Home Health & Hospice

Q: Our patient has a continuing problem with medication compliance and we continue to teach on it. We were then issued a denial. Why would that happen when he clearly needs the teaching?

Homecare Insider, July 22, 2013

 

Q: Our patient has a continuing problem with medication compliance. The nurse repeats the same instruction multiple times and includes the caregiver. The patient does not adhere to the instructions provided. That said, we continue to teach on medication compliance. We are then issued a denial. Why would that happen when he clearly needs the teaching?

A:  Two common reasons for denials related to teaching are as follows:

  • The nurse teaches even though there is no evidence to show that the patient needs the instruction. Most likely, the agency has a policy that the nurse must document some teaching every visit without regard to what the patient needs. In the absence of an identified knowledge deficit, this teaching is not considered reasonable and necessary.
  • The nurse continues to teach about the same problem even though there is no modification in the patient’s behavior.

The second reason fits your situation to a tee. The Medicare Benefit Policy Manual states, “When it becomes apparent after a reasonable period of time that the patient will not be able to be trained, then further teaching ceases to be reasonable and necessary.”

Your agency needs to instruct its nurses on three important points:

  • Teaching is reasonable and necessary if it requires the skills of a nurse to teach the patient or caregiver how to manage the treatment regimen or disease process. Teaching must be appropriate to the patient’s functional loss, illness, or injury.
  • The skill in teaching a patient is in the act of teaching and not the subject taught. For example, teaching foot care to a newly diagnosed diabetic patient requires the skills of a nurse.
  • Follow the teaching-learning process to show that teaching is reasonable and necessary.

You have to know the rules inside and out. There is no hard-and-fast rule like “all teaching is reasonable and necessary.” Use all resources you have, including manuals, to make sure something that has become routine is really compliant.

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