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EZ Pathways
Patient Education
OASIS
Documentation
Expedited Review
Home Health Advance Beneficiary Notice (HHABN)
National Patient Safety Goals (NPSG)
EZ Pathways
Q: What makes EZ Pathways different from other pathways?
A: EZ Pathways are much easier to implement and use than other complicated pathways. You can see from visit to visit how well your patients are learning and improving.
Q: Do you have pathways for all of the diagnoses?
A: There are 17 nursing and 13 rehab pathways, taking care of most major diagnoses.
Q: Does the customer have to license EZ Pathways like some other available pathways?
A: When you purchase the Success Kit, you then decide which and how many pathways you want to purchase.
Q: What if the patient has a secondary diagnosis?
A: Secondary diagnoses, or co-morbidities, are addressed on the pathway you would utilize as your primary reason for providing home care. Regarding
co-morbidities or secondary diagnoses, most nurses teach through medication, which can be addressed on any of the pathway notes.
Q: How do you track variances?
A: By reviewing the pathway visit notes, you can quickly see which variances are being used, if they are appropriate and if the patient is meeting the goals. Further information on this subject is found on the training CD as well as in the Manager’s Reference booklet.
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Patient Education
Q: Do I use the Step by Step patient education instead of a pathway?
A: Step by Step is designed to be used in conjunction with a pathway. They are disease-specific and allow clinicians to focus on the patient’s identified and most important needs. The Step by Step, as well as the pathway teaching sheet, stays in the home with the patient.
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OASIS
Q: How are the new NPI (National Provider Identifier), UPIN (Unique Physician Identification Number) and Current Provider Number recorded on the OASIS?
A: Home health agencies may record the physician NPI on OASIS M0072 (Primary Referring Physician ID) OR may continue to record the physician UPIN since CMS will not edit this OASIS data element for an NPI. OR, agencies may continue to respond “Unknown” to M0072.
For the time being home health agencies must continue
to record their current provider number (now called the CCN) on OASIS at M0010
(Agency Medicare Provider Number) since M0010 does not have sufficient spaces to
accommodate an NPI. Changes to M0010 requirements will be not be implemented
until the next major overhaul of OASIS sometime in the future. [source:
NAHC Regulatory Affairs, listserve post on May 15, 2007]
Q: For a one-visit Medicare Prospective Payment System (PPS) patient, is Reason for Assessment (RFA) 1 the appropriate response for MO100?
A: For a one-visit Medicare PPS patient, the OASIS data should be encoded to generate a Health Insurance Prospective Payment System (HIPPS) code and transmitted to the state system. No discharge assessment is required, as the patient received only one visit. Agency clinical documentation should note that no further visits occurred.
Q: Are there any assessments that can be used for completing a 485, which does not have the OASIS elements?
A: We have non-OASIS assessments for the Start of Care, recertification/update and discharge, which all have the 485 locators to help with data entry. Our comprehensive pediatric assessment also has the 485 locators on it.
Q: Where can I find a 485 worksheet?
A: Each of our OASIS forms has a 485 worksheet attached.
Q: If a home health agency misses the recertification assessment window of 55-60, yet continues to provide skilled services to the Medicare patient, is the agency required to discharge and readmit the patient?
A: When an agency does not complete a recertification assessment within the five-day window, at the end of the certification period the agency should not discharge and readmit the patient. Rather, the agency should send a clinician to perform the recertification assessment as soon as the oversight is identified. The date assessment is completed (MO900) should be reported as the actual date of the assessment, with documentation in the clinical record of the circumstances surrounding the late completion.
Q: Home health patients may return to the hospital after a single visit. Some home health agencies treat these as one-time only visits, do not collect OASIS data, and do not bill the Medicare program. Is this acceptable?
A: Yes, this is acceptable. The scenario appears to fit the criteria for one-time only visits for start of care (SOC) or resumption of care (ROC) visits that became effective December of 2002. Each patient must receive a comprehensive assessment. The agency is not required to assess the OASIS items or encode and submit the assessment. This assessment can be placed in the clinical record for documentation and planning purposes.
Q: A patient is hospitalized and comes back to the agency on day 56. Which assessment do we complete—an Resumption of Care (ROC), a follow-up or both?
A: Effective 10-1-2004, the rules for the simplified method of handling a Significant Change in Condition (SCIC) following an in-patient facility stay during the last five days of an episode were updated. The ROC assessment should be completed, and the MO825 should forecast the subsequent episode. You can find instructions for handling this type of situation by going to www.cms.hhs.gov/OASIS/08_OASISPPS and scrolling down to “OASIS Considerations for Medicare PPS Patients”.
Q: Is MO150 limited to payment for homecare services? If a patient had out-of-pocket expenses for Durable Medical Equipment (DME) or medications, should response ‘10’ (Self Pay) be marked?
A: If equipment or medications essential or integral to the home care episode are being paid by the patient, in part or in full, then response ‘10’ should be marked.
Q: In MO250, does the central line or subcutaneous infusion or epidural infusion or intrathecal infusion or an insulin pump or home dialysis, including peritoneal dialysis, count in responding?
A: Only one question must be answered to determine whether these examples ”count„ as IV or infusion therapy—is the patient receiving such therapy at home? If the answer is yes, then response ‘1’ (intravenous or infusion therapy, excluding total parenteral nutrition (TPN) for MO250 would be appropriate. If the infusion therapy is administered by the physician's office, outpatient center or dialysis center, response ‘4’ (none of the above) should be marked.
Q: If a patient has experienced episodes of recent confusion, but does not demonstrate or report any episodes of confusion the day of the assessment, would the patient be considered ”never„ confused in MO570? Or should the recent history of confusion be considered when responding to the MO570?
A: Information collected from patient or caregiver reports can be utilized in responding to MO570. This includes reports that extend beyond the day of the assessment into the recent past. Therefore, if the patient or family reports that the patient has experienced periods of confusion while awakening over the last week, it would be appropriate to mark ‘2’ for MO570, even if no confusion was experienced the day of the assessment. This same strategy of utilizing reported information from the recent past also applies to scoring of anxiety in MO580 and depressive feelings in MO590.
Q: Which OASIS form do I use for a SCIC with a hospital stay?
A: If it occurs with a hospital stay during (but not at the end of) a current 60-day episode, then you would complete an Resumption of Care. The choice for the Reason for Assessment (RFA) would be ‘3’ Resumption of Care (after inpatient stay). Briggs Form 3491P, click here.
Q: Which OASIS form do I use for a SCIC without a hospital stay?
A: This would be “Other Follow-Up” RFA ‘5’. Briggs Form 3492P, click here.
Q: A patient was admitted to the hospital after going to the ER. The patient returned home after a hospital inpatient stay of less than 24 hours. Does the agency complete the Transfer OASIS assessment and the ROC OASIS assessment?
A: Guidance for MO100 in Chapter 8 includes the following guidance: “The comprehensive assessment is conducted when the patient resumes care following an in-patient stay of 24 hours or longer (for reasons other than diagnostic tests)”. You would not need to complete the Transfer and the ROC OASIS according to this information, but still document the events in the patient’s clinical record. Consider if the events indicate a need for RFA ‘5’ (other follow-up).
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Documentation
Q: Where can I find Conditions of Participation (CoP), The Joint Commission and Community Health Accreditation Program (CHAP) crosswalks for regulations and standards?
A: We have current CoP, The Joint Commission and CHAP crosswalks in both our Home Care and Hospice
Documentation Systems. Not only do we have the crosswalks, but with each form in
the manual, the applicable CoP and accreditation standards crosswalks are also
shown.
Q: Do you have a form that can be used strictly for wound care?
A: Stock No. 3466P, Wound Assessment and Care Tool with
Braden
Scale. Click here.
Q: Does Briggs have competency checklists available?
A: We have a Home Health Personnel policy manual that includes personnel policies,
job descriptions, competency training and evaluation for pre-employment and
annual competency training. Click here.
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Expedited Review
Q: Do you have available the generic and detailed notices of expedited review that the Centers for Medicare and Medicaid (CMS) issued?
A: Those
Expedited Review forms became mandatory July 1, 2005. They
are Briggs
Forms, CMS-10123 and CMS-10124.
Q: Is there a policy for the new expedited review notice?
A: Yes. For an article discussing the Expedited Review and a sample policy that can be incorporated into the operational policies you currently have, click here.
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Home Health Advance Beneficiary Notice (HHABN)
Q: We have orders for SN 3 wk 9 for wound care. Wound improves after three weeks and the patient only needs SN 2 times a week for the remaining 6 weeks, so the physician orders the decrease. Do we need to issue an HHABN? If so, which option?
A: HHABN, Option Box 3 would be issued since the reduction is related to physician orders.
Q: There is a scheduling error and a visit is missed and not made up that week. Is an HHABN needed and if so which option?
A: No HHABN, this is an unplanned event and not a true reduction in the
plan of care.
Q: At the start of care, the patient needs Medicare covered skilled nursing and aides. The patient is incontinent and needs incontinence supplies. These will be provided during the course of the SN or aide visits, but not left for use in between visits because they are not Medicare covered. The patient does not have another insurance to pay for them. Is an HHABN needed and if so which option?
A: No HHABN unless the patient wants to pay for additional supplies out-of-pocket and has a physician’s order for them. Then an HHABN will be required at all the triggering events.
Q: Patient needs a Medicare covered skilled nursing service monthly. Also needs medication box prefilled weekly. The visits only to prefill will be billed to Medicaid. Is an HHABN needed and if so which option?
A: Since Medicare is paying for some of the care you will have to issue an HHABN for the Medicaid covered services at all of the triggering time points until Medicare coverage ends.
Q: A patient is discharged from the agency because outpatient therapy services are starting. This is a multiple discipline case. The SN is discharging today, prior to the end of the visit schedule so she will issue an Option Box 3. PT will discharge with goals met and perform the agency discharge next week prior to the start up of outpatient services. From what I understand, the agency discharge with goals met will result in no HHABN and just the Medicare discharge notice. Is this correct?
A: That is correct, since all Medicare covered services are ending, the Expedited Determination notice will be sufficient notice.
Q: Why is a HHABN required for recertification when there is a decrease in the frequency? A recertification is a new plan of care, why wouldn’t the process start over? Technically, the original POC ended when the 60 day episode ended. Subsequently, explain why we would need to issue an HHABN upon resumption of care.
A: CMS’s position is patients at recertification and resumption of carewill expect care to continue at the level of the original plan of care unless notified. If visits are reduced at these time points (recertification/resumption of care) then the agency must give written notice in the form of an HHABN.
Q: If a patient is a Medicare beneficiary but we will be billing Medicaid for SN and waiver for aide services, because he/she is not homebound or it is not a Medicare skill, would an HHABN be required and if it is, how often?
A: An Option Box 1 will be required at initiation, and renewed annually for medical services provided where a third party, other than Medicare, even Medicaid
is the payer.
Q: An HHABN is required if goals are met early for one discipline but the other discipline continues care. But, if SN and PT are both in, and PT is no longer progressing and the physician agrees, is a HHABN required? What if the family does not agree with the PT and feels the patient is progressing? Please explain.
A: If the PT ends earlier than written on the POC, the MD agrees, and other covered services are continuing, for example, SN, then an HHABN, Option 3 would be required. If the family insists the therapy continue and the MD agrees to write orders for continued therapy, and HHABN Option 1 will have to be issued since you would be providing care that Medicare may not cover (not reasonable and necessary).
Q: If a physician discharges the patient even if the patient still has skilled need, and all services are ending, would we be required to give the Expedited Determination notice only or Option 3 of the HHABN (lack of physician orders) or both?
A: An expedited determination notice would be issued since Medicare covered care ends when there are no physician orders for care.
Q: Can you give an example of when an HHABN is required on initiation of Medicare non-covered items or services?
A: An HHABN would be required on initiation of care that is provided for which you know or believe Medicare will cover, such as personal care services provided by the agency and paid for by Medicaid or any other third party payer.
Q: If Medicare is the secondary payer, does the patient need an HHABN?
A: If Medicare is paying for any of the services then the HHABN will apply at all triggering events for those services which Medicare is paying. If a patient has Medicare as a secondary insurance, yet another insurance is primary and paying for all care, then the HHABN, Option 1, would be required at initiation only.
Q: Does “unplanned situation” include the physician making the decision to discharge services at a physician visit?
A: A patient unexpectedly discharged by a physician is not considered an unplanned occurrence for the purpose for the purpose of the notice requirement. In this case, since all Medicare covered care would be ending the Expedited Determination Notice would be required. If some non-covered care were to continue then an HHABN, Option 1 would also have to be provided.
Q: Are both notices: an Expedited Determination Notice and the HHABN necessary in all unplanned discharges?
A: The Expedited Determination Notice and the HHABN are provided together only when all Medicare covered services are ending but some non-covered care will be provided/continue. For example, all skilled nursing care will end and the home care aide will also have to end. The patient, however, wants the home care aide to continue and will pay out of pocket for the services. The Expedited Determination Notice is provided to allow the beneficiary an appeal process for ending Medicare covered services and the HHABN is provided to inform the beneficiary that Medicare will not cover the home care aide, and what the charges will be. This allows the beneficiary to make an informed decision regarding whether to receive the non-covered care. If there is no other non-covered care continuing the Expedited Determination Notice is the only notice required when all Medicare covered services are ending regardless of whether the discharge is planned or not.
Q: If the patient is transferred to the hospital, there is no need to deliver the HHABN. When the patient returns to the agency two weeks later, the ROC SN frequency is reduced from the original plan of care is an HHABN required?
A: Yes, an HHABN would be required if the ROC frequency was less than the original Plan Of Care. Option Box 3 would be provided since the reduction is related to physican orders.
Q: We have a DME company that is part of our Home Health Company that has a different provider number for Medicare. Would we be required to deliver a HHABN to Medicare DME Patients?
A: If the DME division is billing their supplier number, the HHA is not billing for the DME, the HHABN would not apply. The DME company would be required to provide any advance beneficiary notice related to Medicare non-coverage.
Q: Since we do not charge the beneficiary for wound care supplies, is an HHABN required?
A: An HHABN will have to be given for supplies, even if there is no charge. Supplies are part of home health services that are subject to the HHABN requirements at all triggering events, regardless of charges.
Q: If you are terminating services due to patient non-compliance, would you still need to issue an HHABN even though ALL services are being discontinued? Would you not instead deliver an Expedited Determination Notice?
A: Since the discharge of a non-compliant patient is an agency decision, and the patient may still be in need of skilled care, an HHABN, Option 2 would be issued. The patient has the option of choosing another agency and to comply with a treatment plan.
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National Patient Safety Goals (NPSG)
Q: As a home care agency, are we responsible to provide a list of reconciled medications to the primary physician upon discharge from the agency?
A: NPSG 8B EP.1 does require an “accurate medication reconciliation list to be communicated to the next provider of service”. In the circumstances of most home health care organizations, this does require the list to be provided to the primary care physician and any other consulting physician or service involved in the patient’s care, such as out-patient therapy.
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