Revision to the Medicare Benefits Manual Chapter 7

Medicare recently revised the Medicare Benefits Manual Chapter 7 to bring it into line with last year’s court decision that potential for improvement could not be considered when making a determination of benefit eligibility. The revisions have implications for the clinician for several reasons. One, it means your Agency may be keeping patients that may have been discharged in the past for reaching their maximum potential. And although the revisions which Medicare calls a clarification of the rules may appear to apply to therapy they also apply to nursing.

Section 40.1.1 – General Principles Governing Reasonable and Necessary Skilled Nursing Care states in part: “Skilled nursing services are covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.” But having said that the revision goes on to clarify the importance of documentation. It states: “When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the services needed do not require skilled nursing care because they could safely and effectively be performed by the patient or unskilled caregivers, such services will not be covered under the home health benefit.”

The revision further emphasizes the importance of the documentation in every clinical note by giving specific guidance for documentation. It says in part:

“As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided. These clinical notes are also expected to provide important communication among all members of the home care team regarding the development, course and outcomes of the skilled observations, assessments, treatment and training performed. Taken as a whole then, the clinical notes are expected to tell the story of the patient’s achievement towards his/her goals as outlined in the Plan of Care. In this way, the notes will serve to demonstrate why a skilled service is needed.”

“Therefore the home health clinical notes must document as appropriate:
• the history and physical exam pertinent to the day’s visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, and
• the patient/caregiver’s response to the skilled services provided, and
• the plan for the next visit based on the rationale of prior results,
• a detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,
• the complexity of the service to be performed, and
• any other pertinent characteristics of the beneficiary or home”

“Clinical notes should be written so that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care should not be used. For example terminology such as the following would not adequately describe the need for skilled care:
• Patient tolerated treatment well
• Caregiver instructed in medication management
• Continue with POC
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.”

The manual has revisions to section 40.1.2 Application of the Principles to Skilled Nursing Services also. For instance in section 40.1.2.1 – Observation and Assessment of the Patient’s Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient’s Status there is the following example:

“A patient has chronic non-healing skin ulcers, Diabetes Mellitus Type I, and spinal muscular atrophy. In the past, the patient’s wounds have deteriorated, requiring the patient to be hospitalized. Previously, a skilled nurse has trained the patient’s wife to perform wound care. The treating physician orders a new episode of skilled care, at a frequency of one visit every 2 weeks to perform observation and assessment of the patient’s skin ulcers to make certain that they are not worsening. This order is reasonable and necessary because, although the unskilled family caregiver has learned to care for the wounds, the skilled nurse can use observation and assessment to determine if the condition is worsening.”

In section 40.1.2.3 – Teaching and Training Activities the revision reads in part: “Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient’s condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task. The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education.”

Section 40.2 – Skilled Therapy Services has also been revised to include the following: “To be covered as skilled therapy, the services must require the skills of a qualified therapist and must be reasonable and necessary for the treatment of the patient’s illness or injury as discussed below. Coverage does not turn on the presence or absence of an individual’s potential for improvement, but rather on the beneficiary’s need for skilled care.”

And again the manual emphasizes the importance of documentation for therapy. In section 40.2.1 – General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy it reads:

“As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided. These clinical notes are also expected to provide important communication among all members of the home care team regarding the development, course and outcomes of the skilled observations, assessments, treatment and training performed. Taken as a whole then, the clinical notes are expected to tell the story of the patient’s achievement towards his/her goals as outlined in the Plan of Care. In this way, the notes will serve to demonstrate why a skilled service is needed.”

“Therefore the home health clinical notes must document as appropriate:
• the history and physical exam pertinent to the day’s visit , (including the response or changes in behavior to previously administered skilled services) and
• the skilled services applied on the current visit, and
• the patient/caregiver’s immediate response to the skilled services provided, and
• the plan for the next visit based on the rationale of prior results.”

“Clinical notes should be written such that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care should not be used. For example terminology such as the following would not adequately describe the need for skilled care:
• Patient tolerated treatment well
• Caregiver instructed in medication management
• Continue with POC”

“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.
When the skilled service is being provided to either maintain the patient’s condition or prevent or slow further deterioration, the clinical notes must also describe:
• A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,
• the complexity of the service to be performed, and
• any other pertinent characteristics of the beneficiary or home.”

The revisions provide clarification about a maintenance program. In part it states: “Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services will not be covered.”

The revisions also specify that a maintenance program should be developed in the last visits of a rehabilitative/restorative treatment. The revision states in part: “When the development of a maintenance program could not be accomplished during the last visits(s) of rehabilitative/restorative treatment, the therapist must document why the maintenance program could not be developed during those last rehabilitative/restorative treatment visit(s).”

I would urge all clinicians to read and become familiar with the revisions in the Medicare Benefits Manual, Chapter 7. They clarify requirements for coverage of patient care and for documentation of that care.

PPS Final Rule for 2014

CMS released the final rule, Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014, Home Health Quality Reporting Requirements, and Cost Allocation of Home Health Survey Expenses that will become effective January 1, 2014. What does it mean for the clinicians?

 First you may be asked to change the way you are coding your OASIS because CMS is dropping 170 ICD-9-CM codes from the case mix calculations. They say these codes are for diagnoses that are not treated in the home care setting. As CMS put it in the final rule: “We proposed to remove the 170 codes from assignment to one of our diagnosis groups within the HH PPS Grouper because we concluded that the codes were not reflecting actual conditions being treated or that the condition had no impact on resource use.” They also stated: “We contend that the removal of these codes is appropriate, either because these conditions cannot be appropriately treated in a home health setting, or because these conditions do not impact the home health plan of care and result in overpayments to HHAs.”

 Second, you need to be prepared for the implementation of ICD-10-CM October 1, 2014. The final rule restated that ICD-10-CM will become effective on that date.

 Third, you can expect to be asked to do more with less. As if payment has not been squeezed to the breaking point already this rule, according to the Health Care Association of Florida (HCAF) Christopher Lipson “The final rule will cut Medicare payments to certified providers by 2.7% over four years for a total of 10.8% by 2017. While this is lower than the proposed cut of 14%, this is far from cause to celebrate. This is a drastic cut to the Medicare home health industry which will be incredibly detrimental to providers and patients alike.”

 Finally, there may be more focus on rehospitalizations and emergency room visits because the rule adds two new measures to the outcome reporting. CMS said they are finalizing “the adoption of the two claims-based measures: (1) Re-hospitalization during the first 30 days of HH; and (2) Emergency Department Use without Hospital Readmission during the first 30 days of HH.

Draft OASIS-C1

The draft OASIS-C1 has been released. It contains a number of changes, some of them may help you reduce the time it takes to complete the OASIS and many are to clarify the meaning of the item. There are changes in the skip instructions on certain items due to renumbering of items. Of course this new OASIS is designed to accommodate the ICD-10-CM. It will go into effect October 1, 2014 with the initiation of ICD-10-CM.

M1010: List of inpatient diagnoses will become M1011; and M1016: Diagnoses requiring medical or treatment regimen change within the past 14 days will become M1017. Both items were revised to accept the 7 digit ICD-10-CM codes and both say “no V, W, X, Y, or Z codes” as well as no surgical codes. M1020: Primary Diagnoses becomes M1021 and M1022: Other Diagnoses becomes 1023. Both are revised to accept the 7 digit codes.  M1023 does not allow the use of V, W, X or Y codes. M1024:Payment diagnoses becomes M1025: Optional Diagnoses; and these are no longer used for payment. M1025 does not allow the use of V, W, X, Y or Z codes.

In ICD-10-CM V,W, X and Y codes are found in Chapter 20. They are external causes of morbidity. The Z codes are in Chapter 21; these codes are factors influencing health status and contact with health services.

M1012: List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care will be deleted. CMS came out with guidance some time ago that the item was not used for case mix calculations and would be deleted from the next OASIS revision. You still need to know any inpatient procedures that are relevant to your plan of care and so this information may be removed as an M item in the OASIS but will probably be added to your comprehensive assessment form.

M1310: Pressure ulcer length, M1312: Pressure ulcer width and M1314: Pressure ulcer depth are being deleted. But this is part of your wound assessment so it may not be included in the  M items but it should be added to your assessment form.

Some items are being deleted from specific time points but not completely. M1350: Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving interventions by the home health agency? is being deleted from the Follow up OASIS and Discharge OASIS. M1410: Respiratory treatments utilized at home is being deleted from the discharge OASIS as is M2110: How often does the patient receive ADL or IADL assistance from any caregivers(s) (other than home health agency staff)?

M2440: For what reason(s) was the patient admitted to a nursing home is being deleted. It was found only on the Transfer OASIS.

There are numerous other changes. Where e.g. was being used in the current OASIS, OASIS-C1 uses the wording “for example”. And where i.e. is used it will be replaced with “specifically”. There are other changes to improve understanding of the items. M1000 changes the wording “during the past 14 days” to “within the past 14 days”. Items related to the influenza vaccine were reworded to better reflect the item. They were also renumbered; M1040 became M1041 and M1045 became M1046. The pneumococcal vaccine questions were also reworded and renumbered. The pain assessment item, M1240, was changed to add the world “validated” to the item so it reads in part “…standardized, validate pain assessment tool…” Item k1308 was reworded and column 2 removed; and a new item M1308 was added to capture information on worsening pressure ulcers on discharge that had been captured in column 2. M1334 eliminated option 0 – Newly Epithelialized saying this was inappropriate for the item. The wording in items relating to heart failure, M1500 and M1510, were revised to clarify the item includes the current  assessment. M1730 depression screening added the word validated as the screening tool needs to be standardized and validated. In response 5 for item 1730 Bathing the words “throughout the bath” were removed. The response to M1900 was modified to list relevant ADLs/IADLs. Item M1910 has much of the wording removed and the word “validated” added so it simply reads “Has this patient had a mult-factorial falls risk assessment using a standardized, validated assessment tool?” For M2000: Drug regimen review the word “adverse” was added to drug reaction, “significant” was added to side effect and “non-adherence” was added after non-compliance. Medication Interventions, M2400, was revised to clarify that the reporting period includes the time of the current assessment as was the wording in item 2015: Patient/Caregiver drug eduction intervention. In item 2040 the item title dropped the word “ability” and changed the wording in the stem from “…prior to this current illness …” to “…prior to his/her most recent illness..”. In M2100 asking about the types and sources of assistance needed the item title and stem were revised and several of the responses were revised as well. The “not applicable” responses in M2250: Plan of Care synopsis and M 2400: intervention synopsis were revised to provide clarity. Item M2300: Emergent Care was revised to clarify it includes the current assessment and the word “status” was added to “holding/observation”. For item 2310: Reason for emergent care the wording was changed from “…receive emergent care…” to …seek and/or receive emergent care…” and “adverse drug reaction” was added to response 1.

Will these and/or other revisions that may be made as a result of the public comment to this draft OASIS-C1 help you as a clinician. That is the hope but until the new OASIS is instituted October 1, 2014 that will can not be known for sure.

Clinical and Functional Domains and the Patient Level of Care

On one of the forums I follow someone asked the  question: “Has anyone else used the Clinical and Functional Scores from the OASIS as the determining factor for justifying the nursing and therapy visits in a Medicare period?”

As a clinician accurately scoring the OASIS is important for payment and your managers are probably looking at the scoring to see if your frequency is justifiable. However, I don’t know if you could consider it a determining factor for justifying the number of nursing or therapy visits. When I was working as a Director of Professional Services I always checked the HHRG score to make sure the number of visits looked appropriate. But I did not have a set number of visits for each discipline based on the score. If the clinical score was low and there was a high number of nursing visits scheduled I would bring it to the supervisor and she/he would need to justify the frequency.

I do not feel the clinical score is that great in identifying the nursing needs. Often there is justification for the level of services that are either high or low for the clinical score. I feel the functional score is much better in identifying the need for therapy. But again it is not the definitive factor; it is only one factor that I looked at when deciding if the therapy frequency was appropriate. It is just as important to look at the scoring on individual items. It is not extremely rare to find the nurse scoring on the Ambulation item at 1 the the therapist POC focused gait training with something like 18 visits ordered. Most of the time the nurse would admit that they were in a hurry and did not really watch the patient ambulate. It helped when we had the nurse completing the TUG because then they had to watch the patient ambulate. But there were times when the therapist could not justify all the visits.

Your managers may be using the Clinical Domain and Functional Domain scores to justify your visit utilization. So you should know these scores and if your visit utilization is high or low for the score you should be ready to explain why in terms of the patient’s needs.

For me I used the Clinical and Functional Scores as one of several factors determining if the number of nursing or therapy visits was appropriate for any given patient because in my experience the OASIS did not necessarily accurately predict the intensity of services required by the patient. This led me to the personal opinion that the that the OASIS was created first and foremost as a cost containment tool and only loosely based on patient level of care needs rather than an accurate predictor of the level of care a patient requires that would be used to determine accurate payment. I know Medicare would probably disagree. They would most likely claim the OASIS to be statistically accurate in predicting the level of care and thus their payment is appropriate. I just have not found that to always be the case. I personally feel if Medicare used the International Classification of Function it would be a much more accurate predictor of the patients’ level of care needs and would more clearly show patient progress. But they do not so you as a clinician need ot accurately complete the OASIS and when the Clinical Domain and Functional Domain scores truly do not predict the patient’s need be ready to justify the need to your manager. Balancing patients’ needs and payment is home health care is an extremely difficult task indeed.

Maintenance Patients, Jimmo V Sebelius?

For many years many home health agencies have discharged patients who plateaued even when they needed continued skilled care to maintain their level of functioning or prevent deterioration and exacerbation of their condition. This is because Medicare contractors routinely deny claims when there is no longer potential for improvement. We all know these patients are going to be coming back into the home health system in a short period of time but we had little choice but to discharge.

There were regulations in the Medicare Manual that allowed continued care but the required documentation was so onerous that no one could jump through the hoops with the degree of accuracy needed for payment. The Medicare Benefits Manual Chapter 7 Home Health Services 40.1.2 Management and Evaluation of the Patient Care Plan says “Skilled nursing visits for management and evaluation of the patient’s care plan are also reasonable and necessary where underlying conditions or complications require that only a registered nurse can ensure that essential nonskilled care is achieving its purpose. For skilled nursing care to be reasonable and necessary for management and evaluation of the patient’s plan of care, 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 patient’s overall condition.” And 40.2.1 says “The development, implementation, management, and evaluation of a patient care plan based on the physician’s orders constitute skilled therapy services when, because of the patient’s condition, those activities require the skills of a qualified therapist to ensure the effectiveness of the treatment goals and ensure medical safety. Where the skills of a therapist are needed to manage and periodically reevaluate the appropriateness of a maintenance program because of an identified danger to the patient, such services would be covered, even if the skills of a therapist were not needed to carry out the activities performed as part of the maintenance program.”

However, 30.5.1 specifies that the physician must include the need for management and evaluation in the plan of care. It states “Where a patient’s sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in §40.1.2.2), the physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification;” This makes it much harder to get the documentation needed for maintenance patients.

Having said all this there is a new day dawning in home health. Or at least some hope on the horizon. Your agency may begin utilizing the management and evaluation and therapy maintenance. Why? Because of Jimmo V Sebelius. On January 24, 2013 in the US District Court for the District of Vermont Medicare agreed to and the Judge approved a settlement agreement. The suit alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care. Under the settlement Medicare agreed to Clarifying the policy and updating the Medicare Manuals used by Medicare Contractors to clearly state the coverage is not dependent on the beneficiary’s potential for improvement from therapy, but rather the beneficiary’s need for skilled care. CMS has until January 23, 2014 to make these clarifications and to educate the contractors and providers in them.

So in the meantime some industry leaders are saying the law went into effect when the settlement was made on January 24, 2013. And some agencies are moving to utilize these skills. If your agency is one, no matter if you are a PT or OT or if you are a SN, you should make sure you document in every visit note what would happen if you were not providing the skilled care. And develop you ability in documenting skilled care in maintenance therapy and chronic conditions cases. You should familiarize yourself with the existing standards by reviewing the current Medicare Benefits Policy Manual. Your agency should educate physicians in using the F2F encounter narrative to document the need for skilled maintenance therapy or chronic condition nursing and in the requirement to document the need on the Plan of Care if the patient requires recertification.

If your agency choses to begin providing skilled maintenance therapy or chronic condition nursing now it may well receive denials from the Medicare contractor. But, as some industry leaders have pointed out on appeal to the Administrative Law Judge the judge would most likely look at Jimmo v Sebelius and look at the Medicare Manuals for guidance. Not finding any specific clarification the CMS manuals these industry leaders believe the judge would rule in favor of the agency.

Potentially Avoidable Tool Kit Now Available

I am a home health consultant focused on performance improvement and quality assurance. When I started consulting I decided I needed to put my thought process for reviewing medical records that are identified as potentially avoidable events down on paper so the clients could follow how and why I came to the conclusions I did. This eventually led to a set of chart audit tools. After using these tools for a while I decided I should share them with the home health care community. I compiled them in what I call the “JSR Potentially Avoidable Events Tool Kit”. To read more about this valuable resource go to http://www.homehealthblogger.com

Palmetto Announces Revised LCD’s

On April 29, 2013 Palmetto GBA announced 4 revised Local Coverage Determinations. The post states:

“Jurisdiction 11 Home Health and Hopsice

Local Coverage Determinations (LCDS) Revised

The following Home Health and Hospice local coverage determinations (LCDs) have been revised:

• Home Health Physical Therapy L31542
• Home Heath Speech-Language Pathology L31533
• Home Health Surface Electrical Stimulation in the Treatment of Dysphagia L31534
• Hospice HIV 31535″

It goes on to say “…Please share with your staff and review the revisions for your future references.” However, they do not provide a description of the revisions. I looked at the May 2013 J11 Home Health and Hospice Medicare Advisory but the LCD revision listed was for Home Health Psychiatric Care LCD L31531 effective 3/7/2013. So if the Medicare Advisories are running behind in listing specific revisions it may be a couple of months before you can “review the revisions”. You can and should review the revised LCDs but you may not be able to identify what was revised.

MEDIHONEY for that Pesky Non-healing Wound

I have been interested in Medihoney since the representative introduced it to an agency I worked for years ago. Shortly after we were introduced to it I suggested one of the nurses use it for a wound that was stuck. She said it was almost healed but it just would not finish. I suggested she try the Medihoney and to all of our surprise the wound healed within a just a few weeks. We were able to discharge the patient. So I thought I would talk a little about Medihoney.

According to dermascience.com Medihoney is a medical grade Leptospermum honey. It is considered a “mono floral” honey; that is it comes from just one source. It is honey from the pollen and nectar of the Leptospermum or Manuka plant in New Zealand and only the Manuka plant in New Zealand. It is not well understood why the active honey comes only from this plant in this region. In the technical section of dermascience.com Medihoney information they say it helps stalled wounds move toward healing through:

“Dynamic Moister Balance” ^TM . “MEDIHONEY® dressings create a moist environment, thus, promoting optimal conditions for wound healing. The dressings, with their high sugar content, also display a high level of osmotic activity. This results in an outflow of lymph from the wound, assisting in debridement and edema reduction. There are various dressings in the line to handle a variety of wound conditions, from highly exudating to moderate drainage, to non-exudating.”

Retrieved 5/1/2013 http://www.dermasciences.com/products/advanced-wound-care/medihoney/inside-the-u-s/technology/

“pH Modulation” “Wounds have been shown to heal more rapidly in an acidic environment, which helps to explain why MEDIHONEY® – with a pH near 3.5 – improves the wound healing environment. It has been shown that reducing the pH of a wound will help to modulate harmful proteases and improve oxygen diffusion. In a study of 20 chronic, non-healing wounds treated over a 2-week period, wounds with a pH of 7.6 showed a 30% reduction in wound size. As the pH level increased, wounds healed less effectively or worsened. The use of MEDIHONEY® resulted in a significant reduction in surface wound pH (p=0.001). Each decrease of 0.1 unit of pH was correlated with an 8% reduction in wound size.”

Retrieved 5/1/2013 http://www.dermasciences.com/products/advanced-wound-care/medihoney/inside-the-u-s/technology/

After reading this I have a better understanding why Medihoney moved our patient’s wounds toward healing. I am not a wound care nurse and do not suggest I am any kind of an expert in wound care but I do feel that Medihoney is worth a try if you have a pesky wound that is just not healing. It may not be the product of choice for every wound but I feel it can be an important wound care product in any nurse’s bag.

Therapy documentation Found Wanting by Palmetto

Are you a Physical Therapist (PT), Occupational Therapist (OT) or Speech Therapist (SLP) in home healthcare? You may be putting your agency at financial risk if you are not documenting correctly. On April 18, 2013 Palmetto GBA posted a review of deficiencies in therapy documentation they identified through Additional Documentation Requests (ADR). In this review they identify six problem areas related to the therapy reassessment documentation. PGBA lays the foundation for what they were looking for by stating: “Medicare regulations state, in part, ‘To ensure therapy services are effective, at defined points during a course of treatment, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must perform the ordered therapy service. During this visit, the therapist must assess the patient using a method which allows for objective measurement of function and successive comparison of measurements. The therapist must document the measurement results in the clinical record.'”

 The article then goes on to identify the six areas:

•  ·         Are you including your credentials when you sign the documentation? The first finding was that when the therapists signed the evaluation or re-evaluation form they were not providing their credentials. This made it impossible for the reviewers identify if the person conducting the evaluation or re-evaluation was a therapist or a therapy assistant. They say: “In order for Palmetto GBA to ensure that Medicare regulations are being met, the documentation must clearly provide the therapist and the appropriate credentials.”
• ·         Is your signature legible? An Illegible signature was one of the deficiencies found by PGBA. In the posting PGBA states: “Medicare signature requirements mandate that if the signature of the person signing the document is not legible, identifying information (such as a signature log, attestation statement, typed name under the signature, etc.) must also be included in the documentation”
• ·         If you are documenting your credentials are they legible? PGBA found they could not read some therapists credentials. Stating: “When the credentials are either illegible or missing, Palmetto GBA is unable to verify that the respective therapist actually conducted the evaluation/re-evaluation.”
• ·         Are you including objective measurements and showing successive comparisons of the measurements? PGBA found some medical records did not have measurement results documented. In the posting they say: “Medicare guidelines state, ‘…the therapist must assess the patient using a method which allows for objective measurement of function and successive comparison of measurements.’ Thus, when the documentation does not contain clearly identified measurements in the results, payment cannot be allowed on the claim for those services.”
• ·         Are you performing your reassessments on time? PGBA says they found reassessments were not always being done in the required time frame. Therapists should be tracking all the therapy visits so they know when their reassessment visit is required. Palmetto PGBA says in this posting: “Medicare regulations require that reassessments must be done at least once every 3o days and prior to the 14th and 20th therapy visit.”
• The last deficiency PGBA identified in its ADRs is not under the control of the therapists. This deficiency said some agencies were not submitting the required reassessment(s) when they sent in their ADRs. In the posting PGBA cautions: “When responding to an ADR, it is important that providers include all documentation that applies to the services billed. This may include documentation that contains dates that are outside the dates of service billed on the claim. When therapy services are provided, the documentation submitted in response to an ADR should also include all therapy documentation.”

Care in the therapist’s documentation can avoid five out of these six deficiencies identified by PGBA. Whether you are a PT, OT or SLP you need to be acutely aware of these deficiencies and take care to avoid them. To view the PGBA posting click here.

M1100 Scoring When Patient Goes to Day Care

You admit a patient to home care who lives with their daughter but who goes to an adult day care during the day while her daughter works. How would you score M1100 Living Situation.  That question was answered in the FAQ January 2013.

The answer to question # 7: “In M1100, “availability of assistance” refers to in-person assistance provided in the home of the patient. If the daughter leaves the home to work during the day, but plans to be there for all the nighttime hours for the entire upcoming episode of care (with infrequent exceptions), “8-Patient lives with another person with Regular nighttime assistance” would be appropriate. If the daughter is gone some nights or not present all the hours of the nighttime, “9-Occasional/short-term assistance” would be appropriate.
Assistance provided outside the home is not reported in M1100.”

In order to score the OASIS questions accurately it is important to make sure you investigate every aspect of the item. For M1100 Patient Living Situation, the “Response Specific Instructions” say to first determine the living arrangements. That is, does the person live alone, with another person in the home, or in a congregate living situation. Second you need to determine the “availability of assistance”. How frequently is the patient’s caregiver in the home and available to provide assistance. The instructions point out that the assistance is in-person assistance.

Determining if the person lives alone is not necessarily a cut and dried call. It is clear if the person lives alone in a home or apartment, but what about living in a room in a boarding house. If they are living in their own room in a boarding house and do not have a roommate they are living alone. What if they are living with a live-in caregiver alone and not with others in the home. Well according to the OASIS Guidance Manual they are still considered living alone. The OASIS Guidance Manual also says if they have a caregiver staying with them temporarily they are also considered be be living alone. If your patient can summon emergency help by phone or emergency response system he/she is still considered living alone. Awe but what if they are living with another person, spouse or significant other, family member who has to leave them alone due to occasional travel. They are then considered living with others and not living alone even though they may be left alone on occasion.

So to score M1100 accurately, like many other OASIS items, you need to fully understand what the item is asking and all the ramifications implied withing the item. In this case you need to fully understand all the aspects of your patient’s living situation and living arrangements.