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JILL DYER, BSN, RN, HCS-D, HCS-O Home Health Executive, Consultant J.I.D. Consulting

About the presenter

How Did We Get Here? •  F2F started in 2011

•  Probe and Educate Process •  Pre Claim Review

FACE-TO-FACE

•  “The face-to-face requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition”

Probe and Educate

•  The purpose of this Probe and Educate process is to ensure that HHAs understand:   •  Patient eligibility for Medicare home

health services •  Face-to-face encounter requirements •  Coding •  Medical necessity •  Medicare coverage and payment criteria

Per CMS Pre-Claim Review will: •  Test improved methods for identifying,

investigating, and prosecuting Medicare fraud occurring in the home health program while maintaining or improving the quality of care provided to Medicare beneficiaries.

Pre-Claim Review

Pre-Claim Review

•  Pre-claim review is a process through which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment.

•  Medicare Administrative Contractors will review the request and supporting documentation and make a decision using existing applicable regulations, National Coverage Determination and Local Coverage Determination requirements, and other CMS policies.

How Can You Be Ready?

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Qualifications for Home Health

Essential requirements: 1.  Well documented Homebound Status 2.  Face-to-Face Documentation that meets

criteria 3.  Patient must be under the care of a physician

who establishes the Plan of Care 4.  Clear documentation that the care provided is

Reasonable and Medically Necessary

Medical Necessity, what does that mean?

•  The Medicare contractor’s decision on whether care is reasonable and necessary is based on information reflected in the home health plan of care, the OASIS or a medical record of the individual patient.

•  The decision is based upon objective clinical evidence

regarding the patient's individual need for care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, to prevent or slow further deterioration of the patient’s condition.

Clinical Notes Must Contain

•  History and Physical exam pertinent to the day’s visit –  Including response to previous skilled care

•  Skilled services applied on visit

•  Immediate response to skilled care provided

•  Plan for next visit

•  Vague or subjective descriptions should NOT be used –  Patient tolerated treatment well –  Caregiver instructed on med management –  Continue with Plan Of Care

Skilled Nursing Medical Necessity

•  Reasonable and necessary •  Needed on an "intermittent"

basis •  Not solely needed for

venipuncture for the purposes of obtaining blood sample

•  Medical Necessity for Skilled

Nursing falls into 4 categories.

•  Reasonable and necessary •  Needed on an "intermittent" basis •  Not solely needed for

venipuncture for the purposes of obtaining blood sample

•  Medical Necessity for Skilled

Nursing falls into 4 categories.

G0299 and G0300 Direct Skilled Care

•  G0299 Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting

•  G0300 Direct skilled nursing of a licensed

practical nurse (LPN) in the home health or hospice setting.

G0162 Management and Evaluation

•  G0162 Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting).

G0163 Observation and Assessment

•  G0163 Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient’s condition. Patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting).

Observation and Assessment •  Where there is a reasonable potential for change in

a patient's condition that requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment or initiation of additional medical procedures until the patient's clinical condition and/or treatment regimen has stabilized.

•  The skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential for such a complication or further acute episode.

•  Observation and assessment by a nurse is not reasonable and necessary for the treatment of the illness or injury where fluctuating signs and symptoms are part of a longstanding pattern of the patient's condition which has not previously required a change in the prescribed treatment.

Observation and Assessment

G0164 Teaching and Training

•  G0164 Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting

Teaching and Training may include:

•  Teaching Self-administration of injectable medications, or a complex range of medications

•  Teaching a newly diagnosed diabetic or caregiver

•  Teaching on Oxygen

•  Teaching wound care where the complexity of the wound, the overall condition of the patient or the ability of the caregiver makes teaching necessary

•  Teaching care for a recent ostomy or where reinforcement of ostomy care is needed

•  Teaching self-catheterization

•  Teaching self-administration of gastrostomy or enteral feedings

•  Teaching care for and maintenance of peripheral and central venous lines and administration of intravenous medications through such lines

•  Teaching bowel or bladder training when bowel or bladder dysfunction exists

•  Teaching how to perform the

activities of daily living when the patient or caregiver must use special techniques and adaptive devices due to a loss of function

•  Teaching transfer techniques, e.g., from bed to chair, that are needed for safe transfer

•  Teaching ambulation with prescribed assistive devices (such as crutches, walker, cane, etc.) that are needed due to a recent functional loss

•  Teaching prosthesis care and gait training

•  Teaching the use and care of braces, splints and orthotics and associated skin care

Teaching and Training may include:

•  Teaching proper administration of oral medication, including signs of side-effects and avoidance of interaction with other medications and food.

•  Teaching the proper care and application of any special dressings or skin treatments

•  Teaching proper body alignment and positioning, and timing techniques of a bed-bound patient

•  Teaching the preparation and maintenance of a therapeutic diet

Teaching and Training may include:

Skilled Nursing Medical Necessity

•  Administration of Medications •  Tube Feedings •  Nasopharyngeal and Tracheostomy

Aspiration •  Catheters •  Wound Care

–  (Must document the size, depth, nature of drainage color, odor, consistency, and quantity, and condition and appearance of the skin surrounding the wound in the clinical findings)

•  Ostomy Care •  Heat Treatments •  Medical Gases •  Rehabilitation Nursing and Psychiatric •  Venipuncture: Venipuncture for the

purposes of obtaining a blood sample can no longer be the sole reason for Medicare home health eligibility.

Skilled Nursing Medical Necessity

Therapy Medical Necessity

•  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;

•  The plan must describe a course of treatment which is consistent with the qualified therapist’s assessment of the patient’s function.

Initial Therapy Assessment

The assessment should include: •  The patient’s function

using a method which objectively measures activities of daily living.

•  The measurement results

must be documented in the clinical record.

Therapy That Does NOT Qualify

•  Services involving activities for the general welfare of any patient, e.g., general exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation do not constitute skilled therapy.

•  If unskilled individuals without the supervision of a therapist can perform those services.

Medical Necessity For Therapy

•  A therapist must perform the ordered therapy service visit

•  Assess the patient’s function using a method which allows for objective measurement of function and comparison of successive measurements

•  Document the results of the assessments, corresponding measurements, and effectiveness of therapy in the patient’s clinical record.

Maintenance Therapy •  The patient’s clinical condition requires the specialized

skills, knowledge, and judgment of a qualified therapist to establish or design a maintenance program, related to the patient’s illness or injury, in order to ensure the safety of the patient and the effectiveness of the program

•  The skills of a qualified therapist (not an assistant) are needed to perform maintenance therapy

Reassessment at least every 30 days

•  At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, and compare the resultant measurement to prior assessment measurements.

•  The therapist must document in the clinical record

the measurement results along with the therapist’s determination of the effectiveness of therapy, or lack thereof.

Physical Therapy Skills

•  Assessment •  Therapeutic Exercises •  Gait Training •  Range of Motion •  Maintenance Therapy •  Additional items listed in

Benefit Policy Manual Chapter 7 40.2

Speech-Language Pathology Services

•  Result of an illness or injury and are directed towards specific speech/voice production.

•  Reasonably expected that the skilled service will improve, maintain, or prevent or slow further deterioration in the patient’s ability to carry out communication or feeding activities.

•  Establish a hierarchy of speech-voice-language communication tasks and cueing that directs a patient toward speech-language communication

•  Train the patient, family, or other caregivers to augment the speech-language communication, treatment

•  Assist patients with aphasia in rehabilitation of speech and language skills are covered when needed by a patient

•  Assist patients with voice disorders to develop

proper control of the vocal and respiratory systems for correct voice production

Speech-Language Pathology Services

Occupational Therapy Services

•  Selecting and Teaching Task Oriented Therapeutic Activities Designed to Restore Physical Function.

•  Planning, Implementing, and Supervising Therapeutic Tasks and Activities Designed to Restore Sensory-Integrative Function

•  Planning, Implementing, and Supervising of Individualized Therapeutic Activity Programs as Part of an Overall "Active Treatment" Program for a Patient With a Diagnosed Psychiatric Illness.

•  Teaching Compensatory Techniques to Improve the Level of Independence in the Activities of Daily Living.

•  The Designing, Fabricating, and Fitting of Orthotic and Self-Help Devices.

•  Vocational and Prevocational Assessment and Training

Occupational Therapy Services

Home Health Aide Services

•  Personal care assistance

•  Simple dressing changes that do not require the skills of a licensed nurse

•  Assistance with medications which are ordinarily self-administered and do not require the skills of a licensed nurse to be provided safely and effectively

•  Assistance With Activities which Are Directly Supportive of Skilled Therapy Services but Do Not Require the Skills of a Therapist to Be Safely and Effectively Performed Such as Routine Maintenance Exercises and Repetitive Practice of Functional Communication Skills to Support Speech-Language Pathology Services

•  Provision of Services Incidental to Personal Care Services not Care of Prosthetic and Orthotic Devices

Home Health Aide Services

•  When a home health aide visits a patient to provide a health related service as discussed above, the home health aide may also perform some incidental services which do not meet the definition of a home health aide service (e.g., light cleaning, preparation of a meal, taking out the trash, shopping, etc.) However, the purpose of a home health aide visit may not be to provide these incidental services since they are not health related services, but rather are necessary household tasks that must be performed by anyone to maintain a home.

Home Health Aide Services

Medical Social Services

•  To resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient's medical condition or rate of recovery

•  Obtain available community resources to assist in resolving

the patient's problem (NOTE: Medicare does not cover the services of a medical social worker to complete or assist in the completion of an application for Medicaid because Federal regulations require the State to provide assistance in completing the application to anyone who chooses to apply for Medicaid.)

•  Counseling services that are required by the patient

•  Medical social services furnished to the patient's family member or caregiver on a short-term basis when the HHA can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and direct impediment to the effective treatment of the patient's medical condition or to the patient's rate of recovery.

Medical Social Services

Care Coordination/ Case Management

•  Have a Plan in Place to manage your patients –  In-office case managers, office case managers… who looks at

the total Plan of Care and evaluates it?

•  Schedule Case Conferences and Require Attendance –  Onsite, Skype, Go to Meeting, Conference Call

•  Assess Progress to Goals for each discipline –  Use a case conference document that is easy to complete

and easy to read

•  Recertification vs. Discharge –  What will your new Plan of Care look like? –  Who will notify the physician of Plan and get his/her input? –  Must have physician documentation of anticipated length of

service

Care Coordination/ Case Management

Medical Necessity

•  Information on Medical Necessity can be found in the Medicare Benefit Policy Manual, Chapter 7

•  Section 40 & 50 outline each discipline. The sections include Skilled Nursing; Physical, Occupational and Speech Therapy; MSW, and Home Health Aide.

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