MD Office Referrals

Our rule is we see any patient for any reason for a courtesy admission eval. If not appropriate for service of course we don't admit them (although there is significant pressure to do so). We have no requirements about whether or not the doc has seen the patient in 30 days, but they must be a "current" patient.

So no "recent change in status" is required? I'm having a hard time wrapping my head around referrals that come from the doctor's office when they haven't seen the MD in three months. What prompted the need for home care?

I would at least do the eval visit. You NEVER know what you may find. A lot of times the doc may just have a suspicion that the patient is noncompliant with meds or diet, or maybe the pt called the doc with some type of complaint...you just never know...

Okay, here's the deal. I didn't have time to post much information with the first go-round, but now it's Friday and I have all weekend to stew on this. With it being the end of the month, our marketing team is suddenly bringing in a lot of hinky referrals and clinical managers are having to scrutinize before we staff them.

Case in point: referral comes from doc with order "RN eval." Most recent office visit note over 30 days ago that indicates no change in pt's condition. No new meds. No supporting documentation regarding why this patient needs home care. I ask the marketer for more info and she goes ballistic. It's really hard to try to figure out how to staff if I don't know what the issues are. At a previous agency, I was told that the patient had to have had a recent change in condition (in the last 14 days) to qualify for home health care, but I can't find any CMS data supporting that.

We are also getting a lot of referrals from the neurologists for nebulous reasons that I can't make heads nor tails of, but that's a different story. I've told them that if I can't identify a need with the paperwork they give me, then I will not staff until they bring me some more documentation. Harsh maybe?

Okay - now I see what you're talking about. I know all about those "desperation" referrals. I too, have had to intercept those from time to time, and let the wind out of the marketing sails (pun intended) hehehe....

I have looked all over CMS for some sort of rule/regulation/interpretation to guide this little p*ssing contest between nursing and marketing, but I can't find anything. All I can find is that it must be "physician ordered." Well duh.

M1016 asks for diagnosis or treatment change in the last 14 days. At a previous agency, I was told that if the answer to that question was NA, it was a flag to Medicare that the pt may not need home care and could end up denying payment. Now I'm being told that's not true, the patient doesn't need to have had a treatment change and doesn't need to have seen the physician in the last 30 days to have had home care ordered. I can't find anything in the guidelines or CoPs that gives me a heads up either way and I really feel that these referrals are not appropriate in many cases. In other cases, the need is there but it's not well defined by the referral paperwork.

Where else can I look for guidance?

I have looked all over CMS for some sort of rule/regulation/interpretation to guide this little p*ssing contest between nursing and marketing, but I can't find anything. All I can find is that it must be "physician ordered." Well duh.

M1016 asks for diagnosis or treatment change in the last 14 days. At a previous agency, I was told that if the answer to that question was NA, it was a flag to Medicare that the pt may not need home care and could end up denying payment. Now I'm being told that's not true, the patient doesn't need to have had a treatment change and doesn't need to have seen the physician in the last 30 days to have had home care ordered. I can't find anything in the guidelines or CoPs that gives me a heads up either way and I really feel that these referrals are not appropriate in many cases. In other cases, the need is there but it's not well defined by the referral paperwork.

Where else can I look for guidance?

The Medicare Benefit Policy Manual Chapter 7

https://www.cms.gov/manuals/Downloads/bp102c07.pdf

Which hasn't been revised in five years or so. I've searched the policy manual too, to no avail. If there's something in there that spells it out, please *please* give me a clue where it is.

Okay, here's the deal. I didn't have time to post much information with the first go-round, but now it's Friday and I have all weekend to stew on this. With it being the end of the month, our marketing team is suddenly bringing in a lot of hinky referrals and clinical managers are having to scrutinize before we staff them.

Case in point: referral comes from doc with order "RN eval." Most recent office visit note over 30 days ago that indicates no change in pt's condition. No new meds. No supporting documentation regarding why this patient needs home care. I ask the marketer for more info and she goes ballistic. It's really hard to try to figure out how to staff if I don't know what the issues are. At a previous agency, I was told that the patient had to have had a recent change in condition (in the last 14 days) to qualify for home health care, but I can't find any CMS data supporting that.

We are also getting a lot of referrals from the neurologists for nebulous reasons that I can't make heads nor tails of, but that's a different story. I've told them that if I can't identify a need with the paperwork they give me, then I will not staff until they bring me some more documentation. Harsh maybe?

I agree with you! Maybe it is a question of training the marketing people to obtain information you need instead of merely handing you a very non specific referral. I have asked the marketing rep to please do me a favor and get me a medical diagnosis (which was missing) as well as any other documentation from the doctor she can, for example a recent H&P, Med List, narrative summary, problem list. She started doing this after I asked her, and explained my reason for wanting to know.

Okay, so this begs the question: is a recent change in condition (last 14 days) a *requirement* of Medicare for home care admission, or is this at the discretion of the agency? If M1016 is marked "NA" I know that affects the HHRG score but does it also act as a stop for services? I have been researching this for weeks and cannot find a clear answer. I was hoping someone here had some answers. HELP!