Home Health & Hospice Articles by Topic: Medical necessity

Is the patient in the following scenario considered to be incontinent of stool for the M1620 question?

• Homecare Q&A, Issue 1, January 16, 2019

  This scenario is not specifically addressed in the OASIS Q&As.

What's the best advice you have for an agency that hasn't been through a demonstration like the review choice demo before?

• Homecare Q&A, Issue 17, December 17, 2018

  Choose the pre-claim option.

In the review choice demo, why would an agency choose a post-payment review option instead of pre-claim?

• Homecare Q&A, Issue 17, December 17, 2018

  If you feel pretty confident as an agency that your documentation can pass muster and the totality...

For commercial payers, is it necessary to perform a recertification visit within the required five-day window?

• Homecare Q&A, Issue 16, November 20, 2018

  All payers must follow the Conditions of Participation, which require an update to the...

What's an example of a billing aberrancy that's prompting contractors to target agencies in targeted probe-and-educate reviews?

• Homecare Q&A, Issue 12, July 25, 2018

  We see inappropriate recertifications all over the place.

If a patient requires assistance to complete ADLs but is independent with all gait and mobility, can the person still be considered homebound per Medicare guidelines due to the taxing effort of getting ready to leave the home?

• Homecare Q&A, Issue 11, July 15, 2018

  This question cannot be answered, as each eligibility is established with each particular patient.

How do we determine if it's worth it to submit a request for redetermination?

• Homecare Q&A, Issue 11, July 15, 2018

  First step, ask your biller for the remarks that are submitted by the reviewer at the MAC.

How should we handle cases when there are diagnoses presented on the assessment that weren’t in physcian documentation?

• Homecare Q&A, Issue 10, June 11, 2018

  Diagnoses listed in M1011 (Inpatient diagnosis), M1021 (Primary diagnosis) and M1023 (Other...

Say an agency is starting from scratch on the process of responding to ADRs. What is the first thing that should be put in place?

• Homecare Q&A, Issue 9, May 12, 2018

  First off, know on the front end that the biller is looking for those requested records. Ensure...

Improve documentation, avoid pitfalls ahead of tar-geted probe-and-educate review

• Homecare Direction, Issue 1, January 15, 2018

  Between the cost of denials and additional staffing expenses to cover the time in-volved in...

How do we identify a new ADR in hospice?

• Homecare Q&A, Issue 21, November 2, 2017

  MACs use the Fiscal Intermediary Standard System (FISS) to process Medicare Part A claims...

If a patient has an established stoma and cares for it independently (the agency is not providing any care), does stoma care need to be included on the 485/plan of care?

• Homecare Q&A, Issue 19, October 3, 2017

  If the agency is not performing any care for the stoma (including any assessment, etc.) then you...

What does a psychosocial assessment need to include?

• Homecare Q&A, Issue 14, July 17, 2017

   The CoPs make clear that the plan of care will continue to be based on the comprehensive...

What should you do about a tardy recertification assessment?

• Homecare Q&A, Issue 7, April 4, 2016

  In response to this question, CMS has said that it is not necessary to discharge and readmit the...

Why wouldn’t two overlapping visits be considered reimbursable by Medicare Advantage?

• Homecare Q&A, Issue 2, January 18, 2016

  One of our clients had overlapping visit times. The RN visited, provided skilled nursing care, and...

Is applying transdermal patches to a memory-impaired client three times per week covered by Medicare?

• Homecare Q&A, Issue 2, January 18, 2016

  Thank you for your question and commitment to compliance. Application of the transdermal patch is...

In Focus | Improper payments remain an issue

• Homecare E-News, Issue 47, November 30, 2015

  The U.S. Department of Health and Human Services released its Agency Financial Report for fiscal...

Weekly Roundup

• Homecare E-News, Issue 47, November 30, 2015

  Assisted- and independent-living centers can be attractive places to do business for the home...

Inside Story | The role of the care plan and visit notes in maintaining a compliant clinical record

• Homecare E-News, Issue 43, November 2, 2015

  The written care plan is not simply busywork. It is essential in the organization, delivery...

What should be our frequency of visits?

• Homecare Q&A, Issue 18, September 17, 2015

   We have an 87-year-old woman who was referred by the wound care center for care of a wound...

We discharged a patient who then resumed services. Are we going to have troubles receiving reimbursement?

• Homecare Q&A, Issue 17, September 8, 2015

  If an agency discharges a patient and that patient resumes services, there may be questions about...

Can we provide two home health aides to provide care for a quadriplegic patient?

• Homecare Q&A, Issue 15, August 3, 2015

  Yes, Medicare will cover two visits if two individuals are needed to perform a covered service...

If the patient does not require a skilled bath, can our agency continue to provide this under the state personal care program?

• Homecare Q&A, Issue 15, August 3, 2015

  Medicare doesn’t differentiate between skilled and unskilled personal care because there...

Can a social worker make just one visit to a patient?

• Homecare Q&A, Issue 15, August 3, 2015

  If the patient qualifies for medical social services, the social worker can make one visit if...

Is it true that in order for a patient to receive social services under Medicare, that patient must have a skilled need requiring a nurse or a therapist?

• Homecare Q&A, Issue 15, August 3, 2015

  Yes, it’s true. Medical social services and home health aide services are considered...

Is it true that instead of discharging patients when goals are met, we can recertify them under management and evaluation?

• Homecare Q&A, Issue 15, August 3, 2015

  What this agency heard is in error and could lead to denials. Just as with any Medicare-covered...

When do we ever admit patients and not teach them?

• Homecare Q&A, Issue 15, August 3, 2015

  There are very few times that a clinician will admit a patient and not complete some teaching...

Will Medicare cover nursing services twice daily for a PICC line flush and dressing change?

• Homecare Q&A, Issue 15, August 3, 2015

  Flushing a peripherally inserted central catheter (PICC) line does indeed require the skills of a...

If the patient has an ostomy, cannot change it, and there are no caregivers to learn, does the agency stay in indefinitely?

• Homecare Q&A, Issue 15, August 3, 2015

  Changing an ostomy bag, even if the patient can’t do it and there’s no caregiver...

When does Medicare consider a wound as chronic/nonhealing and no longer pays for services?

• Homecare Q&A, Issue 15, August 3, 2015

  You won’t find any mention in the Medicare coverage criteria about chronic or nonhealing...

I have read that CMS in 2015 has added to the Medicare manual that physicians need to estimate how much longer the skilled services will be required. Is there any clarification on this, and are we seeing any claims being denied due to this?

• Homecare Q&A, Issue 14, July 16, 2015

  According to the final rule for 2015, physicians must state the length of skilled services for...

Homecare Q&A

• Homecare Q&A, Issue 13, July 2, 2015

  July 3, 2015

What does Patient Care 484.60: Care Planning, Coordination of Services and Quality of Care mean for agencies?

• Homecare Q&A, Issue 8, June 9, 2015

   First, let’s review for everyone reading what the current CoP is and what is being...

When there is a patient who might be a candidate for maintenance therapy, how do we conduct a proper assessment to determine what kind of therapy is needed?

• Homecare Q&A, Issue 0, June 9, 2015

  Although the diagnosis and the functional limitations do not stand alone in determining the medical...

If the physician orders vital signs, blood sugar monitoring, and/or pulse oximetry, do we need acceptable parameters on the plan of care?

• Homecare Q&A, Issue 11, June 3, 2015

  If the physician orders vital signs, blood sugar monitoring, and/or pulse oximetry, do we need...

Is okay to use a range when defining visit frequency?

• Homecare Q&A, Issue 11, June 3, 2015

  Will you please clarify whether or not it is okay to use a range when defining visit frequency? For...

How are we supposed to use observation and assessment for patients on telemonitoring?

• Homecare Q&A, Issue 10, May 17, 2015

  How are we supposed to use observation and assessment for patients on telemonitoring?

How can extended daily visits be justified and covered?

• Homecare Q&A, Issue 10, May 17, 2015

  How can extended daily visits be justified and covered?

Can we use "zero" as a frequency in writing physician orders?

• Homecare Q&A, Issue 10, May 17, 2015

  Can we use “zero” as a frequency in writing physician orders? For example, physical...

Can a single physical therapy visit determine a need for occupational therapy that is covered under Medicare?

• Homecare Q&A, Issue 10, May 17, 2015

  Can a single physical therapy visit determine a need for occupational therapy that is covered under...

What are the new therapy reassessment requirements that CMS solidified in its 2015 PPS final rule?

• Homecare Q&A, Issue 10, May 17, 2015

  What are the new therapy reassessment requirements that CMS solidified in its 2015 PPS final rule...

What does the proposed standard Patient Care 485.65: Quality Assessment & Performance Improvement mean for my agency?

• Homecare Q&A, Issue 9, May 3, 2015

  My agency has been reviewing the proposed Conditions of Participation (CoP). We are looking at the...

How do we get paid when we have two different payers?traditional Medicare (Part A) and MA?within the same 60-day episode?

• Homecare Q&A, Issue 9, May 3, 2015

  How do we get paid when we have two different payers—traditional Medicare (Part A) and...

What happens to patients who can self-inject but cannot pre-fill insulin syringes?

• Homecare Q&A, Issue 9, May 3, 2015

  What happens to patients who can self-inject but cannot pre-fill insulin syringes?

When does Medicare consider a wound as chronic/nonhealing and no longer pay for services?

• Homecare Q&A, Issue 9, May 3, 2015

  When does Medicare consider a wound as chronic/nonhealing and no longer pay for services?

Is it an appropriate use of Medicare to do three weeks of assessment and venipuncture for a patient hospitalized with deep vein thrombosis (DVT)?

• Homecare Q&A, Issue 9, May 3, 2015

  Is it an appropriate use of Medicare to do three weeks of assessment and venipuncture for a patient...

Can we get an MD order for a new start of care (SOC) date based on the patient request?

• Homecare Q&A, Issue 9, May 3, 2015

  Regarding M0102 and M0104: We received a referral and we contacted the patient within the...

Where in the CMS guidelines does it indicate that there should be short-term and longterm goals for therapy?

• Homecare Q&A, Issue 7, April 3, 2015

  Palmetto and CGS have specific local coverage determinations (LCD) regarding shortand long-term...

Does the start of the VFOs for the HCA need to begin on the day of the new cert period, or can it begin the following week?

• Homecare Q&A, Issue 7, April 3, 2015

  You can write orders for when the services begin.

How do you encourage reporting and open communication?

• Homecare Q&A, Issue 6, March 17, 2015

  What you are looking for is a nonpunitive, “just” culture for your agency, or a...

Is a patient who is toileted every two hours covered under Medicare?

• Homecare Q&A, Issue 6, March 17, 2015

  In combination, the nurse and HHA can provide up to 35 hours a week in medically necessary...

Is it true that the physical therapist has to make a visit no less than once every two weeks when a physical therapy assistant is involved with the same case and primarily doing most visits?

• Homecare Q&A, Issue 5, March 3, 2015

  On the federal level, the CoPs/ Medicare Benefit Policy Manual states that for all certified...

Will home health remain exempt from overtime compensation in most circumstances like it has for 40 years?

• Homecare Insider, Issue 1, January 5, 2015

  Will home health remain exempt from overtime compensation in most circumstances like it has for 40...