Home Health 101 for Clinicians Carol E Anderson, RN, BSN, CHPN

Home Health Services are Prescribed Services Home Health Services are prescribed by a physician by way of a verbal order to evaluate or admit to home care. The RN does a comprehensive assessment and then MUST obtain orders for further services. This verbal order is documented in Locater 23 on the 485 and it means that whomever signs that has spoken to the physician LISTED on the 485 about the plan of care that is being developed.

Home Health Care is Prescribed Care Needs a physician’s order, written or verbal to evaluate for HH services Needs a verbal order at SOC for further services Signed by physician before the episode can be billed. State Licensing Boards for Therapists and Nurses in every state require that physicians orders must be followed.

Home Health is typically paid for by Medicare, who: Requires an order from a physician who will oversee the 60 day episode of care not the hospitalist that gave you the referral Requires that the patient be homebound This is an assessment, not a choice or an agreement Requires that the services be MEDICALLY necessary Most common denial reason Requires that the services be “skilled” While teaching can be a skill, consider if it is medically necessary for a home health nurse to do the teaching.

Medicare’s Prospective Payment System Pays 50-60% of the expected cost of care up front Less than 5% of the nation’s claim are ever audited So when you wonder why you “got away with it at another agency” now you know In 2013 of the tiny percentage of records that Medicare and its contractors reviewed over 40% were “in error” euphemism for fraudulent.

Documentation Required to Support a claim for a Home Health Episode A Face –to-face encounter from a physician A Plan of Care that has been developed with a physician and serves as a PHYSICIAN’s order. An OASIS assessment which documents support for medical necessity and tracks the outcome performance of the agency Visit notes that document services that are IN ACCORDANCE with the plan of care.

Common Missteps A home health employee documents a pulse oximetry reading on the record when no pulse oximetry is ordered Considered a “medical test” not a “vital sign” The Plan of Care contains orders to obtain pulse oximetry readings PRN respiratory symptoms when no problems with respiratory system are documented on the 485 The Plan of Care is “canned”. EVERY plan of Care should be individualized and based on the assessment of the patient and their condition Every Plan of Care has the frequency of 1w9 Huge waving red flag that the plan of care is not individualized

Lets review the requirements Plan of Care Medical Necesity Physician Order Skilled Need

Medicare Benefit Policy Manual Chapter 7: 30. 2 Medicare Benefit Policy Manual Chapter 7: 30.2.1 Content of the Plan of Care This means it is a physician’s order and you state licensing board REQUIRES YOU TO FOLLOW MD ORDERS The HHA (Home Health Agency) must be acting upon a physician plan of care that meets the requirements of this section for HHA services to be covered. The plan of care must contain all pertinent diagnoses, including: The patient's mental status; The types of services, supplies, and equipment required; The frequency of the visits to be made;

…what else is required? Prognosis; Rehabilitation potential;   • Prognosis;   Rehabilitation potential;   Functional limitations;   Activities permitted;   All medications and treatments;   Safety measures to protect against injury;   Instructions for timely discharge or referral; and   Any additional items the HHA or physician choose to include. …what else is required?

If the plan of care includes a course of treatment for therapy services: • The course of therapy treatment must be established by the physician after any needed consultation with the qualified therapist;   • The plan must include measurable therapy treatment goals which pertain directly to the patient’s illness or injury, and the patient’s resultant impairments; • The plan must include the expected duration of therapy services; and • The plan must describe a course of treatment which is consistent with the qualified therapist’s assessment of the patient’s function.

30.2.2 - Specificity of Orders The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.

SN x 7/wk x 1 wk; 3/wk x 4 wk; 2/wk x 3 wk, (skilled nursing visits 7 times per week for 1 week; 3 times per week for 4 weeks; and 2 times per week for 3 weeks) for skilled observation and evaluation of the surgical site, for teaching sterile dressing changes and to perform sterile dressing changes. The sterile change consists of (detail of procedure). Orders for care may indicate a specific range in the frequency of visits to ensure that the most appropriate level of services is provided during the 60-day episode to home health patients. When a range of visits is ordered, the upper limit of the range is considered the specific frequency. Example 1

Example 2 SN x 2-4/wk x 4 wk; 1-2/wk x 4 wk for skilled observation and evaluation of the surgical site. Orders for services to be furnished "as needed" or "PRN" must be accompanied by a description of the patient's medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician order would have to be obtained

The Fiscal Intermediary has this to say (in order to get paid: ) Physician signature legible and dated Signed and dated prior to billing the end of episode claim Orders in proper format Orders signed and dated Verbal orders signed before billing the claim Medication orders include name of drug, dosage, route and frequency New and/or changed prescription medications 'New' medications are those that the patient has not taken recently, i.e. within the last 30 days 'Changed' medications are those that have a change in dosage, frequency or route of administration within the last 60 days

Documentation to support beneficiary is appropriate for Medicare Home Health Services New onset or acute exacerbation of diagnosis Acute change in condition Changes in treatment plan as a result of changes in condition (i.e. physician’s contact, medication changes) Changes in caregiver status Complicating factors (i.e. simple wound care on lower extremity for a patient with diabetes) Homebound status is supported Need for a skilled service is supported

New onset or acute exacerbation of diagnosis There is an area on the 485 and the OASIS for the clinician to document this data. It MUST BE FACTUAL (if the diagnosis exacerbated or new onset on SOC, how did you get an order to evaluate or admit the patient? These dates support medical necessity If you don’t know the date leave it out. Should be able to support with documentation such as A new or changed medication (with dates on the medication profile) The OASIS assessment provides for you to document a recent hospitalization or a condition that required a change in meds or tx in the past 14 days. This too MUST BE BASED ON FACT. Do not put the SOC or Recert date.

“The reason that this information is assessed at the BEGINNING of the OASIS assessment is because if there is no recent exacerbation or onset of a disease (in reality and supported by documentation other than the assessment you have not yet started) then you do not have a home health patient” That’s a quote from me based on the information just presented. There are some rare exceptions to this fact and that is when the skill being provided is ongoing, it trumps the requirement for onset and exacerbation. i.e, insulin administration, wound care, foley maintenance, B12 injections, etc.

Other supporting documentation includes: 1. Acute change in condition 2. Changes in treatment plan as a result of changes in condition (i.e. physician’s contact, medication changes) 3. Changes in caregiver status 4. Complicating factors (i.e. simple wound care on lower extremity for a patient with diabetes) 5. Homebound status is supported 6. Need for a skilled service is supported The 485 and the OASIS are legal documents. All statements MUST be FACTUAL

Therapy Documentation 1 Therapy Documentation 1. Orders include frequency and duration, specific procedures and modalities 2. 'Eval and treat' orders only cover 1 visit (the evaluation) because of #1 3. The therapist must obtain a verbal order for the treatment plan and document it on the therapy eval which is sent to the MD for signature 4. Measurable goals for each discipline 5. Skilled care evident on each note

More about therapy *Every note signed and dated Visits consistent with physician orders *Notes reflect progress towards goals *Assessments are completed *Initial assessment contains assessment of function which objectively measures activities of daily living * Reassessments performed timely to reassess the beneficiary and compare resultant measurement to prior measurements *Assessments performed by therapist, not assistants *Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals *Visit notes have documentation that the intervention ordered took place

Nursing Documentation Daily skilled nurse visit orders contain frequencies w/ indication of end point If insulin administration is reason for service, documentation of why beneficiary or caregiver cannot administer Skilled care evident on each note Every note signed and dated Visits consistent with physician orders If teaching and training, clear documentation of tasks to be taught and progress toward beneficiary/caregiver accomplishing that task For observation and assessment, documentation of beneficiary status after 21 days Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals Visit notes have documentation that the interventions ordered took place

Following the Plan of Care All clinicians MUST provide care in accordance to the Plan of Care. The Plan of Care is a physician’s order. Your State Board requires that you follow physician’s order. In the event you are not able to follow the POC, the physician must be notified.

When to Notify the Physician Every missed visit This refers to the order. Not the actual knock at the door. If you scheduled a visit on Tuesday you can still make it up on any other day until Sunday and will not have breached the physician order. Document that the physician was notified of the missed visit if you were unable to follow the frequency.

When to Notify the Physician When you are unable to perform the intervention due to the patient refusal When there is a change in patient’s condition. New orders may need to be obtained.

Requirements Obtain a verbal or written order to evaluate for home health Perform a comprehensive assessment Develop a plan of care with the physician Based on the assessment Individualized to the patient Make use of care pathways from the American Diabetic Association or the Association of Congestive Heart Failure Nurses, or WOCN , etc BUT AVOID TEMPLATES Document the verbal order to begin the plan of care Therapists: Document the verbal order to begin the therapy plan of care Utilize the plan of care during every visit to ensure that you are providing and documenting the care exactly as written

Last but not least AVOID TEMPLATES IN THE 485 This a pitfall of using technology Your 485 should not things like place on hold if hospitalized (you’ll be following a transfer process if that happens. Don’t say “may accept orders from other physicians” While you might receive orders from other physcians the MD on the 485 has ultimate responsibility and must agree to update the care plan. Don’t order a recertification visit. This should be done with a skilled visit or it is not a billable encounter.

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