Home Health & Hospice

Nonroutine Supplies Warning Sign

Homecare Insider, January 12, 2009

The revised Prospective Payment System (PPS) includes a case-mix severity model for supplies. There are six levels of payment, correlated to the patient’s case-mix, ranging from $14.12 to $551. The fifth and last position of the Health Insurance Prospective Payment System (HIPPS) code on the claim reports the patient’s severity level and whether or not the agency is providing supplies.

One red flag that points to trouble: Too many HIPPS codes ending in a number.
If the last position of the HIPPS code is a number, the agency is not providing supplies to the patient. Documentation in the clinical record can explain this. Examples: The plan of care does not call for any supplies. The patient wants the agency to use her supply of dressings.

If the HIPPS code ends in 4, 5, or 6, the score totals 28 to 99+ points for which the agency is receiving additional payment — up to $551. However, the agency is not providing supplies and a medical reviewer may investigate to determine why. Example: The patient has an ostomy and a stasis ulcer, which her husband has treated for years. The patient is receiving only physical therapy. Because the plan does not address the ostomy or ulcer, the agency is not providing supplies. And the agency is wrong. It is responsible for providing nonroutine supplies to treat the patient’s condition and comply with the plan of care and the consolidated billing requirement.

One could counter: If the plan of care doesn’t have to include the ostomy or ulcer because the patient is receiving only therapy. However, the plan must address these two medical issues. The Conditions of Participation, §484.18, say that the plan of care includes all pertinent diagnoses and patient treatments. It does not exclude those which the patient or caregiver manages. The plan should note the diagnoses, treatments, and necessary supplies, even if homecare staff are not providing the care. And the clinicians caring for this patient must pay attention to the conditions.

Reporting and documenting nonroutine supplies is essential to an agency’s success in the PPS. It is just one of the important topics on the agenda for Beacon Health’s seminar, “Mastering Medicare: OASIS, Documentation, and Diagnosis Coding.” The seminar debuts in Orlando on February 23 and 24; the special hotel room rate expires February 6. Download the brochure.

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