OASIS Alert

Published on Wed Sep 05, 2012 PDF

Don't be surprised to see your acute care hospitalization (ACH) outcome data change. CMS plans to use claims data to calculate that figure for display on the Home Health Compare website, rather than continuing the current method of using OASIS data, CMS says in the home health prospective payment system proposed rule published in the July 13 Federal Register.

"Claims data are a more robust source of data for accurately measuring acute care hospitalizations than other data sources," CMS maintains. However, CMS has to work out some technical issues with the Home Health Compare files before it will post the claims-based figure. Until then, CMS will continue to display the OASIS-based figure.

CMS appears to plan to use claims data for the "Emergency Department Use Without Hospitalization" measure as well, the proposed rule indicates.

Worried about receiving denials when teaching dementia patients with behavioral disturbances? Check out a new coverage article from HHH Medicare Administrative Contractor NHIC for tips on what your MAC will be looking for.

"Teaching and training activities ... in the case of the beneficiary population with dementia and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances," NHIC explains.

But for teaching to be covered, clinicians should document the answers to a list of questions about the disturbance, ranging from "What is the frequency of the behavior" to "Are there other possible explanations for the behavior," NHIC instructs.

Remember: "In the home health setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained," the MAC tells providers.

The article, which includes example scenarios with interventions, is at www.cms.gov/medicare-coverage-database/details/article-details.aspx?rticleId=51856&ver=2&name=&ContrId=206&ContrVer=1.

Get ready to feel the RAC pain other providers have become accustomed to. Now's the time to make sure your documentation backs up your OASIS answers.

Region C Recovery Audit Contractor Connolly Inc. has posted this HHA issue: "Medical Necessity and Conditions to Qualify for Services." According to the RAC for 15 states and two U.S. territories, the "medical record will be reviewed to validate that the Home Health Services provided were both reasonable and medically necessary, and that the patient met the conditions to qualify for Home Health Services." The review will cover claims back to October 2007, Connolly says.

"This is definitely not good news," warns consultant Pam Warmack with Clinic Connections in Ruston, La. "In my dealings with providers I find that documentation to support medical necessity is often lacking."

The problem: "Medical necessity is one of the top two reasons for denials from most of the MACs," Warmack laments. "Medical necessity can be difficult to explain and difficult to defend upon appeal."

Reasons for subpar medical necessity documentation vary. Sometimes, "patients are recertified and there is simply not clinical evidence to support the need for continued services," Warmack explains. Other times, "the problem is that the clinical staff -- most frequently nurses -- don't know how to document in a style that supports the need for care."

Bottom line: "I teach documentation classes over and over and over and find the same problems with documenting towards medical necessity persisting," Warmack tells Eli.

Solution: "Providers really, really need to take heed of this newest threat and get their clinicians in compliance with documentation requirements," Warmack urges.

Note: Details about Connolly's issues are at www.connolly.com/healthcare/pages/ApprovedIssues.aspx and DCS's issues are at www.dcsrac.com/IssuesUnderReview.aspx.