¡ Select Data
¡ Susan Carmichael
¡ MS, RN, CHCQM, COS-‐C, FAIHQ
¡ Sources:The Conditions of Participation
Medicare Benefits Manual, essentially Chapters 7, 10, and 30
¡ Section I
¡ Auditors Unleashed
¡ Home Health Eligibility Criteria
¡ Homebound Status
¡ Section II
¡ Skilled Nursing Visits and Medical Necessity
¡ Common Documentation Deficiency Areas
¡ Skilled Need: Teaching
¡ Section III ¡ ADRS ¡ Late Entries ¡ Wound Care ¡ Psychiatric Care ¡ Section IV
¡ Therapy Care and ICD-‐9 Coding ¡ Supportive Services: MSS
¡ Supportive Services and Home Aide ¡ Daily Visits
¡ M1020, M1022, M1024 and Coding Points ¡ The Wisdom of the Home Health Clinician ¡ Summary
¡ Certification and Accreditation Surveyors-‐ ensuring compliance with State licensure laws and CMS CoPs
¡ Recovery Audit Contractors RACs-‐ contingency motivated
recovery audit contractors (retrospective focus)
¡ Medicare Administrative Contractors MACs-‐ can impose “severe administrative action” such as up to 100%
prepayment review, payment suspension, and use of statistical sampling for overpayment estimation of claims (current and prospective focus)
¡ Comprehensive Error Rate Testing CERTs-‐ described as the “QI for MACs “looking at claims payment accuracy
¡ Medicaid Integrity Contractors MICs-‐ described as the RACs of Medicaid
¡ Program Safeguard Contractors PSCs– Conducts billing audits and chart reviews
¡ Zone Program Integrity Contractor Z-PICs- primary goal is to
identify cases of fraud, develop the investigation, and refer to the OIG. Will replace PSC
¡ HEAT- The more aggressive investigator of essentially DME and Home Health.
Using state of the art technology to expand the CMS Medicaid provider audit program
¡ Expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton
Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay
¡ NOTE: Fiscal Intermediaries reviewing denials May 28, 2008- October 31, 2009
identified lack of medical necessity and homebound status unsupported in the medical record.
¡ Goals include:
¡ More consistency in surveys with
¡ Focus on standards that are the most
closely associated with providing a high quality of care
¡ Now, more than ever, the focus is the
assessment and the Plan of Care with visits reflecting skill and purpose directly tied to that plan of care.
¡ All Medicare certified providers are paid on a
prospective payment system (PPS) based on a case mix score
¡ That score (based upon the clinician OASIS
integrated assessment) must have an
appropriate skilled discipline specific care plan that is a part of the overall Plan of Care
¡ Supported by Visit notes that clearly reflect
purpose specific to the goal expectations of the POC
¡ Provide evidence that the care given meets
clinical standards
¡ Justify reimbursement for the payor
¡ Provide protection from liability
¡ Means of communication among individuals
providing services
¡ Provide accurate data regarding care for
¡ Record must be accurate in all respects
¡ Content of the record should contain
measurable and objective data
¡ Interventions must be specifically
documented and be relational to the POC
¡ Document what was taught and to whom
¡ Document what was learned and by whom
¡ Legal signature includes: Full Name, Full
¡ Homebound Status
¡ Under the Care of MD, DO, DPM
¡ CMS expects that the patient’s physical
condition and/or physical limitations are such that it would be a considerable and taxing
effort for the patient to leave home.
¡ NOTE: Refer to CMS Benefit Policy Manual,
¡ Dependent on the limitations of the patient
¡ Dependent on the patient’s illnesses
¡ Can be acceptable for patient to attend
partial hospitalization
¡ Can be acceptable for the patient to attend
medical appointments
¡ NOTE: For a patient to be eligible to receive
home health services, the regulation requires a physician to certify that the patient is confined to his/her home.
¡ If the patient has a diagnosis involving
upper extremities only, how are they homebound?
¡ Documentation would need to demonstrate
the patient’s loss of upper extremity use and thus, example, the patient could not open doors or use handrails on stairways or
required assistance by another individual.
¡ Then describe the considerable and taxing
¡ Patient just recently had surgery.
¡ What kind of surgery? Is there weakness? Is
there pain? Are their ADLs restricted? What is the plan? Does frequency and duration match the POC and the diagnoses?
¡ Without adequate documentation, the visit,
¡ You answered M1860 as patient able to
ambulate with a cane but you document homebound status because, “the patient is
unable to leave the home without assistance”.
¡ Clear documentation that it is with
considerable and taxing effort for the
beneficiary to leave home. (74% of ADRs 2009
reviewed, for lack of homebound status, were denied).
¡ NOTE: Documentation of “short of breath” does
not justify homebound status. Acceptable
documentation would include “short of breath after ambulating 10 feet and requires rest
¡ The patient’s residence is where the patient
makes their home:
¡ Their personal dwelling
¡ Residing with a family member or friend
¡ In an assisted living facility
¡ “The patient’s zip code is used for Home
Health Compare to determine places where your agency provided service” Chapter 3, OASIS Guidance Manual,M0060.
¡ “A medical treatment plan of care or the
optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments”
¡ See 42 CFR Part484, Conditions of Participation,
Subpart A General Provisions and 484.18 Plan of Care.
¡ CMS accepted no stamped signatures
effective 2007
¡ “The physician’s signature on the Plan of Care
must be obtained as soon as possible and
must be obtained prior to billing Medicare for reimbursement”
¡ Does your billing system have built in
compliance rules so no claim is submitted to CMS without signed physician orders?
Section II
¡ To meet the requirement for “intermittent”
skilled nursing care, a beneficiary must have a medically predictable recurring need for
skilled nursing services…at least one every 60 days.”
¡ Skilled services are those services that are
medically reasonable and necessary to the
treatment of a patient’s illness or injury”
¡ It must be clearly documented that the
services provided required the skills of the professional clinician AND that the patient condition/illness/injury warranted those
¡ Services can be performed by:
-‐Nurse; Registered or supervised LVN/LPN -‐Physical Therapist, Speech/Language
Pathologist (referred to in CMS home health operational and billing manuals as Speech Therapist), and
-‐Occupational Therapist (OT may not perform RFA1 OASIS assessment certification but may perform a recertification.
¡ Documentation must identify why the skills of a SN
or PT, OT, MSW are required:
¡ Inherent complexity of care
¡ Condition of the Patient
¡ Accepted standards of practice
¡ Identify reasonable potential for complications if no
skilled intervention
¡ Identify the pt/cg inability to perform a procedure
¡ Remember the records:
¡ MUST have a specific order for
EVERYTHING the clinician does
¡ The clinician:
MUST do EVERYTHING that has a physician order and
MUST document EVERYTHING done… thoroughly.
¡ Repetitive clinical notes are frequently seen
stating the same things over and over with no patient progress identified; how is it that the clinician is unable to teach a new med
successfully within a visit or two?
¡ Notes from different disciplines reflect lack of
plan coordination
¡ Visit notes do not substantiate orders and goals
on Plan of Care/485
¡ Clinical interventions without orders are non
billable
¡ Three Types of Teaching:
¡ Initial Teaching of a patient requires instruction on
a new order, new medication, new diagnosis
¡ Reinforced Teaching requires teaching/instruction
on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching
¡ Re-‐teaching involves evaluation and reinstruction
on a medication, diagnosis, treatment, etc that the patient has had prior instruction
¡ The appropriate care must be coordinated
with all clinicians and the patient
¡ Each documented visit must be able to stand
alone and clearly reflect homebound status on EACH and EVERY visit, clearly supports skilled need, and identifies status of the
patient progress with each note reflecting support of the physician’s ordered plan of care.
¡ Per the Medicare Benefits Policy Manual
chapter 7, skilled nursing:
¡ Requires the skills of a registered nurse to
oversee the nursing care
¡ Skills performed by a skilled nurse do not
necessarily skill the care
¡ Care delivered by the skilled nurse must be
¡ Agencies should be aware that 1 Visit RN
visits are being reviewed as to intermittent need.
¡ Why is the RN performing only one visit? An
order for 1 visit does not meet the requirement for intermittent care.
¡ If SN has 1 visit and therapy is the primary
service, nursing requires an order for at least two visits (and a skilled need) and a well
documented assessment unless SN is
conducting the OASIS assessment only. (If the latter is the case, the therapist must skill the case first and the RN must visit AFTER therapy, on the same day or within the 5 day window to complete the OASIS C ).
¡ If a chronic diagnosis is the primary reason for
ongoing care, the skilled nurse should be VERY VERY clear as to why (s)he is still making visits.
¡ If visit notes do not EACH stand alone and link to
the care plan, the nurses visits are at risk.
¡ The casemix co-‐morbidities; such as CHF, CAD,
COPD, DM, Parkinson’s disease should be included in the diagnoses list. If they are
standing alone, the nurse should carefully justify the skilled need because of the chronic disease.
¡ In justifying observation and assessment, note if:
¡ There is significant change in meds, treatments,
or conditions
¡ There is teaching and training needed
¡ The condition or disease symptomatology has
exacerbated or changed in another way
NOTE: the SN care must tie to the POC and the
discipline specific care plan as well as the ultimate outcomes.
¡ Teaching on new medications must include
instruction or intervention on the related diagnosis.
¡ The clinician providing injections such as insulin,
require specific documentation to support the need; specifically why the patient cannot self inject the med such as tremors, impaired cognitive function, and no willing and capable caregiver. Just that final statement is insufficient.
¡ Consider a SW verifying with family (patient approval
of course, under HIPAA) that no family member can perform the care. Do this function each episode to verify the situation has not changed.
¡ Be certain the skilled nursing visit supports
the diagnosis and the reasons for the SN visit.
¡ If the primary diagnosis is DM but the
majority of the visits are directed toward CAD, the SN should be alerted as it appears there is an incorrect primary diagnosis.
¡ Note: Of ADRs selected, those with 1 SN
and 4 therapy visits had a denial rate of 73%
¡ Per CMS, In 2008, the 5 reasons for ADR denial
included:
1. Downcoding due to inaccurate primary diagnosis 2. Therapy visits not medically necessary thus
disallowed
3. None or poor documentation for medical
necessity
4. Skilled observation initial identified need then no progress documented
5. Timeliness with ADR response (Agencies should check weekly for ADRs on the FISS system)
¡ Physicians are being interviewed re POCs and
patient homebound status.
¡ Denials for no physician orders , lack of
homebound status, and untimely orders are on the rise.
¡ NOTE: Recertifications require a verbal or
signed written order prior to ongoing visits into that episode. Receiving a signed POC within 30 days (with no VO) of the episode, would disallow all visits within that period.
¡ Treating a missing order as a late entry is not
allowed. Backdating an order is illegal and considered a fraudulent practice.
¡ If an agency has missing orders, they should
discuss the issue with the physician and obtain the appropriate order but note the CORRECT date, it was obtained.
NOTE: Auditors are seeking trends. An oversite, properly
corrected and documented reflects intent to correct an omission not perpetuate a fraud. Take action to instill processes so this issue does not reoccur.
¡ For over a decade, effective February 5, 1998, “drawing
blood for laboratory tests is not considered a qualifying skilled service under Medicare Part A home health
benefit. If a patient qualifies for home health service based on another skilled service and requires
venipuncture then the services may be considered for coverage. (Balanced Budget Act of 1997)
¡ NOTE: Having a primary documentation of
long term anticoagulant therapy (V58.61)
should reflect teaching and assessment on the disease process, as well monitoring of other
¡ Wound Care Coverage must have specific
physician orders for one or all of the following:
¡ Instruction/teaching on the wound care
¡ Performance of the specific wound care
¡ Assessment as to wound site progress/
complications
NOTE: Documentation must include type of
wound with size, depth, drainage, odor, color, skin condition, with specific interventions
¡ A stasis ulcer with a status of early/partial
granulation adds two points to the Home Health
Resource Group (HHRG). A “not healing” status adds 11 points. Auditors will look for the specific
documentation to support each.
¡ In addition, an early/partial granulation adds 25
supply points and not healing adds 36 points. (CMS –Regulation number 1560-‐F)
Note: Inadequate venous circulation to the affected area should be clearly documented.
¡ Homebound status can be applied in these cases
if the patient refuses to leave the home because of manifestation of the disease or condition
process or
¡ The patient is unsafe leaving the home because
of behavior issues outside the home.
NOTE: Is OT involved with the psych care? While
nursing tends to use words, OT may assist to e.g. displace internalized anger through
specific activities, which can also identify an objective sense of outcome achievement.
¡ Evaluate the Patient
¡ Teach regarding the disease process
¡ Discuss ways to cognitively restructure how
the patient can approach ADL s
¡ Psychotherapeutic interventions using
techniques, such as cognitive restructuring therapy
¡ Assisting the client to achieve optimal
¡ For the disease combination Alzheimer’s and
Parkinson’s Disease, there is a 75% denial rate for SN.
¡ Frequently, there are full denials because SN
visits are not medically necessary.
¡ Should the psych nurse visit and assist with
routine establishment and cueing education for the caregiver.
¡ NOTE: If there are no changes SN is not
The therapy treatment plan must:
¡ Relate to the exact diagnosis that has required
therapy intervention
¡ Identify visit frequency and duration
¡ Identify the present and prior functional level
¡ State specifically the procedures, treatments,
and/or exercises to be performed
¡ Clearly list the reasonable goals to be achieved
¡ Specify the rehab potential
¡ In 2008, claims chosen with 10-‐11 therapy
visits and discharge in episode two had a 74% rate of denial essentially due to poor or
insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment.
¡ NOTE: Do not use V57.1 Physical Therapy if
SN is also involved with the care. (CMS OFFICIAL CODING GUIDELINES 2009)
¡ If 781.2 Abnormality of Gait is used to
justify PT care, PT needs specific
documentation to support gait and
balance and strength e.g. TUG or Tinetti Test Tools.
¡ Gait training should be specific with objective
measurement progress.
¡ The gait should be described specifically and
graphically; ataxic, spastic, staggers with increase in ambulation of ___feet this day.
¡ If 719.7-‐ Difficulty in walking is coded, the
therapist should be clear that this is due to e.g. degenerative and chronic joint disease.
¡ Use for e.g. gait deficiencies due to lower
¡ If muscle weakness 728.87 is coded, there
should be manual muscle tests indicating weakness.
¡ The therapeutic plan should have specific
exercises and goals related to the weakness.
¡ NOTE: Absence of a specific exercise plan can
¡ The OT evaluation and documentation should reflect
prior and present level with realistic goals.
¡ If PT is also involved with care the OT should clearly
delineate a plan that justifies the OT intervention.
¡ NOTE: Have objective tests with clearly defined short
and long term goals that are measureable and can be achieved within a realistic time point with direct
¡ Medical necessity must be evidenced EVERY
visit. Document progress towards goals every visit.
¡ NOTE: High incidence of visit denials when
both PT and OT are providing care.
¡ Of the ADRs selected, 1 SN and 4 OT visits
have a denial rate of 71% essentially, because OT is not an initial qualifying skilled service.
¡ Medical Social Services can be added when
skilled services are in place.
¡ Covered services include:
Assessment of financial situation, community
services available, personal/family social factors, and the potential for counseling
Patient risk areas identified
NOTE: If a patient has a LUPA, 5 visits or less, and 1 visit is an MSW, the denial rate, as of 2008
data, was 67%.
¡ Medical Social Services have non covered
services that, if required, may be performed along with a covered service.
¡ Non-‐covered services include:
¡ Assistance with Living Wills and Advance
Directives
¡ Assistance with Medicaid Applications and
Meals on Wheels
MSS is a service requiring a physician’s approval.
¡ Home Health Aide Services are supportive
and under the supervision of an RN, if
multidiscipline case. If therapy only, the therapist may supervise the home health aide.
¡ Supervision must be in the patient’s
¡ When skilled nursing visits are ordered daily,
there must be a , “finite and predictable
endpoint to daily skilled nursing visits.” It can be listed in days, weeks, months, or have a specific date.
¡ The visit documentation must substantiate the
skill and substantiate the endpoint. The Medicare Home Health Benefit was not
established to provide daily skilled visits but rather, to provide intermittent skilled nursing services.
¡ “The one and only exception to this rule is a
patient who requires and qualifies for skilled nursing services to perform daily insulin
¡ The Plan of Care must be signed PRIOR to
submission of the claim
¡ A date stamp in Box #25 should be present
when the Plan of Care is received
¡ The POC must be supported by the clinician
visits with a congruent final claim.
¡ There must be congruence between the
OASIS 6 coding spaces: POC/485: 9 spaces+ E code on the UB-‐04 claim
¡ Field 11,12,13 Diagnosis Coding
M1016, changes in past 14 days
¡ M1018-‐ Prior conditions ¡ M1242-‐ Pain ¡ M1300-‐1350-‐ Integumentary status ¡ M1410-‐1510-‐ Respiratory ¡ M1610-‐1630-‐ Elimination ¡ M1700-‐M1750-‐ Neuro/psych ¡ M1800-‐1890-‐ Functional deficits ¡ M2100 Equipment needs ¡ M2200-‐ Therapy needs
Field 10 Meds
¡ Meds vs diagnoses
¡ Have ordered use been listed for PRN meds
¡ Are OTCs listed?
¡ Are they New or Changed?
Field 14 DME and Supplies
o Complete documentation of wound, outcome,
ostomies, catheters
o Congruence with M1300-‐M1350 Integumentary
o Congruence with M1410-‐M1510 Respiratory and
¡ Field 16-‐ Be certain the nutritional
requirements are well documented and congruent with M1800-‐M1890
¡ Field 18A/B Functional activities and
Limitations
¡ M2100e-‐Equipment needs
¡ Field 21 Orders for disciplines and
treatments:
¡ Document interventions which support
¡ Field 21 Orders for disciplines and treatments
¡ M2200 therapy need should be congruent
with care
¡ Include descriptive terms on each visit such as
assessing, teaching initially or reteaching
¡ Field 21 Therapy example: Pt w CVA and residual
weakness having PT and OT F/U:
¡ _#Therapy to provide therapeutic ex bilat UEs to
include ROM and strengthening; Self-‐care ADLs to include teaching dressing UE/LE with adaptive equipment, grooming while standing, transfer
training-‐toilet, transfer and balance activities.
¡ Frequency and Duration: Therapy 3xwkx2 then
2xwk2, then 1xwk2
¡ What will be done? (Action Steps)
¡ Who will Do it?
¡ How frequently will it be done?
¡ How will the care be evaluated?
¡ In place of “instruct low NA diet”, consider writing SN to instruct patient/cg on low NA diet and effects on fluid retention.
¡ In place of SN to perform wound care consider writing SN to provide skilled observation and evaluation of surgical site, teach and reteach if necessary to insure tacit learning sterile dressing changes to pt/cg and perform sterile
dressing changes. Washed wound with sterile saline and applied sterile 4x4 and cover w dressing. If pt/cg
performed the task then note the specific observations.
¡ Do not forget to note the size and depth of the wound.. Stage if appropriate.
¡ From the 6 lines of M1020 and M1022, CMS
makes a payment decision.
¡ Agencies should review progress notes and
case management coordination to the SPOC
¡ Documentation should support the codes
which are sequenced on the OASIS and POC.
¡ NOTE: Clinicians should learn to establish
an audit trail on the way toward expected patient outcomes.
¡ Official Coding Sources:
-‐The annually published CMS ICD-‐9-‐CM Coding Guidelines
-‐The Coding Clinic
§ Allowable Coding Sources:
-‐OASIS Chapter 3
-‐Appendix D to Chapter 3
¡ Promoting accurate coding selection in
M1020, M1022, and M1024.
¡ Comply with provisions of HIPAA, Title II.
¡ Comply with refinements to the PPS Grouper
effective January, 2008.
¡ Comply with Section 1862 (a)(1)(A) of the
Social Security Act to ensure payment is reasonable and necessary.
¡ Diagnoses must comply with specific criteria
to qualify as a primary or secondary diagnosis: -‐Code by adhering to ICD-‐9-‐CM coding
Guidelines
http://www.cdc.gov/nchs/icd.htm
-‐Code only relevant medical diagnoses
-‐Code only diagnoses supported by OASIS, POC, and clinician documentation
¡ List diagnoses in the order that best reflects
the seriousness of each condition and supports the disciplines and services provided.
¡ SOURCE: Official CMS I-‐CD-‐9-‐CM Coding
¡ Assess degree of symptom control in relation
to identified signs and symptoms, medication profile review, frequency and duration , care plan and treatments.
¡ Clarify which diagnoses and symptoms have
been controlled in the past, both poorly and well.
¡ The primary diagnosis should be the key
reason for the POC and be the most intensive service.
¡ These diagnoses coexist at the time the POC
was established.
¡ Approved co-‐morbid diagnoses that could affect
the plan of care even if that diagnosis is not a focus of care: CAD, CHF, COPD, Diabetes,
Parkinson’s Disease and HTN.
¡ In 2012, CMS will eliminate case mix for two
hypertension codes: 401.1 Benign essential hypertension and 401.9 Unspecified essential hypertension
¡ These codes require VERY specific plans of care to
substantiate need as they are case mix diagnoses. Once named case mixes, these diagnoses were
more frequently used and are now closely reviewed. They include:
¡ -‐Low Vision
¡ -‐GERD
¡ -‐Depression
¡ -‐HTN as a non SOC primary diagnosis
¡ Acute care coding is retrospective.
¡ Home Health coding is prospective.
¡ The diagnoses on the OASIS must match the
POC/485 and the UB04
¡ Clinicians must be certain the POC
(primary/secondary diagnoses) and the discipline specific care plan are
substantiated by each visit and that each visit can withstand scrutiny on its own.
¡ Documentation to substantiate coding and care
have become critical to agency providers.
¡ Documentation has become the key
communication tool for care.
¡ Documentation has become the first and last line of
defense with the scrutiny of the industry auditors.
¡ Documentation provides the demonstration of the
skills of the clinician and justifies the retention of the agency payment received.
¡ A Prayer was said…
¡ They were old and feeble
¡ Their heads were snow white
¡ They could hardly make it
¡ They were a sorry sight
¡ Saint Peter told an angel
¡ Go out and help them in
¡ They are old and so decrepit
¡ And no doubt full of sin
¡ But, put them in the gold room
¡ With others of their clan
¡ Set up the banquet table
¡ Bring in the angel band
¡ Stand by and feed them slowly
¡ On earth they worked with Medicare