Agency can't bill Medicare...it's not my fault...right?

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Specializes in OB, M/S, HH, Medical Imaging RN.

I did an admit last week on a (young) 65 y/o who had an abcessed tooth gone bad. She ended up with an abcess in her neck and had surgery.

On the oasis I marked her as needing assist with grooming and dressing the upper half because of the bulky dressing and the pain in her neck. She said it hurt to move her neck and her daughter was helping her to sponge bath and dress her upper half and brushed her hair for her. She said she could dress her bottom half. They have stairs in their home and she went up to get something and had absolutely no problems with the stairs.

Today I get questioned....how are we going to bill Medicare if she can dress her bottom half and use the stairs? Um gosh...that's not my problem. I was sent to admit the patient.

The surgical incision, which was left 50% open, teaching daily wound care to CG, new meds, teaching IV meds (which had to be mixed by CG) and PICC line flushing and maintainance, pain, needing help with ADL's, incontinent of urine (wears depends pads) were plenty of reasons for the patient to be homebound. Especially the pain. She was taking Dilaudid.

I set the frequency for just the admit visit and then a discharge visit for 5 days later when the IV meds were finished and the PICC line would be pulled. Yesterday when I went out to do the DC I got a call from the DON who said "No don't DC, we're doing another 1 week 4 just to make sure she doesn't redevelop any problems (avoiding a loopa?) anyway now it's....

"We can't bill Medicare for this patient, she doesn't qualify as homebound, why did you mark that she could dress her bottom half and can use stairs"?

How about because it's the truth and my license is on the line. Change it if you want to but I won't sign the 485. Now I ask you whose fault is this?

If it's mine, be honest, I can take constructive criticism. Thanks!

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Specializes in pedi, pedi psych,dd, school ,home health.

GRRRRR I always hated the attitude that we only admitted pts who would qualify for lots of reimbursement$$$$$:angryfire

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Specializes in Gerontology, Med surg, Home Health.

I'm still new to HH and still learning the rules, but from what you've said, we would have admitted her to service. Someone admitted a 60 year old guy to my team who had a fractured pelvis...that was it and they put him down for 3 visits a week the first week! A fractured pelvis...60 years old...cripes they send 85 year old people home with fractured pelvises (pelvi??) and no home care.

As long as there is a need for teaching,medication management,IV meds, ...those all qualify someone for home care. And just because you can walk up one flight of stairs doesn't mean you can safely leave your home.

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Specializes in OB, M/S, HH, Medical Imaging RN.
I'm still new to HH and still learning the rules, but from what you've said, we would have admitted her to service. Someone admitted a 60 year old guy to my team who had a fractured pelvis...that was it and they put him down for 3 visits a week the first week! A fractured pelvis...60 years old...cripes they send 85 year old people home with fractured pelvises (pelvi??) and no home care.

As long as there is a need for teaching,medication management,IV meds, ...those all qualify someone for home care. And just because you can walk up one flight of stairs doesn't mean you can safely leave your home.

Thank you! Thank you! That's how I felt about it but you said it so much better.

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Specializes in Lie detection.

Your agency is either crazy or super meticulous. Homebound also allows for someone to GO TO CHURCH so technically they could walk up a flight of stairs and more.

The pt. was homebound. Does your agency need some direction?

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Specializes in Case Management, Home Health, UM.

your patient is homebound. as long as she requires assistance to leave home for medical appointments, church and the like, she qualifies for home care:

an individual does not have to be bedridden to be considered as confined to the home. however, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. if the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. absences attributable to the need to receive health care treatment include, but are not limited to, attendance at adult day centers to receive medical care, ongoing receipt of outpatient kidney dialysis, and the receipt of outpatient chemotherapy or radiation therapy.

(from the cms publication 11 manual, section 204.1, a).

sounds like your soon-to-be ex-employers are either having difficulty interpreting the above regs, or are trying to give you a hard time before you leave next week. i think it's the latter.

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Specializes in Utilization Management.

Who actually dresses her wound? Who assesses the wound?

I had a patient who, although young, was unable to do her wound care because of a jaw abscess I&D, and for the time she was under my care, had a drain. The drain was pulled the day of DC, but no way could this woman manage to see and dress her wound appropriately.

She walked just fine too.

I don't do HH, but I think you did the responsible thing, DG.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

being homebound is a requirement mainly for medicare, medicare hmo, medicare private fee for service insurance and some medical assistance plans; not requirement most commercial payors ---want that pt out of hospital and paying for least costly care. most post-surgical care patients are considered temporarily homebound as not permitted to drive and have medically restrictive limitations.

often those patients with upper extremity injury/problems don't reflect their true status using just oasis question scores. clinical description in notes is what makes/breaks being reimbursed for these patients if chart requested for 488 review for payment.

if it hurt to move her neck wouldn't be surprised if daughter needed to help get clothes out of dresser drawers, place in reach of patient, therefore needing assistance, even if patient could pull on undies and pants herself.

if this was a small agency with less than 100 patient census, could understand needing every oasis point, but for a multi-office location, must be under financial gun to be this nitpicky or they truly don't understand mc regs.

i had the opportunity to listen to the oasis coding audio conference presented by fazzi assoc -- part of 3m oasis integrity project

updated recommended questions and techniques for oasis m0 items

(link posted in thread helpful tips on completion of the oasis )

our entire staff was in serviced afterwards. we also presented inservices "think like a therapist" and "think like a nurse" to pt and nursing teams with improvement in case mix index and mc reimbursement to agency.

taking the time to finesse oasis question and coding key to bottom line in homecare for it makes or breaks an agency.

medicare most likely will pay for care if noted "homebound due to surgical restrictions: part of documentation. i also would follow patient for 2-3 weeks after picc removed to eval wound healing, eval medication compliance and potential complications.

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Specializes in OB, M/S, HH, Medical Imaging RN.
Your agency is either crazy or super meticulous. Homebound also allows for someone to GO TO CHURCH so technically they could walk up a flight of stairs and more.

The pt. was homebound. Does your agency need some direction?

Well....they certainly did need some direction and now we're going to get it. The owner came in yesterday and fired both the care manager and DON. Everyone said they felt sorry for them but they had had it coming for at least 2 years and they had caused their own problems.

They asked me to stay on a PRN basis since they are gone and I told them I would. They first asked me to take the care managers position but I told them I had already committed to the hospital and couldn't do that. I am off four days a week so I can definately help out PRN and can help train new nurses.

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Specializes in OB, M/S, HH, Medical Imaging RN.
being homebound is a requirement mainly for medicare, medicare hmo, medicare private fee for service insurance and some medical assistance plans; not requirement most commercial payors ---want that pt out of hospital and paying for least costly care. most post-surgical care patients are considered temporarily homebound as not permitted to drive and have medically restrictive limitations.

often those patients with upper extremity injury/problems don't reflect their true status using just oasis question scores. clinical description in notes is what makes/breaks being reimbursed for these patients if chart requested for 488 review for payment.

if it hurt to move her neck wouldn't be surprised if daughter needed to help get clothes out of dresser drawers, place in reach of patient, therefore needing assistance, even if patient could pull on undies and pants herself.

if this was a small agency with less than 100 patient census, could understand needing every oasis point, but for a multi-office location, must be under financial gun to be this nitpicky or they truly don't understand mc regs.

i had the opportunity to listen to the oasis coding audio conference presented by fazzi assoc -- part of 3m oasis integrity project

updated recommended questions and techniques for oasis m0 items

karen, awesome post! thanks for the link. i have a question? is nasonex

nasal spray considered an inhalant medicaton for pursose of answering the oasis? or just neubulizer, albuterol, xopenex? it doesn't state that clearly but does talk about pouring the med out of a bottle, measuring, etc....nasal spray is not like that so i chose "no inhalation medications prescribed", how are nasal sprays handled or considered? thanks so much.

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Specializes in Case Management, Home Health, UM.
Well....they certainly did need some direction and now we're going to get it. The owner came in yesterday and fired both the care manager and DON. Everyone said they felt sorry for them but they had had it coming for at least 2 years and they had caused their own problems.

What goes around....comes around.

Maybe this will be a big wake up call for the owner that she needs to be on top of the day-to-day operation of her agency from now on...before problems like the ones you have been describing have a chance to get started.

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Specializes in OB, M/S, HH, Medical Imaging RN.
What goes around....comes around.

Maybe this will be a big wake up call for the owner that she needs to be on top of the day-to-day operation of her agency from now on...before problems like the ones you have been describing have a chance to get started.

Amen!

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