Know Your Single Nursing Visit Rules For OT Episodes
Published on Thu Jan 01, 1970
Intermediary edit hits episodes with 1 SN visit and 1 or more OT visits. Trying to bill for episodes with a single skilled nursing visit and any number of occupational therapy visits could be a costly mistake. Regional home health intermediary Cahaba GBA is editing such home health agency claims and issuing widespread denials, it says in its September newsletter for providers. "The primary denial reason was due to the one-time nursing visit not being medically necessary or not intermittent," the RHHI ex-plains in the Newsline. "To be covered as skilled nursing services, the services must be intermittent, require the skills of a nurse, and must be reasonable and necessary to the treatment of the patient's illness or injury." Toll: The cost of this mistake is great in otherwise OT-only episodes. If medical reviewers can deny the nursing visit, the entire episode will get denied because OT is a dependent service. That means OT is allowed only when another qualifying service -- skilled nursing, physical therapy or speech-language pathology -- is present, notes therapist and consultant Cindy Krafft with Fazzi Associates based in Northampton, MA. Review The Basics Definition: For Medicare coverage, "intermittent" means "a service ordered generally every 60 days ... and less than daily," Cahaba notes. In special circumstances, that can be 90 days. In other words, patients must require more than one skilled nursing visit per episode to be eligible for home care under the intermittent criteria, explains consultant Judy Adams with LarsonAllen based in Charlotte, NC. Exception: There is an exception for when a single SN visit is OK, Krafft points out. "It would be valid if the nurse intended to do more than one [visit] but something stopped that from happening -- like the patient refused further nursing care," she tells Eli. Pitfall: Some agencies have a hard time understanding that a nurse visit to complete OASIS doesn't qualify the patient for Medicare. Even if the nurse furnishes another qualifying skill on that visit, it still won't be billable in an otherwise OT-only episode due to the intermittent criteria. By the way: Single SN visits with otherwise physical therapy-only episodes are allowed, Krafft acknowledges. "But it still can raise suspicion," which could land you in the medical reviewers' crosshairs, she warns. Once a patient does qualify for a home health episode, OT can be the only discipline involved for the rest of the episode and even for a subsequent episode, Adams notes. The hurdle is securing the qualification. Try this: One strategy is to split the medically necessary nursing services into two visits, Krafft suggests. "Two visits are better to show what the need was -- and to follow up on any teaching done at [...]
