Medical Review:
WARD OFF SOCIAL WORK DENIALS WITH THESE 5 TIPS
Published on Thu Feb 09, 2006
Schedule MSW inservices before medical review hits you.
Is your documentation for social work visits up to snuff? If not, it could cost you hundreds or even thousands of dollars per episode.
Cahaba GBA has seen a number of denials for "claims meeting the episode threshold, billing five visits, one being a Medical Social Worker (MSW)," the regional home health intermediary explains in a recent posting to its Web site. When medical reviewers deny the social work visit, the episode is reduced to a low-utilization payment adjustment (LUPA).
MSW visits also get scrapped when medical reviewers deny the skilled nursing visits, because Medicare covers social work visits only as dependent services, Cahaba notes.
Steep cost: LUPAs can bring a full-paying episode under the prospective payment system (base rate $2,264) down to a handful of per-visit payments (base rate $99 per skilled nursing visit).
Follow these expert tips to help your MSW visits stand up against medical review: 1. Avoid near misses. If you have a large number of episodes exceeding the LUPA threshold by a social work visit or two, it's time to reexamine your practices. "I would not expect to see frequent MSW visits being the visit that puts the patient from LUPA to episode," says Sharon Litwin with 5 Star Consultants in Ballwin, MO. Agencies with many such cases will be waving a red flag to medical reviewers, Litwin warns. 2. Determine medical necessity. HHAs must meet two requirements when furnishing social work visits, Cahaba notes. First, services must be necessary to "help resolve social or emotional problems that may affect treatment of a patient's medical condition, or rate of recovery." Second, services must require the skills of a qualified social worker or social work assistant under supervision of an MSW.
When the patient receives only a few skilled nursing visits and an MSW visit is requested, Litwin recommends holding a thorough case conference to assure medical necessity prior to having the social worker go in.
If the lack of specific resources for the patient are impeding the care, such as medication, food, care or safety measures, "this can easily meet the medical necessity," she tells Eli.
Avoid this pitfall: "Medicare does not cover services for completion or assistance in the completion of an application for Medicaid," Cahaba warns in its posting. "Federal regulations require the state to provide this assistance." 3. Document the problem. Many claims fall victim to medical review denials because documentation can't stand up to scrutiny. "I see poor documentation in many cases," Litwin observes.
The MSW and nurse (or other clinician) who participated in the case conference need to clearly document the factors they considered in determining the medical necessity of the social work visit. "Especially in these cases in which [...]
