Home Health & Hospice Week

Medicare's crackdown on management and evaluation services for home care patients isn't a very nice holiday present, but you don't have to let it torpedo claims for your patients who require the services.

Starting in January, the Centers for Medicare & Medicaid Services will require a new physician narrative of clinical justification for patients requiring M&E as their only skilled service (see Eli's HCW, Vol. XVIII. No. 41, p. 314). The new mandate may make M&E billing harder, but you can prevail if you know the ropes.

Follow these expert tips to comply with the new rule and secure your rightful reimbursement:

1. Know when E&M is allowable. Home health agencies must look at the new language CMS finalized in the home health prospective payment system 2010 update: "management and evaluation of a patient care plan is considered a reasonable and necessary skilled service only when underlying con-ditions or complications are such that only a registered nurse can ensure that essential non-skilled care is achieving its purpose."

More details: Further, "to be considered a skilled service, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of licensed nurses to promote the patient's recovery and medical safety in view of the overall condition," CMS continues in the rule. "Where nursing visits are not needed to observe and assess the effects of the nonskilled services being provided to treat the illness or injury, skilled nursing care would not be considered reasonable and necessary, and the management and evaluation of the care plan would not be considered a skilled service."

"Agencies must understand the appropriate patient situations for M&E," urges consultant Sharon Litwin with 5 Star Consultants in Ballwin, Mo. "I still see confusion on this."

2. Document carefully. In order to qualify for M&E, clinicians must carefully document why the patient meets the complexity requirement, advises Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. "The documentation needs to describe all the complexities of the case -- multiple diagnoses, many caregivers, need to coordinate among many caregivers or services from multiple programs, nutritional issues, any complications the patient has, nutritional requirements, etc.," Adams tells Eli.

This complexity will also need to be reflected in the physician's narrative. "It has been difficult for home health staff to document adequately to show the need for M&E, so I doubt physicians will be able to describe all of the complexities that would justify a nurse (or therapist) to provide visits to coordinate and teach all of the aspects of the complex patient needs," Adams worries.

3. Provide a patient summary. CMS makes clear in the final rule that home care staff must not craft the physician's narrative statement. But the HHA may consider furnishing a helpful summary of the patient's care to assist the physician when she is drafting her statement, Adams suggests. "Agencies could perhaps provide an outline of issues and reasons why skilled care is needed to the [physician] and ask him or her to write the narrative," Adams tells Eli.

4. Educate ordering physicians. It won't be much fun, but you'll need to educate your referring physicians about this new requirement. "I doubt many of them will want to receive that information," laments Chicago-based regulatory consultant Rebecca Friedman Zuber.

Tip: Be sure to emphasize to referring physicians how home care will improve patients' outcomes, Litwin offers. Then cast the narrative requirement as the help you need to continue the patients' home care services.

5. Don't let technicalities trip up your payment. The final rule is very specific about where the physician must sign the narrative. If it is in an addendum, the doc must sign the addendum in addition to the plan of care. If the narrative is included in the plan of care, it must come directly before the physician's signature.