Teach staff reasonable and necessary care
Teach staff reasonable and necessary care
As Medicare lowers reimbursements and cracks down on fraud and abuse, education managers need to grill their staffs on the distinctions between reasonable and necessary care and care that is simply desired.
Perhaps it once was the physician's judgment alone that determined how a patient would be treated, but no more. Increasingly, someone else is managing the care. And in the case of Medicare, if an agency doesn't have documentation and logical reasons to back up decisions about providing certain services, then there could be compliance problems.
Agencies also need to be vigilant about whether patients truly are homebound. (See guide to homebound status, p. 50.)
This means nurses need to be able to tell the difference between what a patient wants and what a patient is entitled to under Medicare.
"Often we get real wrapped up with our patients, and we have to decide whether this is something we have to do for the patient because he wants it, or is it something he really needs," says Lorraine Waters, RNC, BSN, MA, director of Southern Home Care of Jeffersonville, IN.
Southern Home Care had a patient, for instance, who wanted physical therapy to continue long past the point where the patient had reached maximum benefit, Waters says. "That's a hard one because it's hard for some patients to cease being dependent."
For nurses who have trouble deciding when a patient truly needs a skilled service under Medicare guidelines, Southern Home Care has a decision tree that serves as an easy guide. It clearly answers their questions to a variety of home care scenarios. (See skilled-care decision tree, p. 56.)
Also, Waters adds, education managers should remind nurses to document everything they do for a billed service. "If they're teaching, go into the specifics of what they're teaching. It's not enough to say, `meds taught'; you should say which medications and what was taught."
One way to teach and remind staff about these rules is to create a peer review process for nursing charts, Waters suggests.
Each Southern Home Care staff nurse is assigned one or two charts to review each month. They use the same form as the quarterly chart review, and they go through a co-worker's chart to check all documentation details. The exercise's main purpose is to help nurses learn from their review experience.
"It's another teaching method, and we even have home health aides reviewing their charting," Waters says.
The agency also provokes discussion about "reasonable and necessary" care by giving staff six case studies. These cases will encourage staff to think about the different issues and concerns an agency has when deciding whether a service is reimbursable under Medicare.
Here are the case studies:
Situation: A patient has extensive bone metastasis and has experienced several pathological fractures. The physician orders an aide for personal care three times a week. The agency sends a nurse to provide a bath, rather than the aide. Is that billable?
Answer: Yes. See HIM-11 (Medicare guidelines), Rev. 277, page 14.5; 205.1.A.2. Example 1: "The patient's condition is such that the bath could be given safely and effectively only by a nurse."
Situation: The physician orders nursing to teach a new medication regime to a patient when there is a possibility of adverse drug reactions. After several visits, it becomes apparent that the patient remains unable to take the medications properly and cannot verbalize drug reactions. Are further nursing visits billable?
Answer: No - depending on time frame. HIM-11, Page 14.10; 205.1.3 (Teaching & Training Activities): ". . . where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not/is not able to be trained, then further teaching and training would cease to be reasonable and necessary."
Situation: The physician orders nursing visits to provide sterile dressing changes twice a day to a large abdominal wound and to teach wound care. Patient's daughter is eager to learn, and she demonstrates an ability to do the dressing and is available to do the dressings twice a day. Can the nurse continue to make any billable visits?
Answer: Yes. HIM-11, 205.1; page 14.16. See note referring to B1 and B3.
Situation: The physician orders visits four times a week for a multiple sclerosis patient who is unable to do her own personal care. An aide gives her a bath twice a week and washes the patient's hair on the other two visits. Are all these visits billable?
Answer: No. HIM-11, 206.2a; page 15.7, Example 2: "Only two visits are reasonable and necessary since the services could have been provided in the course of two visits."
Situation: A patient with a well-established colostomy is elderly and forgetful, often forgetting to change the bag regularly, and he has difficulty managing the change because of arthritic fingers. The aide is ordered to visit one to two times per week to change the bag. Is that reasonable and necessary?
Answer: Yes. HIM-11, 206.2a; page 15.7, Example 4: "Home Health Aide services at the appropriate frequency to change the bag would be considered reasonable and necessary to the treatment of the illness or injury." (Note: the patient would still need a qualifying service, i.e., skilled nursing, PT, or S-LP, and be homebound.)
Situation: A patient with malignant melanoma is terminally ill and has refused hospice care. The physician has ordered an assessment, teaching, and treatment. Is terminal care covered under regular home care?
Answer: Yes. HIM-11, 205.1.A.4; page 14.7, Example 3: "A patient with malignant melanoma is terminally ill and requires skilled observation, assessment, teaching, and treatment. The patient has not elected coverage under Medicare's hospice benefit. The skilled nursing care the patient requires would be covered, notwithstanding that his/her condition is terminal because the services require the skills of a nurse."
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