? about SN frequency orders on 485

  1. OK, work is driving me NUTS! I want as many opinions as possible on this issue.

    OK< let's say it is Saturday, you are opening a post-op CABG, seven new meds, elevated BP first visit. You decide you think he should have SN for 6 weeks.

    Write the order.

    Assuming it's Medicare, I write SN 1-3 W6. With PPS, it doesn't matter, you are not paid per visit, only per episode. So who cares if it is higly specific?

    Before PPS, my old super at my first HH job said show a decreaase in frequency, Meidcare likes to see that. SO for above pt, 2-3W3 then 1-2W3 for example.

    my NEXT JOB, WAS AFTER pps STARTED, THEY SAID IT MADE NO DIFFERNCE to them (caps by accident sorry) 1-3 W9 for a cardiac pt was OK.

    Now, back to former employer, they have deiced to show a decreasing frequency, but said it's for CHAP, they want to see an individualized POC.

    Issue 2: SOC on a Saturday. My present agecny is making a federal case out of us writing 1W1, then 2-3 W3, then 1-2W2.
    Sop we look more specific, knowing that if saturday is the last day of the week, we know we will only make one visit that week. BUT, my argument is 1-3 W 6 covers all of the above!! If we just go once on the saturday, we are still in compliance. If the chart is reviewed, the examiner should see the visit frequency decrease as the pt improves. I swear it's a control issue.

    NOW I can admit I see the usefulness of 1W1 for a daily wound, which, if I opened on a Saturday I would write 1W1, then 5-7W3, the 3-5W3, then 1-3W3. I completely see the rationale in that, since 5-7 for 4 weeks would put us out of compliance for week 1. AND, it makes perfect sense to show a decreased freq for a daily wound, even if we need to write a 487 later to cover ongoing daily visits.

    Is anyone else's agency this picky? I mean my former agency couldn't care less, they just wanted it to be easy for the nurses, so that it was hard to be out of compliance with the orders. We had a state inspection while I was there, and they had no problem with this issue. I honestly think it's a control issue. The supervisor told me she changed my order, which if I had made an error, I would not mind, but in my mind, no error was made, since a sat visit is still within the 1-3 range of # of visits that week. Frankly if they want to change it , it truly makes NO DIFFERENCE, so I figure knock yourself out. The other supervisor, they are NEVER consistent, said at a meeting, they went on and on around the room on this issue, and as far as she could tell, there was no decision made, so is this just that the other supervisor thinks it is the right way to do it? And wants everyone to do it her way?? Why must they nitpick every piece of paper? NEVER do they say, wow, you reaLLY WENT THE EXTRA MILE FOR THIS PT. (caps again, it's this tiny laptop.)

    So, tell me how you would write orders for the follwing scenarios...

    New diabetic, vs wnl, but fbs 378 on admit visit. Ct needed freq direction while admin self-inj for second time. It is Thursday, you need to visit tomorrow for sure to watch the inject again, and check sugar, ct's glucomter hasn't arrived yet. He;s Medicare. Write your orders.

    Old diabetic with removal of infected skin graft s/p partial foot amputation. Orders are daily NS wet-to dry. Pt lives alone, has no willing CG, he is also arthritic and cannot reach or render wound care himself. Mediacre. It is Friday first visit.

    Saturday, new CVA pt with BP on admit of 198/72, and 172/68 other arm. Asymptomatic of HTN (no H/A), CT scan per wife, in hospital, showed mult CVA's past and present, they had no idea he ever had a CVA in the past. Ct has not taken any of his meds yet, NOrvasc, Lopressor, Dyazide, etc. SN thinks he should have a visit on Sunday again later in afternoon, to see if taking meds amde any differnce. After SN reviews actions and se of all meds and new meds ecotrin and plavix, wife decides she is not filling rx for these as ct had "rectal hemorhage" 6 months ago and was told never to take asa. Doc on-call doesn't know pt, of course, OK with BP recheck since asymptomatic, and can hole plavix and asa one day w/o a crisis. Pt will also get PT and ST eval. Write orders for SN freq.

    OK, sorry for any typos, I'm tired and wanted to get this down while fresh in my head.
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  2. 19 Comments

  3. by   hoolahan
    These are my answers to the above sceanrios...

    New diabetic
    1-3W9, and 4 prn for disease related complications

    Old diabteic
    2W1, 5-7W2, 3-5W3, 1-3W3 (No prn as he would most likely need ongoing dailys and a new 487 addressing and supporting that fact. This is typical for my agency. They have some daily wounds open for 3 years!!)

    CVA
    1-3W6 and 2 prn for dz-rel comp's

    What do you think? Aren't these individual enough. If anyone read my notes instead of looking at the stupid numbers, they would know why I wrote what I did, I am a good documenter!(Sp?)
  4. by   NRSKarenRN
    My agency's visit pattern standards re MC patients has changed since PPS: no longer focus on tight decreasing visit patterns.
    New expectation is that client receives appropriate visits to MAXMIZE functioning, prevent rehospitalization and have highest possible level of functioning. Expect more visits in first month, taper second month or next recert as appropriate.

    Guidelines initial certification:

    1. All patients receive 60 day visit patern for 8-9 weeks; exception patients post CEA that follow standard orders---3 week visit pattern only.

    2. DAILY wound care patients MUST have that necessary statement "Projected DC date for daily wound care" ( as determined by Dr. ... LOL, always the nurse) .... very nasty wounds project 90-120 days, moderate complex 2-3 months.....they ARE LOOKING FOR A DATE now, just not "3 months". IF THIS STATEMENT NOT ON 485 POT FOR MEDICARE CLIENTS, AUTOMATIC Medicare payment denial....no way around it, even with photo's. (Learned that lesson 10 yrs ago when first agency ATE 6 MONTHS daily visits, ouch)!

    If patients needs longer daily pattern, better make sure that a different wound care routine has been tried in an attempt to be able to reduce visits on recert. In prior life, would decrease visits from daily to QOD, just to PROVE that decreasing from daily pattern caused worsening wound status, therefore giving you justification for daily wound care. Expectation is that agency also utilizes CETN/WOCN RN for wound care eval re appropriateness of treatment.
    P.S. MUST have documentation in the chart why patient or caregiver unable to perform wound care in order to get paid!

    3. PRN rarely used at this agency...only for catheter dependent + CHF patients... your examples are good justification for use PRN visits.

    4. USe MANAGEMENT AND EVALUTAION as a nursing order...this alows you to visit 1-2x a month when the patient ONLY needs minimal supervision/evaluation/ assessment to ensure COMPLIANCE with careplan/ medication managent....also use when multiple lay caregivers involved in patients care.

    5. Visist pattern is to reflect severity of diagnosis.

    6. Patients only receiving visits for med administration B12 , Epogen, Neupogen etc. need to have initial lab work in the chart proving low B12 levels/anemia on admission....they also expect lab work periodically to evaluate condition, written on 485 POT.

    7. DON"T write wound care orders including "apply bandaid" ----ANYONE is capable of applying a bandaid( i.e. nonskilled)...use the word DSD (which a bandaid IS) instead... you are evaluating this wound for S+S of infection/ compliance with wound care with treatment plan AND S+S of wound complications; which is a nursing SKILL lay people don't have!! INCLUDE SITE OF WOUND CARE AND FREQUENCY OF CHANGE.

    8. CLIENTS WITH SURGICAL INCISIONS: a stapled/steri stripped incision is NOT fully granulated.... is a wound ---write wound care orders: OTA(open to air) or covered with a DSD (dry sterile dressing) daily????

    9. INCUDE orders for oxygen, trach care and frequency of change/ who changing if not RN; Vent patients must have ventilator settings.

    10. If client receiving a service from another agency that you are not providing, document agency/care involved.
    i.e. PICC LINE care and IV Vancomycin managed by ZZ TOP agency.


    Guidelines for Recertification:

    1. Expect to see different visit pattern from initial 485 POT. We usually change SN from 1-3, to 1-2wk/9 unless doing woundcare, med administration eg calcimar, epogen etc. PT/OT/ST can use 1-3wk.

    2. Sometime will write 1-2wk/4, 1-2mo/1 ; 2 prn disease exacerbation for second/subsequent assessment if mainly doing only disease assessment/evaluation or 1-2 mo/2; 3 prn disease exacerbation.

    3. MUST DOCUMENT HOMEBOUND STATUS at least monthly in notes and reflected on 485.


    My pet peeves re reviewing recerts:

    a. Check DX---make sure that dx listed primary is the one you are ACTUALLY treating/evaluating etc!!! Reorder as appropriate, add/delete DX as needed.

    b. CHECK THE MEDS carefully..............can't tell you how many tmes I see antibiotics written on initial POT for only 7 days STILL on 3rd recert!!!!!!

    c. Clients getting Epogen: Anemia DX.; Neupogen: leukopenia;
    Insulin( if teaching DM mgmt): some type of diabetes ---should be part of diagnosis.

    d. Indwelling Catheter clients: type + size of catheter, frequency of change and PRN visits needs to be on POT; include need for irrigation and amounts; sterile vs clean insertion if indicated for intermittent catheterization.

    e. Correct the darn wound care orders.... 6 months to 1 year later I expect to see different orders, especially if some wounds healed in month 2 !!!!!!!!!!

    f. Update the Goals.....if you remove a diagnosis +/or add diagnosis: remove old goals from recert + add new ones!

    Ok, I'm through with the nags!
    Last edit by NRSKarenRN on Oct 28, '01
  5. by   Roxeliza
    NRSKarenRN, your initial & recert tips were very helpful, any more goodies on OASIS or PPS issues?
  6. by   nicola
    I don't know if any one is still reading this thread... but wanted to comment on the thread. First, both agencies I worked for were that picky - much to my frustration! I always had to have a calendar to see when the week started and when the 60 days ended....

    We did use PRN, but very specifically. We'd write "1-2 PRN for exacerbation of hyperglycemia"

    I think, Hoolihan, the best way to resolve your issue would be to find a way that satisfied HCFA regs... Don cha love it...
  7. by   NRSKarenRN
    For your reading "pleasure", check out HCFA's: Medicare Home Health Insurance Manual #11, knwon as HIM 11, our payment bible. It has all the rules and regs in it.....updates are sent as transmittal memos with link at top of page.


    Table of Contents
    Chapter I General Information About the Program
    Chapter II Coverage of Home Health Services
    Chapter III Start of Care Procedures
    Chapter IV Home Health Billing Procedures

    check these Chapter two sections---most rules here:

    203. CONDITIONS TO BE MET FOR COVERAGE OF HOME HEALTH SERVICES
    203.1 Reasonable and Necessary Services
    203.2 Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services
    204. CONDITIONS THE PATIENT MUST MEET TO QUALIFY FOR COVERAGE OF HOME HEALTH SERVICES
    204.1 Confined to the Home
    204.2 Services Are Provided Under a Plan of Care Established and Approved by a Physician
    204.3 Under the Care of a Physician
    204.4 Needs Skilled Nursing Care on an Intermittent Basis or Physical Therapy or Speech- Language Pathology Services or Has Continued Need for Occupational Therapy
    205. COVERAGE OF SERVICES WHICH ESTABLISH HOME HEALTH ELIGIBILITY
    205.1 Skilled Nursing Care
    205.2 Skilled Therapy Services.
    206. COVERAGE OF OTHER HOME HEALTH SERVICES
    206.1 Skilled Nursing Care, Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy
    206.2 Home Health Aide Services
    206.3 Medical Social Services
    206.7 Part-time or Intermittent Home Health Aide and Skilled Nursing Services

    http://www.hcfa.gov/pubforms/11_hha/hh00.htm
    Last edit by NRSKarenRN on Nov 17, '01
  8. by   wenron
    We have to write on oasis (wounds)
    wound to be resolved by ...% by wk
    or wound will resolve without s/s infec by...

    We are not allowed to write 1-3 w3, we have to write exactly how many days we go out ie 3wk3 2wk2.

    This all gets so confusing at times and I am so afraid pt's are going to be missed.

    We did get a 98% on our audit, so we must be doing something right. I still have a lot to learn.

    Wendy
  9. by   Furball
    OMG! You guys just made my hospital job look easy!

    I don't miss those oasis questions one bit...whew!
  10. by   KP RN
    Hi y'all!! I have a few comments, then a couple of questions regarding frequencies on the 485....
    At my agency, we are not allowed to range visits (2-3w4, etc). It has to be exact.(2w4).
    When I open a case, as case manager, I will project my 8-9 weeks worth of visits,(ie:4w1,3w3,2w3,1w2). My projection is discussed with the pt when the case is opened and it is written on the admission/authorization sheet which is signed by me and the pt. A copy of this goes into the chart.
    For some reason, my office will decrease my frequency when they type up the 485. (3w1,2w1,1w7).
    Is this common practice in home health? Is it an OK thing???
    Just wondering.......
    Last edit by KP RN on Mar 23, '02
  11. by   hoolahan
    KP, do you know what the HHRG is for those pt's? Maybe the cost of your predicted visits came out higher than the HHRG's were calculated to be. Howevere, it still seems to me that your supervisor should run this by you. I have heard this happened a few times at my agency too, not to me, but if I were you, I would go to the source and ask, especially if the pt and yourself signed a contract stating that was the way you were planning to visit. We do not get that specific on our consent forms. Either they should keep what you have written, or redesign your forms. I would be really upset if that were hapening to me. If they think you are doing something wrong, they should tell you. I would consider reporting the supervisor to corporate compliance. But talk to him/her first.
  12. by   KP RN
    Thanks for your post, Hoolahan!
    My next question is...when the patient asks me why my actual visit schedule doesn't match my initial projection, what would be a good response?? Especially if I believe she needs the visits? CHFer with frequent rehospitalizations?? This is a patient who might call the Medicare hotline and say she's not getting the services she's entitled to? Can my agency get into trouble with MC for altering visit frequencies in the name of cost containment? Am I the only HH who has these problems?????
    What to do?????
  13. by   hoolahan
    First, go to the source. Ask for an explanation and explain that you feel her changing a signed document that you and the pt agreed to is setting you up for fraud. Ask if there is something you have been doing wrong. Maybe that part of your consent form needs to be deleted. Why do you need to say exactly how many visits? Change the terminology to "D/C when goals are met" or "Home visits schedule discussed" or something like that. Otherwise, I would tell that supervisor, she needs to call the pt and document that she explained to them the reason she decreased the vs freq.

    If that doesn't get you anywhere,I would refer the pt back to my supervisor. I would show the pt my paperwork I submitted, and then explain that the supervisor changed the visits and I would request the pt call the supervisor, or I would call from the pt's home and say "Mr. So and So was reviewong his consent form and he has asked me why he has not been getting visits as per the agreement. Since I was not aware of the change until the orders were printed, I assured him you would be able to expplain what happened. Then I would document the call to the supervisor. I would also ask the supervisor to document in the progress notes if she changes the freq, WHY she did so, so that you will be able to easily communicate that to the pt.
  14. by   cjk02
    My goodness! From reading your posts I feel like I have it pretty easy (but don't tell my boss!). At my agency we are still writing frequencies in ranges (1-3/wkx3wks) and in decreasing order. For dailies we do not need to write ranges (7/wkx9wks). We base our frequencies on the patient's need at the time of admission and it frequently cahnges througout the course of their treatment, in which case we write a new order for the change in frequency and the reason why. In the case of prn visits, we write an "extra visit" order as needed to cover them. The whole system seems to work out well and nobody gets missed. When I first started in home health writing frequencies was pretty confusing but I guess I've worked for the same agency long enough that it actually makes sense to me!

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