Medicare and Skilled needs

anticoagulationurse · May 2, 2010

Unfortunately just a blood draw is NOT considered a Skilled Need by Medicare. So, if you go out even for a one time visit, it will have to be non-billable with or without a blood draw, unless there are other skilled needs. In this case it seems it is an inappropriate referral and the MD office just needs to be re-informed of the HH requirements so they can make more appropriate case referrals. Our agency has decided we will see ALL referrals regardless if they "seem" skilled or not or whether they seem to fit the requirements or not based on the referral papers. But that does not mean we admit every referral. Since we started this, we have a lot more no-gos.

You cannot do the blood draw if you decide not to admit the patient and make it a no-go (ie, if patient SO or DPOA doesn't sign the admission agreement/consent). But, if blood draw is the only need, you cannot admit the patient in order to just do the blood draw.

A lot of times an outside lab comes in a few days a week to draw labs. Check into that. Also, why can't the RN's that work at her facility do it? When I get cases like this, I do my best at the visit to find alternative means to meet the patient's needs, even if it means I am not meeting the need directly. That makes for a happy referral source (MD), and patient family but sometimes and annoyed staff at the facility.

annaedRN, RN · May 2, 2010

Agree with anticoagulation nurse. Here is a link that may help answer some questions for you. I've noticed that Medicare is very specific is some regards (like venipuncture is not a skilled service) and clear as mud in others. Somewhat open to interpretation...but if the need for assessment or teaching provided by a nurse is justified in your opinion....then just document your butt off :) Always document the homebound status too....

http://www.cahabagba.com/rhhi/coverage/home_health/index.htm

KateRN1 · May 3, 2010

The driving question behind skilled needs is: Does it take a licensed health care provider (a nurse or therapist) for the thing to be done safely?

For example, if the patient is on Coumadin and has weekly PT/INRs, the task is not the skilled need, but the assessment and teaching is. Anyone can do a fingerstick PT/INR, but only a licensed nurse can interpret the result, know to ask for orders based on the result, and teach the patient a low vitamin K diet. Only a nurse can assess how well the patient is following the dosing schedule, the diet restrictions, and the ability of the patient to follow up. The teaching is your ultimate skill in this scenario.

Another example: The patient recovering from a hip fracture. Anyone can teach stretching exercises, but the licensed physical therapist is required to assess the patient's balance and gait, make recommendations, assist the patient to learn a safe home exercise program, and evaluate the follow-through. The exercises are not the skilled need, the education is.

Make sense?

erroridiot · May 3, 2010

http://www.cms.gov/manuals/downloads/bp102c07.pdf

The Medicare Benefit Manual Chapter 7 will tell you what you need to know about skilled visits for Home Care.

It also explains the blood draw issue very clearly.

erroridiot · May 3, 2010

Does anybody have any information regarding what Medicare considers skilled visits?? Our agency has said a lot about the nursing needing to have a skilled need if in a home.. But, I always get referrals that the office sends me to do and it goes like this... Today, I had one that I got yesterday. The woman was DC'd from the hospital. She had a diagnosis of possible cholecystitis. She had been in the hospital and the paperwork indicates that they last did labs on her a few days ago.. The referral states that we were to admit to do a lab that needed to be sent to the Dr. prior to an appt this coming Friday. It is for Amylase, Lipase, CBC, and CMP. I called and spoke with her nephew who states that she is doing ok and this was all that she would need done as she lives in an assisted living center that has CNA's and an RN that oversee her care. He said she is very well taken care of. So, basically, if I go out they will probably not need me to go out and see her all the time... The agency says we have to have 5 visits in a cert. period... It may not happen if there is nothign to teach (the patient has Alzheimer's and I have found most of the nurses in these situations are not teachable...). So, do I go out and do blood draw and then schedule no further visits??? She has Dementia, Depression, and HTN... She is in her 80's. Just needing advice.

ALF patients are difficult to skill. Any patient with memory loss should not sign the consent unless someone else is there to sign as a cosignature.

You can't skill the visit unless you teach the patient or caregiver, and most of the caregivers will not come to the ALF to meet with you and the staff that work there are variable in responsibility.

If your agency is sending you to see patients to draw blood, the visit is not billable. If the agency is doing this alot, or sending you to see patients who can not retain information with no caregiver present, then the agency will be subject to RAC financial reversals or ADR financial reversals at some point in the future.

If the family states they need nothing but a lab draw then document it, calmly report it to your supervisor, and document that. Don't make any waves. Keep a copy of the documentation in a safe place.

Personally, with this type of agency, I would quietly look for another job. Agencies that operate like this are closing left and right in my area and they are a dime a dozen.

It will catch up with them eventually.

Hope this helps.

anticoagulationurse · May 3, 2010

ohhhh! Thanks for the link, Very helpful! Some things may have changed since 2003, I am guessing.

spejsa · May 3, 2010

Thank you for that information. I keep trying to convince the LPN that I work with, that things like this are wrong. Then, the office sends us to do this then when we can't get the 5 visits in we are in trouble.. then, when we can't go out just to do "blood draws".. and so on and so on... And they pass the blame on the nurses but the office is the main problem.

HmarieD · May 3, 2010

Just a note on the "5 visits" - Medicare does not require that we do at least 5 visits. Your agency needs to be very careful here. If an agency does 4 or less visits in a 60 day cert period, they get paid per visit instead of by the 60 day episode (called a LUPA). Reimbursement is much less, so many agencies try to squeeze out five visits, but if they are doing this without a skilled need they are committing fraud.

spejsa · May 3, 2010

Then today I had a conversation with the LPN I work with and she said that we have to go out to do a wound dressing change daily on a patient because the family REFUSES to do the dressing. This patient also doesn't go to dr appts (missed last week appt with wound doctor)... also didn't have Cipro filled since 2 weeks ago... she says we cannot discharge and she sees him so what do I do? I have to dc but she sees the patient...

KateRN1 · May 3, 2010

Why do you want to discharge that patient? Wound care is certainly a skilled need, especially when the caregiver refuses to do it. I take issue with the daily part, though, as most wounds do not need daily care and actually will not heal due to disturbance of the wound bed. Consult with an WOCN if you have one available. The patient doesn't get discharged just for missing a few doctor visits. As long as you still have a doc claiming the patient and willing to sign the 485, what's the problem? And why hasn't the patient filled the rx? Is it a money issue? An inability to get to the pharmacy issue? Other issue? Look into the reasons and work from there.

Sounds like a social worker is in order for this patient.

spejsa · May 4, 2010

A social worker is in order. Remember, KateRN1, I am new to home health. This particular patient has a history of drug abuse. He told the LPN last week that he has had no pain meds since DC from hospital as his family took his pain pills. I thought that we had to have somebody in the home to teach and that was the basis of home health. So, we can go eternally on daily visits? The problem with my agency is... We can make daily but the weekends are a problem b/c all of us are in different areas.