Need clarification about SOC, certifications, etc

[nurse955]

If it seems like I'm asking stupid or silly questions, please exercise patience with me. I'm new to home health nursing, medicare regulations, POC, SOC, etc. I have found responses posted by members on this website to be more helpful, clear and informative.

Can someone explain to me start of care, plan of care, certification, reimbursement and correlation with episode of care.

Is the date of admission same as SOC date?

I know the POC is also refer to as 485. Is this different from the careplan or should I complete a separate nursing diagnosis care plan?

How is the certification period defined? Is it 60days from the SOC(new pt) and what about recertification?

I read on the medicare website that payment is based on episode of care, what does that mean?

Do I submit claims for every skilled visit made?

Are private insurance/HMO payment system better than CMS

[caliotter3]

I can address this one: Only one agency I have worked for that I remember, had a form setup for the "nursing care plan". It was filled out at the start of care, and a copy just kept in the field chart for looks. Nurses only ever refer to the 485, if even that.

[KateRN1]

Okay, I'll try to answer the questions that you've posed.

The start of care date is the same date as the admission date is the same date that the first billable service was rendered.

Episode of care = certification period = 60 days.

Recertification is to provide another 60 day episode of care. A recertification OASIS assessment must be completed between days 56-60 of the episode for compliance.

Plan of care = Form 485 = nursing care plan = physician-ordered plan of care. Your agency may also require a nursing diagnosis care plan but CMS does not. Check your policy and procedure manual or ask your director of nursing/clinical services.

Reimbursement is the amount of money that your fiscal intermediary pays on behalf of Medicare based on the OASIS assessment, number of therapy visits, and timing of the episode of care. Reimbursement is determined by the HIPPS code. There is a recent thread in this forum regarding that, take a look.

If you are asking these questions, you should not be submitting a claim. Hopefully you are working for an agency that is submitting claims. You must complete a visit note or OASIS assessment for each visit that meets the criteria for skilled care for it to be billable, as well as being within the ordered frequency.

Private insurances and/or HMOs (including Medicare Advantage plans) are rarely as lucrative as straight Medicare. They put restrictions on the number of visits allowed and require increased documentation and authorization for further visits that may not be allowed.

Best place to start learning about home care is directly from CMS.

http://www.cms.gov/HomeHealthPPS/

[hearts_and_thoughts]

I, too, have stupid questions that I find it difficult to locate an answer.

1). On page 1 of my 485, the box #23 that requests my signature states the following: Nurse signature and Date of Verbal SOC where applicable.

So, I haven't been dating it because Date of Verbal SOC was not applicable.

My boss is telling me to date the signature for date of signature and don't pay any attention to the "Date of Verbal SOC where applicable" directions.

On page 2 (addendum), box #11 states: Optional Name/Signature of Nurse/Therapist and box #12 states: Date: So, I've been only dating the page 2 addendum in box #12.

My boss says the state is going to "ding" me/us because I haven't been dating in that box #23. Grrrrr...

[hearts_and_thoughts]

Another question I have that is difficult to find an answer for. On the Oasis that we purchase through Med Pass or Briggs Forms, there are 3 colors of ink. The Red Ink items are for the 485. But, I can't find any regulations showing these RED INK items are required to be completed. My employer tells me that if we mark a Red Ink box then that has to show up on the POC or we get cited by the state (OH). I told my employer we should purchase the OASIS form that doesn't have the RED INK items because we should not give them that opportunity to cite us if we just stop buying that particular form and instead use the one without the RED INK sections!!

[paradiseboundRN]

I think you need to get this book, ASAP.

[h=1]Handbook of Home Health Standards - Revised Reprint: Quality, Documentation, and Reimbursement, 5e (Handbook of Home Health Standards & Documentation Guidelines () [spiral-bound] [/h] Tina M. Marrelli MSN MA RN (Author)