Medical Review:
SIDESTEP THESE MEDICAL REVIEW LANDMINES
Published on Mon Jan 21, 2008
You're courting claims denials if you don't guard against these common problems.
Medical reviewers are going over home health agency claims and records with a fine-tooth comb--will yours hold up to the examination?
Regional home health intermediary National Government Services conducted recent probe reviews on different groups of claims, yet came up with the same problems causing denials, according to a message NGS sent to providers.
In addition to diagnosis coding problems, NGS reviewers found these three reasons topped the denial and downcode list: 1. OASIS downcoding. "The medical record documentation does not support the OASIS M0 item response," says NGS, formerly United Government Services and Associated Hospital Service of Maine. Reviewers most commonly downcoded claims for M0 items in the clinical severity domain.
Example: The provider chose response #2 for M0420 on pain. That response indicates that the patient has pain "daily, but not constantly" that interferes with her activity or movement. "However, there is no mention of pain, medication adjustments and response in the [plan of care] or the medical record," NGS says. "We would be unable to validate that the patient had pain 'daily, but not constant.'"
"The problem with validating the OASIS scores is again a result of coding for reimbursement," believes regulatory consultant Rebecca Friedman Zuber in Chicago. Home health agencies must encourage staff to choose the most appropriate OASIS item response based on the patient's condition, not on reimbursement considerations. Tip: Review OASIS answers against clinical documentation, Zuber suggests. Then take those case studies and use them as a teaching tool for your staff.
Also try having staff do their own mock medical reviews of their records. Let them "see if they can verify the OASIS scores," Zuber counsels.
Watch out: Your staff may be marking inaccurate OASIS responses in response to your urgings to claim higher reimbursement, Zuber cautions. "Agencies need to examine the messages they are sending their staff to see if they are in fact encouraging this type of thing," she instructs. "If they are, they need to quit."
If you aren't pressuring staff to claim more reimbursement, then you need to train and supervise them more closely to ensure OASIS compliance, she suggests. 2. Lack of skilled services. Another top denial reason across claims is that "skilled services were not reasonable and necessary or no longer required," NGS found in the reviews.
"HHA personnel seem to understand less about the coverage rules than they did prior to PPS," Zuber laments. "Many home health clinicians don't understand what Medicare considers to be a skilled service anymore as training hasn't focused on this since PPS came in."
It's not just field staff who are missing Medi-care coverage knowledge, Zuber tells Eli. Agency clinical supervisors also need to brush up on coverage basics. [...]
