Presented by: Arlene Maxim, RN-Founder A.D. Maxim Consulting, LLC.

Transcription

1 Presented by: Arlene Maxim, RN-Founder A.D. Maxim Consulting, LLC. On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors were inappropriately applying an Improvement Standard in making claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits). KORNETTI, DIANA & ARLENE MAXIM 1

2 CMS published a Fact Sheet that we will cover here. The results of this settlement agreement requires that CMS makes specific changes in the Medicare Policy manual that will include clarifications to existing policies and new educational materials relating to patients with long term needs. In this fact sheet CMS indicates The goal of this settlement agreement is to ensure that claims are correctly adjudicated in accordance with existing Medicare policy, so that Medicare beneficiaries receive the full coverage to which they are entitled. CMS has indicated that the contractors got it wrong!! KORNETTI, DIANA & ARLENE MAXIM 2

3 CMS is quick to point out that there is- No Expansion of Medicare Coverage: Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage. Again, CMS states they will clarify that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration KORNETTI, DIANA & ARLENE MAXIM 3

4 CMS indicates that the policy never supported the imposition of an Improvement Standard rule-ofthumb when determining if there was a skill required (i.e. Skilled Management and Evaluation or Therapy Maintenance) to prevent or slow deterioration in a patient s condition. The fact sheet further indicates that a beneficiary s lack of restoration potential cannot, in itself, serve as the basis for denying coverage, without regard to an individualized assessment of the beneficiary s medical condition and the reasonableness and necessity of the treatment, care, or services in question. Again, they are trying to clarify that a rule of thumb cannot be used in determining denial or coverage of claims. KORNETTI, DIANA & ARLENE MAXIM 4

5 However, they also point out that when nonskilled personnel can perform the care-coverage criteria will NOT be met!! Among the key provisions of the proposed settlement agreement are the following: 1. A nationwide class will be certified consisting of all beneficiaries who received an adverse administrative decision based on the Improvement Standard that became final and non-appealable on or after January 18, Many of those class members will be entitled to re-review of their claims. KORNETTI, DIANA & ARLENE MAXIM 5

6 The Centers for Medicare & Medicaid Services (CMS), with input from plaintiffs' counsel, will revise relevant portions of the Medicare Benefit Policy Manual to eliminate any suggestion that a beneficiary must show a potential for improvement, with the need for skilled care being the determinative factor. CMS also has the option of issuing a Ruling on the corrected policy. CMS will engage in a nationwide Educational Campaign, using written materials, interactive forums, and national calls, to communicate the corrected maintenance coverage standards to providers, contractors, and adjudicators. KORNETTI, DIANA & ARLENE MAXIM 6

7 CMS will do random samplings of QIC decisions to determine if the corrected policy is being applied, review up to 100 claims brought to them by plaintiffs' counsel, and meet with plaintiffs' counsel five times on a bi-annual basis The Court will maintain jurisdiction for up to two or three years after the end of the Educational Campaign (the time frame depending on whether CMS issues a Ruling), during which time plaintiffs may seek enforcement of any settlement provisions that they believe the Secretary is not complying with. KORNETTI, DIANA & ARLENE MAXIM 7

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9 Myth 1-You cannot recertify patients. If you do, you will be under medical review. Myth 2-Skilled Management and Evaluation of an Unskilled Care Plan is not covered. Myth 3-Therapy is not covered under the Medicare Program. KORNETTI, DIANA & ARLENE MAXIM 9

10 Who Is Eligible Patient must be homebound Unskilled Caregiver Complex Care Plan Homecare myths related to Skilled Management and Evaluation (SM&E) We will get ADR s-medical Reviews Medicare won t cover SM&E OBVIOUS SKILL KORNETTI, DIANA & ARLENE MAXIM 10

11 The patient s need for homecare is easy when there is an obvious skill identifiedi.e. wound care, teaching on new and changed medications, etc. As long as a nurse can identify a skill as he/she knows it, re-certifications are easy and pretty straight forward. Documentation for Skilled Management and Evaluation necessitates a somewhat more complex plan of care. KORNETTI, DIANA & ARLENE MAXIM 11

12 With the increase of an aging population upon us, there will be an intensified need for skilled management (nursing) and maintenance therapy (therapists). In the current version of the Medicare Benefit Policy Manual, Chapter 7, Section , Management and Evaluation of a Patient Care Plan is clearly outlined. The use of this skill will be valuable as a means to reduce hospitalizations and emergency room visits for those patients with complex care plans. KORNETTI, DIANA & ARLENE MAXIM 12

13 Identifying Skill 1. Observation and Assessment 2. Management and Evaluation of Patient Care Plan 3. Teaching and Training Activities 4. Administration of Medications 5. Tube Feedings 6. Nasopharyngeal; and Tracheostomy Aspiration 7. Catheters 8. Wound Care 9. Ostomy Care KORNETTI, DIANA & ARLENE MAXIM 13

14 10. Heat Treatments 11. Medical Gases 12. Rehabilitation Nursing 13. Venipuncture 14. Student Nurse Visits 15. Psychiatric Evaluation Skill #2 Management and Evaluation of a Patient Care Plan KORNETTI, DIANA & ARLENE MAXIM 14

15 The Patient s Bridge to Care Between Two Acute Episodes Management and evaluation of a care plan was identified as a new skilled nursing service in the April 1989 revisions to the Medicare Policy KORNETTI, DIANA & ARLENE MAXIM 15

16 The skill involves the management of a complex care plan involving unskilled services designed to provide oversight and avoid complications in a patient's overall medical plan of care. Management and Evaluation could be viewed as case/care management and evaluation of a complicated care plan. KORNETTI, DIANA & ARLENE MAXIM 16

17 Once the need for management and evaluation is identified and ordered, it can serve as a qualifying skilled service for the provision of other home care services: home care aides medical social services supplies Management and evaluation is not intended to serve as the primary mechanism for providing long-term care. However, there are no time restrictions for carrying out this skill. KORNETTI, DIANA & ARLENE MAXIM 17

18 Skilled nursing visits for management and evaluation of a patient's care plan are reasonable and necessary when underlying conditions or complications require that only a registered nurse can ensure that essential non-skilled care is achieving its purpose. For skilled nursing care to be reasonable and necessary for management and evaluation of the beneficiary's plan of care KORNETTI, DIANA & ARLENE MAXIM 18

19 The complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the patient's recovery and medical safety in view of the beneficiary's overall condition. Patient Type KORNETTI, DIANA & ARLENE MAXIM 19

20 Many of these items can be found right in your OASIS assessment!!!! Typically the age group is between years of age. Assessment Items we might look for, include, but are not limited to: Confusion or altered mental status (M1700/1710) Impaired vision (M1200) KORNETTI, DIANA & ARLENE MAXIM 20

21 Some level of pain (M 1242) Dyspnea (M1400) Skin Integrity issues-including edema (M1350) Multiple co-morbidities (M1020) More than 5 medications that are taken multiple times throughout the day (M2000-M2040) Multiple physicians Use community resources-i.e. home delivered meals, handicapped transportation, emergency response systems KORNETTI, DIANA & ARLENE MAXIM 21

22 In understanding management and evaluation, remember these three important points: Briefly document the complicating factors resulting in a high potential for complication or for ensuring that essential non-skilled services are achieving its purpose to promote the beneficiary's recovery and safety. KORNETTI, DIANA & ARLENE MAXIM 22

23 Skilled management and evaluation involves finding that recovery and safety cannot be assured unless the total care, skilled or not, is planned and managed by a registered nurse. Skilled management and evaluation should be a specific order when it is the only skilled nursing service rendered. MUST BE REGISTERED NURSE-No LPN/ LVN s KORNETTI, DIANA & ARLENE MAXIM 23

24 DETERMINING FREQUENCY Frequency is determined by: Patient Need Number of Caregivers Complexity of the Care Plan Example: 3 X month X 1; 2 X month X1 KORNETTI, DIANA & ARLENE MAXIM 24

25 DETERMINING DIAGNOSIS Coding Rules and Principles DO NOT CHANGE!! Code as you would any other record-based on assessment findings!!! KORNETTI, DIANA & ARLENE MAXIM 25

26 1. Depending on the size of your agency, go back through 3 months worth of discharged patient records. 2. Determine how many discharged patients were either readmitted to your agency or admitted to an acute care setting (or another Agency). KORNETTI, DIANA & ARLENE MAXIM 26

27 3. Use the criteria we identified earlier in this presentation in identifying possible candidates for the skill. - Don t be afraid to recertify!! - Train your staff in Management and Evaluation for Nursing!!! Understand how to design an appropriate plan of care: Include safety issues related to patient Frequency of any hospitalizations/er visits within last 12 months Describe risks for patient if he/she were discharged. KORNETTI, DIANA & ARLENE MAXIM 27

28 Understand how to write a visit note for SM & E Include a head to toe assessment of the patient-look for CHANGES in his/her condition. If changes are identified, complete a SCIC assessment and return to routine skilled care. Include a detailed analysis of the relationship between the caregiver and the patient; Include documentation that clearly outlines the ability of the caregiver to follow the complex care plan. KORNETTI, DIANA & ARLENE MAXIM 28