The assumptions with Hypertension have been more difficult to embrace. For some time coders have accepted the assumption of a cause and effect relationship between hypertension and chronic kidney disease. But now the guidelines specifically address the relationship between hypertension and heart involvement, as well as kidney involvement. Coding Guidelines states: “These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.”

The assumption is made by the classification between HTN and Heart Disease (I11.- and I13.- codes). When heart disease is present with HTN, such as CHF and HTN, code it using a code from category I11 followed by an additional code for the type of heart failure.

What if the patient has HTN, CKD, and heart failure? As long as there is not other documentation indicating another cause for the heart failure or kidney disease use a code from category I13 followed by a code indicating the stage of CKD and a code for the type of heart failure.

Coding Clinic in May 2016 advised home health coders that the word “with” in ICD-10 coding manuals should be interpreted to establish a cause-and-effect relationship between a diagnosis and the subterm condition linked to it.

Heart failure can occur independent of other conditions, although it is most often associated with another diagnosis. Many of these are presumed causal relationships linked by the terms “with,” “in” or “due to” in the alphabetical index or tabular list. The most common is hypertension.

You are correct!  It is confusing. For Medicare payers, the first 60-day certification period or “payment episode” begins with SOC and ends on day 60, subsequent recertification periods are also 60 days long (for example, day 61 through day 120).  On January 1, 2020, PDGM introduced two 30-day payment periods within the 60-day episode. However, one Plan of Care continues to cover the 60-day episode.

For home health quality measures based on OASIS data (process measures & outcome measures), the “care episode” aka “quality episode” begins with every SOC or ROC and ends with every Transfer or Discharge.  It is possible for a quality episode to be less than 60 days (for example, beginning with SOC and ending with a Transfer on day 34) or much more than 60 days (for example, beginning with a ROC and ending with a Discharge 90 days later).

No. The Medicare Benefit Policy Manual, Section 40.1.2.1, states that O & A is reasonable for three weeks. It may be reasonable for longer time periods if there is documentation of unstable condition. Some examples of this would be unstable labs, vital signs, weight changes, edema, or medication changes. The regulation goes on to say that a longstanding pattern of patient’s condition or no attempt to change treatment makes O & A unnecessary.

No. According to Condition of Participation §484.18: Acceptance of Patients, Plan of Care, and Medical Supervision, care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine.

The Federal Conditions of Participation, §484.36(b)(2), requires documentation of 12 hours of in-service training per year for home care aides. The training must be more than basic skills and must be supervised by an RN.

In this situation, you would not be responsible for the cost of ambulance transport.  Hospice is responsible for transportation needs that are related to the hospice diagnosis and occur after the election date.  However, CMS does not consider it the hospice’s responsibility to pay for ambulance transports which occur on the effective date of the hospice election, but prior to the initial assessment and prior to the plan of care’s development.  The regulations also state that the initial assessment must be conducted in the location where hospice services will be provided, and the plan of care is developed from that initial assessment and from the comprehensive assessment.

In order for the home health agency to consider it complete, F2F supporting documentation within the certifying physician’s medical record must contain: (1) Information that justifies the referral for Medicare HH services – the patient is homebound and in need of skilled services; and (2) the actual clinical note for the F2F encounter that occurred within the required timeframe, was related to the primary reason for home care, and was performed by an allowed provider type. In addition to obtaining the actual visit note, the home health agency may supply to the certifying physician information from the comprehensive assessment that supports the patient’s homebound status and need for skilled care. This HHA-generated information must be signed by the certifying physician. It is the home health agency’s responsibility to ensure the certification (including documentation of F2F) is complete prior to billing the final claim. [For specific CMS guidance on certification and F2F, refer to the Medicare Benefit Policy Manual, chapter 7, section 30.5 – Physician Certification and Recertification of Patient Eligibility for Medicare Home Health Services.]

One reason for differences when comparing an outcome measure percentage on your CASPER report and that same measure on HHC is due to differences in the risk-adjustment methodologies (for example, an agency’s percentage for “Improvement in Ambulation” might be 72% on CASPER and 76% on HHC because of risk-adjustment).

Definitely. When any document with Personal Health Information is no longer needed, it should be disposed in a secured document disposal container or shredded immediately.

Medicare is a health insurance program for:

• People age 65 or older,
• People under age 65 with certain disabilities, and
• People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Part A Hospital Insurance – Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B Medical Insurance – Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

The Conditions of Participation are silent on who does perform comprehensive assessments after the start of care. OASIS Guidance Manual: Any discipline qualified to perform assessments-RN, PT, SLP, OT-may subsequent assessments.

Therapy evaluations should contain objective measurements for range of motion, strength, balance, as well as assistance needed to complete ADL and IADL tasks. Therapy goals should be measureable and have a functional component, i.e.: Pt. will ambulate from bedroom to kitchen using walker independently to retrieve morning medication safely. Therapy notes should clearly tell a story of what took place during the treatment–patient’s status prior to the treatment, any skill done during the treatment and how the patient responded to the treatment. The discharge summary should contain the goals set and if they were met, and if they were not met, the reason why.

This will depend on the state practice act, as states rules on supervision vary from state to state. Medicare requires the qualifying therapist, in this case the PT, perform a functional re-assessment of the patient at least every 30 days. This requirement is outside of the PTA’s scope of practice; therefore, the PT must perform this visit.

Yes. Per Section 102.004 of the Texas Human Resources Code, an individual, corporation, association, partnership, or other private or public entity providing convalescent and nursing home services, home health services, or alternate care services must display the Texas Rights of the Elderly Poster in a conspicuous location for residents and employees to view.

An agency must conduct a criminal history check authorized by, and in compliance with, Texas Health and Safety Code (THSC), Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly or Persons with Disabilities) for an unlicensed applicant for employment and an unlicensed employee. The agency must not employ an unlicensed applicant whose criminal history check includes a conviction listed in THSC §250.006 that bars employment or a conviction the agency has determined is a contraindication to employment. The criminal history check must be performed at least every 12 months for unlicensed employees who have face-to-face encounters with an agency’s patients. The provisions in this subsection apply to an unlicensed volunteer if the person’s duties would or do include face-to-face contact with a client.

Yes, you must report this. The Texas Administrative Code, Rule §4.554 outlines the regulation regarding abuse, neglect, and exploitation (ANE) of a client by an employee of the agency. It states that if an agency has cause to believe that a client served by the agency has been abused, neglected, or exploited by an agency employee, the agency must report information immediately. Texas regulations require that your agency has a policy on ANE and enforces it.

Absolutely:

www.alz.org

www.osha.gov

www.americanheart.org

www.mayoclinic.org

www.tahc.org

www.NAHC.org

www.CMS.gov