, The certifying physician will still be required to certify that a face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of thestartofthehomehealthcareandwasperformedbya physician or allowed non-physician practitioner as defined in (a)(1)(v)(A), and to document the date of the encounter as part of the certification of eligibility. 10

11 F2F FINAL RULE 2015 Update For instances where the physician is ordering skilled nursing visits for management and evaluation of the patient's care plan, the physician will still be required to include a brief narrative that describes the clinical justification of this need as part of the certification/re-certification of eligibility as outlined in (a)(1)(i) and (b)(2). In determining whether the patient is or was eligible to receive services under the Medicare home health benefit at the start of care, we will require documentation in the certifying physician s medical records and/or the acute /post-acute care facility s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of home health eligibility. We will require the documentation to be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described at (a)(1) and (b) F2F FINAL RULE 2015 Update HHAs should obtain as much documentation from the certifying physician s medical records and/or the acute/post-acute care facility s medical records (if the patient was directly admitted to home health) as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria have been met and must be able to provide it to CMS and its review entities upon request. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided. Therefore, in order to determine when documentation of a patient s face-to-face encounter is required under sections 1814(a)(2)(C) and 1835 (a)(2)(a) of the Act, we proposed to clarify that the face-to-face encounter requirement is applicable for certifications (not recertifications), rather than initial episodes. A certification (versus recertification) is considered to be any time that a new SOC OASIS is completed to initiate care. 11

12 2015 FINAL HH Regulation Question: What happens if the face-to-face encounter is completed during the 90-day period prior to the start of care (SOC) and then the patient's condition changes? *Answer: In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care (SOC), the certifying physician or an allowed non-physician practitioner (NPP) must see the patient again within 30 days after admission. Specifically, if a patient saw the certifying physician or NPP within the 90 days prior to SOC, another encounter would be needed if the patient s condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan. F2F FINAL RULE 2015 Update Make sure that you are clear IF the agency supplements the visit note or discharge summary with additional information from the comprehensive assessment to support homebound status and the need for skilled services, this must be sent to the physician to sign and date, making it a part of the medical record of the patient. Lastly, please understand that the home health agency MUST obtain the visit note and/or discharge summary and this document MUST contain the first three criteria: 1) a visit date that falls in the required timeframe for the F2F; 2) the reason for the visit is related to the primary reason for homecare; and 3) the visit was performed by an allowed provider type. 12

13 Homebound Definition In the Calendar Year (CY) 2012 Home Health (HH) Prospective Payment System (PPS) proposed rule published on July 12, 2011, CMS proposed their intent to provide clarification to the Benefit Policy Manual language regarding the definition of "confined to the home". In the CY 2012 HH PPS final rule published on November 4, 2011 (FR ), CMS finalized that proposal. In order to clarify the definition, CMS is amending its policy manual as follows: Homebound Definition For purposes of the statute, an individual shall be considered confined to the home (homebound) if the following two criteria are met: Criteria-One: The patient must either: Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence OR Have a condition such that leaving his or her home is medically contraindicated. If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below. Criteria-Two: There must exist a normal inability to leave home; AND Leaving home must require a considerable and taxing effort. 13

14 Homebound Documentation Examples of Taxing Effort SOB experienced after ambulating 15 feet Unsteady gait makes leaving home unsafe w/o assistance Hip pain makes transferring into a vehicle very difficult Unable to leave home without constant supervision due to memory loss and disorientation States he has not left home except for physician appts Requires a walker because of pain from recent TKR surgery Paralysis of left extremities makes the patient wheelchair bound and requires assistance of caregiver to leave home Recent hospitalization for pneumonia has resulted in significant weakness and debility CABG surgery has resulted in significant pain, SOB and weakness Infected surgical wound results in significant pain * 14

15 *Therapy Clarifications *EFFECTIVE DATE APRIL 1, 2011 *Qualified therapist assess, establish goals and re-assess patient *Measurable treatment goals be described in the: *Initial Evaluation *Plan of care *Clinical record *Methods used to assess a patient s function include *Objective measurement *Successive comparison of measurements *There must be objective measurement of progress toward goals and/or therapy effectiveness. Therapy Clarifications Documentation Requirements Evaluation and POC goals must include: *Objective measures of function (e.g. swallow, bathing, dressing, walking, stairs, use of devices) *Described correlation between *Treatment for illness/injury to professional standards *Measurable goals related to illness/injury *Short and long term goals *Specific target dates 15

16 * Common ADR denial Reasons: *HHA did not submit the required reassessment(s) when responding to the ADR request *Credentials missing *Illegible credential with signature *Illegible signature of the therapist *POC missing short and long term goals *Goals missing specific target dates *Objective measurement results are not documented *Reassessments are not being completed within the required timeframe General Principles Governing Reasonable and Necessary PT, OT and ST services The service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist. The skilled services must be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury. General exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation do not constitute skilled therapy. 16

17 Initial Therapy Assessment For each therapy discipline, a qualified therapist (instead of an assistant) must assess and document the patient s function using a method which includes objective measurements which correspond to the therapist s discipline and POC goals. Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must functionally assess the patient. Therapy Reassessment (must be performed in conjunction with an ordered therapy service) At least once every 30 days, for each therapy discipline Performed by a qualified therapist (instead of an assistant) Must provide an ordered therapy service, Must functionally reassess the patient Must compare the resultant measurement to prior measurements Must document the effectiveness of therapy, or lack thereof. The 30-day clock begins with the first therapy service (of that discipline) and resets with each reassessment 17

18 Therapy Visit Notes The history and physical exam pertinent to the day s visit (including the response or changes in behavior to previously administered skilled services) The skilled services applied on the current visit Patient/caregiver s immediate response to the skilled services provided Plan for the next visit based on rationale of prior results Vague or subjective descriptions of the patient s care should not be used. Patient tolerated treatment well Patient has improved muscle strength/rom Continue with POC Guidance/Guidance/Manuals/Downloads/bp102c07.pdf Avoid Under or Over-Documentation A descriptive, patient/visit-specific free-text narrative that contains the above mentioned CMS requirements is imperative in each visit note to support medical necessity. Cloned or copy-pasted narratives were identified by the OIG as targeted areas of concern in EMR records. Denials are likely when only check-boxes are utilized. Fraud charges could result if the electronic record is over-documented and misrepresents services that were actually provided. 18

19 *Therapy Clarifications Orders = PT 2w PT (1) PTA (2) PTA (3) PTA(5) PTA(7) PTA (4) PTA(6) PTA(8) PT (9) PTA(10) Continue * Therapy Clarifications continued Orders = PT 2w PTA (11) PTA(13) PTA (12) PTA(14) PTA(15) PT(16)

20 Questions Faculty Contact Info Melinda A. Gaboury Chief Executive Officer Healthcare Provider Solutions, Inc. 810 Royal Parkway, Suite 200 Nashville, TN Phone Fax 20