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

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1 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 of the patient, the patient is determined to no longer be confined to their home. Since the patient no longer qualifies for ongoing Medicare services, we move forward with the agency discharge, specifying a discharge reason of patient no longer homebound, and that visit is still billable under Medicare. The clinician s discharge visit note includes the skilled care provided by the clinician during the visit and the reason for the discharge (i.e., during the assessment it was determined that the patient was no longer homebound). The patient is issued the discharge notice. re other agencies billing for the final skilled visit when the discharge reason is no longer homebound? Yes, you are correct. Since you provided a skilled service and determined during your assessment that the patient no longer met homebound criteria, it is appropriate to bill that visit. The clinician should complete the visit information and provide the patient with the discharge notice. Will you please clarify whether or not it is okay to use a range when defining visit frequency? For example, if the patient has wound care daily, but often goes to the clinic for follow-up, is it okay to put 6 7 times per week? nother example related to PT/INR lab draws: If that is the only reason you are seeing the patient, you might go weekly or every other week or monthly, so what would be the proper way to document visit frequency? t one time we heard that you could do a range, but understood that you would be accountable for the top end of the range and had to notify the physician of a missed visit if you did not provide visits at the top end of the range. Is this accurate? Ranges are acceptable, and you are correct that a surveyor expects to see the top end of the frequency. Let me caution you, though, on your second example of PT/INRs. These are not an independent qualifying skill and not the basis for home health visits. CMS also expects patients plans of care to be individualized, so a blanket everyone gets a range should be discouraged. Maintenance therapy Would the following patient type be a better candidate for restorative or maintenance therapy? The patient lives alone in her own home. She has been managing with her heart failure over the past 10 years. She has been hospitalized three times in the past few years due to fluid overload and is being referred to therapy for a second time in the past six months with complaints of fatigue and inconsistent completion of her self-care. Because of her chronic condition, her mobility and self-care issues that have been problematic to varying degrees for at least the past six months, a vague past level of function, and the fact that the management of heart failure as it relates to mobility and self-care makes it a primary focus of care, this patient is a good candidate for maintenance therapy HCPro, a division of BLR. ll rights reserved. Page 1 of 4

2 Generally, when making this decision for patients, remember that although the diagnosis and the functional limitations do not stand alone in determining the medical necessity of therapy, they both play critical elements in clinical decision-making. Tools such as the Gold Spirometric Criteria and the NYH Functional Classification provide a structured methodology for understanding the condition of the patient as opposed to a one-size-fits-all approach to these complex medical conditions. Therapists working with those with one or more chronic conditions must seek out appropriate and current information to incorporate into clinical practice and bolster the skilled level of care provided. Based on the findings of a thorough and comprehensive assessment, the therapist can then make the decision to implement a plan that focuses on restorative/rehabilitative- or maintenance-driven interventions. Keep in mind that this is not a onetime-only decision, as a patient can move between both of these courses of care based on his or her presentation combined with the skilled judgment of the therapist. The process begins with assessment, but questions remain about what that looks like in a maintenance therapy situation. dditional discussion is warranted for therapists practicing in the postacute environment. Clinical documentation What are some tips when evaluating our documentation system? s a progressive case manager, you have decided that you want to improve your patient s care by improving the documentation of nursing observations. You also want to reduce the time it takes to document the nursing process. But before you decide to make a recommendation to revise a form or two, take a moment to read the seven items below. Can you concur with all of the following statements? Our clinical and patient-satisfaction outcomes speak for themselves. For example, assessment and management of pain is well documented in the medical record and cited in the patientsatisfaction survey as 90+. When I have to investigate an adverse event, the documentation gives me all of the information I need to draw my conclusions and take action, if warranted (i.e., standards, policies, etc., were followed). t any point in the patient s care, I can find evidence of documented progress or appropriate interventions to improve the patient s care. When I review a specific clinical record, I can see that I used the nursing process and there were measurable goals. There is clear communication and collaboration evident in the clinical record (e.g., conversations, consultations, communication among team members). Discharge planning is clearly documented at the onset, frequently (according to agency policy), and not left to the day of discharge. When the clinical records are audited as part of ongoing performance improvement, the compliance rate is 95% 100% (or your target rate). If you agree with each of these statements, you probably don t need to change much. If you disagree with any of these, you may need to think about seriously looking at your documentation system in an effort to improve patient safety and outcomes. In any healthcare agency today, you will find numerous documentation forms or screens, if electronic based on history and what someone thought was needed for the regulatory and accrediting agencies. When reviewing documentation, remember that incomplete records are an invitation to disaster. You must document completely in all areas indicated by organizational policy; nobody wants to review a clinical record in retrospect and see gaps in their documentation. Careful attention and compliance with good charting skills is never a waste of one s time HCPro, a division of BLR. ll rights reserved. Page 2 of 4

3 You can be sure that complete clinical records reflect quality patient care. n incomplete and inaccurate clinical record leaves an organization and the nurse vulnerable to allegations of negligence. n incomplete clinical record: Demonstrates that care was incomplete Contains gaps, reflecting poor clinical care Demonstrates noncompliance with organization policies Is used to support allegations of negligence Is used to support allegations of fraud Failure to document completely can thus lead to regulatory deficiencies and legal consequences. If the documentation is incomplete, contains gaps, and was not consistently completed according to the organization s policies, it can be used to support the allegation that there was poor patient care or, worse, that negligence was involved. If the case goes to court, it also allows juries to conclude that the nurse did not collect sufficient data, make good clinical decisions, or implement appropriate interventions in compliance with professional and organizational standards. Referrals Can a nurse practitioner who runs her own practice make a referral to a home health agency? nyone a physician, a social worker, a family member can refer a potential patient to a homecare agency. However, a physician must be the one to order the necessary services for any patient in a Medicare-certified agency. What do we do if a patient has been snatched away from us? s one part of its process, when accepting a patient who has elected to transfer, an agency must notify the original agency about the patient s 2015 HCPro, a division of BLR. ll rights reserved. decision. However, in spite of this procedure, it appears that some agencies are losing patients to other agencies that arrive on the scene later. These agencies learn about the patient s transfer when they receive a PEP for their episode of care. Some have called this snatching. So what can an agency do when it believes its patient has been snatched? CMS Publication 100-2, Chapter 7, 10.8, says that if the original agency disputes a transfer, the initial agency must call its intermediary to resolve the dispute. The intermediary is responsible for working with both agencies to resolve the dispute. If the receiving agency can prove that it fulfilled its responsibilities, it will start a new episode and the original agency will receive a PEP; if it can t provide documentation, the original agency will receive payment and the receiving agency will not. Orders Can we accept orders from a physician s secretary or office nurse who is communicating with us instead of the physician? The Interpretive Guidelines for (a) say an agency should have policies and procedures for accepting written physician s orders communicated verbally by a discharge planner, nurse practitioner, physician s assistant, or other authorized staff member. The agency must then obtain the physician s signature on the order. Can we use standing orders for many of our specialty programs, like wound care? Homecare providers cannot use standing orders per se. The regulations require all orders to be included in a plan of care that is developed with and signed by the patient s physician. It is possible for an agency to develop protocols, spelling out specified care and procedures for a patient in a given situation. Then when admitting a particular patient, the clinician would obtain the physician s approval for the orders in the protocol and include them in the patient s plan of care. Page 3 of 4

4 If the physician orders vital signs, blood sugar monitoring, and/or pulse oximetry, do we need acceptable parameters on the plan of care? There is no regulatory requirement to document parameters for physician notification on the plan of care. The Conditions of Participation, (b), require clinicians to notify the physician about changes that suggest a need to modify the plan of care. If the surveyor identifies instances when a clinician has failed to respond to significant findings, he or she can cite the agency. For example: The home health aide documented that the patient with a catheter had an elevated temp and her urine had become cloudy and streaked with mucus. The nurse recognized these as findings that suggested a need to modify the plan of care and notified the physician. The nurse complied with the regulation; parameters were not necessary. Volume 18, Number 11 What exactly does an order for evaluate and treat allow a therapist to do? Does this mean that anything can be done in the initial visit but not in subsequent visits without additional orders? Many therapists, by virtue of state licensure and practice acts, can independently prescribe for and treat non-homecare patients. Physician authorization is not necessary. When therapists enter the homecare arena, they lose this right. Federal statutes for home health care require all services and visits to be on a plan of care signed by a physician. n eval and treat order permits therapists to conduct an evaluation and only an evaluation. They cannot provide any medically driven treatments during the initial visit or make any additional visits beyond the evaluation until they ve obtained authorization. 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

5 BO O K! N EW ENSURE PROPER CRE PLNS & DOCUMENTTION FOR MINTENNCE THERPY PTIENTS Medicare coverage for maintenance therapy in the post-acute world has been unclear, causing improper documentation and reimbursement for home health agencies, skilled nursing facilities (SNF), outpatient therapy, and rehabilitation facilities. This guide contains both regulatory information and analysis as well as hands-on, practical advice for care and documentation. dvice given is specific to each post-acute care setting. The guide also features tips from consultants, tools from the Center of Medicare dvocacy and information from CMS, downloadable materials, and sample forms and worksheets for easy comprehension of information. This book contains tips, tools, and resources on: $130 Identification of maintenance candidates Goal writing strategies Compliance with reassessment expectations Care planning for the maintenance patient Documentation auditing fter reading this book, readers will be able to: Understand the proper use of maintenance therapy Identify when and how to document care as maintenance therapy Determine which patients qualify as needing maintenance therapy 3 CONVENIENT WYS TO ORDER: Visit: Call: customerservice@hcpro.com Plan and assess care of maintenance therapy patients Document maintenance therapy with confidence Use the tools provided to help with comprehension and documentation For faster service, please use source code MB at checkout. Copyright 2015 HCPro, a division of BLR. ll rights reserved