Acorn’s End Blog

My client started with a skilled nursing visit which established the SOC date. Several days later, PT started and they say they have their OWN SOC date for their first billable visit. I say the client has only one SOC date. Who is right?

The start of care date (M0030) is the date of the first reimbursable service and is maintained as the start of care date until the patient is discharged. It should correspond
to the start of care date used for other documentation, including billing or physician orders. There is only one Start of Care date for the episode, which is the date of the first billable visit.

My patient lives in an assisted living facility where the assisted living staff take care of all of my patient’s medications. I am confused about M2010. Who do I educate?

When completing the OASIS process measures that address patient/caregiver education, M2010, Patient/Caregiver High Risk Drug Education and M2015, Patient/Caregiver Drug Education, for patient’s residing in an assisted living facility, it may be appropriate to educate the patient and/or the staff administering the medication on the topics included in each item. As with patients who live at home, the decision to direct the teaching to the patient, caregiver, or both should be made by the assessing clinician, based on the specific circumstances. For the purposes of selecting a response, the facility staff would be considered caregivers.

A client is discharged from the hospital and will receive only PT after the hospitalization. Our agency does not allow PT to do SOC nor ROC assessments. I know the RN may not complete the OASIS assessment before the first billable visit at SOC, but may the RN see the patient before the therapist when the patient is coming home from the hospital?

The Comprehensive Assessment of Patients Condition of Participation (484.55) (d) states the comprehensive assessment must be completed within 48 hours of the
patient’s return home from the inpatient facility stay of 24 hours or longer for reasons other than diagnostic testing. It is acceptable for the RN to make a non-billable visit in a
PT only case and complete the ROC assessment within 48 hours of discharge and the PT to visit to evaluate either before or after the RN’s assessment visit, as long as the PT
visit timing meets federal and state requirements, physician’s orders, and is deemed reasonable by professional practice standards. The resumption of care date (reported in M0032) is the first visit following an inpatient stay, regardless of who provides it, whether or not the visit is billable, and whether or not the ROC assessment is completed on that first visit.

My BIGGEST question is about the timeline for M2002. The directions state the physician must RESPOND with acknowledgement of receipt of info and/or further advice or instructions. My question is - must that occur within 1 calendar day? What if you called on Wednesday (within 1 calendar day) and he didn’t get back to you until Friday…he’s still acknowledging the information. Where does it say they MUST acknowledge in 1 calendar day?

When completing M2002, Medication Follow-up, if the physician or physician designee
responds within one calendar day and there is a resolution to the clinically significant medication issue or a plan to resolve the issue, Response “1-Yes” should be selected. If an on-call physician is contacted and informed of the medication issue, but the due to the
contacted physician’s unfamiliarity with the patient, you were directed to contact the primary care practitioner on Monday, no one reconciled, or formulated a plan to reconcile the specific medication issue identified within one calendar day, so “0-No” should be selected.

If a medication issue is identified on day 5 after the SOC, the physician is contacted within one calendar day and responds back with a plan for reconciliation on day 6 after the SOC, this 2-way communication could not be captured at the SOC, but M2002 could be marked “1 -Yes” at a ROC time point, reflecting that the identification and 2-way communication w/plan for reconciliation had occurred as required by the item.

Home health agencies and hospices may not technically be under Recovery Audit Contractor (RAC) reviews just yet, but at least one RAC is investigating areas that affect home care & hospice.

Health Data Insights (HDI), the RAC contractor for Region D, posted 66 new approved issues for review in January. Most of them apply to hospitals, but HDI is also approved to review durable medical equipment topics, two of which affect home health and hospice. The RAC will look for DME claims improperly paid for beneficiaries in a hospice stay. This could cause suppliers to come knocking on hospice doors for payment for claims dating as far back as Oct. 1, 2007.

CMS approved “Medical Supplies and Home Health Consolidated Billing” as another RAC issue on Jan. 6. The RAC will look for DME and supply claims paid by Medicare that should have been covered by an HHA under bundling back to Oct. 1, 2007, which could cause suppliers to go back and ask agencies for those payments.

While this has not yet been an activity for Minnesota RAC, now that one RAC has identified home health and hospice issue, the others won’t be too far behind. Expect to start seeing letters form the RAC (in region D at least for now). When you receive a request for information, respond promptly. RAC demonstration noted a significant percentage of claims recouped simply because the provider failed to provide documentation in a timely manner. Don’t donate money to Medicare because you did not respond in time!

The Centers for Medicare and Medicaid Services (CMS) held an open door forum for home health care, hospice, and durable medical equipment (DME) on Wednesday, January 20, 2010. Here are the highlights
OASIS-C resources: CMS reminds providers that there are several resources available for staff education, including:
OASIS-C Guidance Manual (September 2009) — http://www.cms.hhs.gov/HomeHealthQualityInits/downloads/HHQIOASIS-CManual200912.zip
OASIS-C National Provider Calls. The transcripts of all three calls are available at — http://www.cms.hhs.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp#TopOfPage
OASIS submission and CASPER system: Beginning in late February, CMS will roll out changes in security. CMS is moving from an agency-shared login ID to personal login IDs. Any person responsible for submitting data or accessing reports will need his/her own login ID. CMS will work with small groups of states, completing the rollout in July. Each state’s OASIS Welcome page will post details. For more information, click on — https://www.qtso.com/download/Conversion_Personal_Login_IDs.pdf.
Home health capitalization requirements: CMS is trying to ensure that regional home health intermediaries (RHHI) apply the capitalization requirements consistently. The intermediary will verify that a new agency meets the requirements at the time of application and prior to receiving billing privileges. Find more information on the capitalization requirements in Transmittal 312 at — http://www.cms.hhs.gov/transmittals/downloads/R312PI.pdf.
Agency Sale: Sale of an agency within 36 months of the effective date of Medicare enrollment: Medicare contractors cannot provide information about a change in ownership. The seller must maintain records and the buyer must perform due diligence.
Home Health Advance Beneficiary Notice (HHABN): CMS says that the notice was approved; however, it will be another couple of months before it’s ready.
PSF SAS Data Files Last week, CMS posted the January 2010 quarterly Provider-specific Files (PSF) Statistical Analysis Software (SAS) data files. These files contain information about the facts specific to home health providers that affect computations for the Prospective Payment System (PPS). Download them at —http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/Downloads/hha_sas_psf1001.zip
CMS Updated Pricer: CMS has updated the Home Health PPS Pricer for calendar year 2010. The Pricer makes:
Download the Pricer zip file at — http://www.cms.hhs.gov/PCPricer/Downloads/ZZWeb_HHA1031001.zip. Check out the Pricer Web site at — http://www.cms.hhs.gov/PCPricer/05_HH.asp.

A new and improved Home Health Quality Improvement (HHQI) National Campaign will launch January 13, 2010. As a HHQI Local Area Network of Excellence (LANE), we are the central hub of campaign activity in our state.

The goal of the HHQI National Campaign is to improve the quality of care home health patients receive as measured by a reduction of avoidable hospitalizations and improvement in the management of oral medications for home health patients. Throughout the campaign, new Best Practice Intervention Packages (BPIPs) will be released quarterly to share effective strategies with home health care providers. These free resources are for all agencies that join the HHQI movement at www.homehealthquality.org

In additional to exclusive educational resources, HHQI National Campaign participants will be able to set improvement targets and view rates related to the publicly reported acute care hospitalization and oral medication measures through a free target-setting tool at the Home Health STAR (Setting Targets Achieving Results) Web site, available January 2010 at www.hhqi-star.org.

Throughout 2010 and 2011, Campaign participants and supporters will also enjoy free access to online sharing tools designed to facilitate the flow of information between participants, stakeholders and health care settings. By encouraging communication, these tools will seek to unite providers across settings under the shared vision of reducing avoidable hospitalizations and improving medication management.

Please visit www.homehealthquality.org for more information on the campaign. Registration begins January 13, 2010. Home Health agencies will have the opportunity to become a National Campaign Premier Home Health Agency, if registration is completed by January 20, 2010.

Week January 18
When looking at the patient’s living situation (M1100), consider the following:
• Availability of assistance refers to in-person assistance provided in the home of the patient.
• If a person is in an assisted living or congregate setting with a call-bell that summons help, this is considered in-person assistance.
• Assistance via telephone is not included in this question. This item documents the time caregiver(s) are in the home and available.
• Use professional judgment to determine if someone will be available to provide any assistance to the patient.
• A patient with only live-in paid help is considered to be living alone.

Week January 11
High-Risk Medications
Several steps may help avoid patient issues as well as OASIS compliance related to high-risk medications:
1) Identify what quality organization or source you will use to help you identify high risk medications such the Institute for Safe Medication Practices, JCAHO, or (for elderly) the Beers criteria. High risk meds include anticoagulants, antipsychotics, diuretics, and anti-epileptics.
2) Pay special attention to whether patients really need these high risk medications. Don’t assume the physician signing the 485 is the one who put the client on this medication. For example, consider the client who is on Coumadin to prevent clotting post-hip replacement. However, the hip replacement occurred 2 years ago. Some sources report that such prophylaxis has a limited time period for clinical effectiveness - usually three months. Speak with the physician about getting the client off this medication.
3) For elderly clients, review their list of medications against the Beers criteria. For a list of these medications, go to: http://www.dcri.duke.edu/ccge/curtis/beers.html
4) When feasible, involve the patient and family in medication discussions, especially if the client has multiple physicians prescribing medications.

Senator Collins (R-ME) and Senator Conrad (D-ND) introduced Senate Bill 2814 on November 20, 2009. This bill would allow for advance practice providers other than physician to order and monitor home care services for patients. Despite several State laws that already allow this, it is not allowed by the Federal Government so it is prohibited under federal reimbursed payment systems such as Medicare and Medicaid. Take a look: http://www.govtrack.us/congress/billtext.xpd?bill=s111-2814

Scenario: Skilled nurse visit to the patient’s home determines no SN needed, making this visit a non-billable Medicare visit. PT also visits and also determines there is no need for any further PT visits. Must you complete an OASIS assessment?

According to CMS, yes you must. CMS says even if the RN’s assessment visit is non-billable it is considered a two-visit episode, and therefore the OASIS requirements apply.