Worried about ADR’s and Denials based on the inability to effectively code your nursing visits? A nursing visit is no longer just a nursing visit. CMS has now mandated that more specific information regarding the sort of services being provided be present on all Home Health claims. Whether prepared or not, the 2011 PPS Rule mandates that you must code your claims correctly to avoid future problems. As we forge forward into the audit and denial era, care programs must be developed and delivered in accordance with the rules, and must be reasonable and necessary to be covered. Get up to speed with the following reference and quick guide for nursing.
G0154: Direct skilled services of a licensed nurse (RN or LPN) in the home health or hospice setting, each 15 minutes.
Some services can be considered skilled on the basis of complexity alone e.g.) intravenous and intramuscular injections or insertions of catheters as long as REASONABLE and NECESSARY to the treatment of the patient’s illness or injury.
HOT TOPIC: WOUND CARE –this appears to be a the focus of much confusion throughout the industry. Wound care is covered as skilled when it requires a nurse to provide safe and effective services to treat the illness or injury. Denials on wound care will be based on all documented findings. Look to next months nursing news letter on “Comprehensive wound documentation and coverage” for further insight.
The bottom line here is – just because a nurse does it, does NOT make it skilled. If the service can be performed by a nonmedical person, without the direct supervision of a nurse, the service cannot be considered a skilled nursing service. The skilled service must be reasonable and necessary to the diagnosis, treatment, patient’s illness or injury within the context of the patient centered medical condition. Your documentation must clearly demonstrate that this is the case.
G0164: Skilled services of a licensed nurse (RN or LPN) in the training and or education of a patient or family member, in the home health or hospice setting, each 15 minutes.
Skilled nursing visits for teaching and training activities are REASONABLE and NECESSARY where the teaching or training is appropriate to the patient’s functional loss, illness or injury. Keep in mind, where it becomes apparent after a reasonable period of time that the patient, family or caregiver will not, or are not able to be trained, then further instruction/training would NO LONGER be reasonable or necessary, and you can not keep performing this. Some examples of training and education would include but are not limited to:
-teaching of self administration of injectable meds
-teaching a NEWLY dx diabetic patient or caregiver on DM management
-teaching wound care
-teaching recent ostomy care
-self-cath teaching
-self-administration of enteral feedings
-bowel and bladder training when dysfunction exists
G0162: Skilled services by a licensed nurse (RN only) for the management and evaluation of the plan of care, each 15 minutes.
I think it is important to point out that this is an RN ONLY code first and foremost. Skilled nursing visits for the management and evaluation of the patient’s care plan are also reasonable and necessary when underlying conditions or complications require that ONLY a registered nurse can ensure that ESSENTIAL NONSKILLED care is achieving this purpose. Quite a difficult one to justify in past history. Your documentation must clearly justify the cause and effect here as to why a nonmedical person cannot do this, and the skill of an RN is required.
E.g.) A patient with a long history of DM recovering from a fracture and open reduction of the femur. The patient requires services about skin care, diabetic diet, oral medication compliance, and therapeutic exercises. Though a nonmedical person, if properly trained, could manage this, only a skilled person could understand the relationship among these services and the effects on each other until the condition stabilizes. Again, your documentation must show how the above situation is present on every visit you perform in order for this to apply. There must be a clear relationship between the management of the plan and why it requires the skill of a registered nurse.
G0163: Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient’s condition, each 15 minutes.
The services must be reasonable and necessary when the likelihood of change in a patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification or treatment or initiation of additional medical procedures until the patient’s treatment regimen essentially STABILIZES.
E.g.) Abnormal/fluctuating vitals
-weight changes
-changes in edema
-symptoms of drug toxicity
-abnormal/fluctuating lab values
-respiratory changes relevant to the patient’s medical condition
** Keep in mind: observation and assessment by a nurse IS NOT reasonable and necessary to the treatment of the illness or injury where these indications are part of a long standing pattern of the patient’s condition, and there is NO attempt to change the
treatment to resolve them.
Questions heard around the world of nursing…
“How do I code an admission/SOC?”, “What do I do when I am performing more than one thing on my visit?”, “Why do I have to do the billing decisions on my case?”
The answers are simple….You report the most appropriate G code for that visit which reflects the service for which most of your time was spent. This is inclusive of your admission. Know the facts, be responsible, only you will know what your most time was spent on and can assign the appropriate code to your visit. It is not solely a billing function; it is the accurate reflection of the services you provided and the documentation you submitted to justify the code. Remember to only code those visits with initial episode dates of 1-11-11 or later, or you will have your claims rejected by the F.I.
As discussed in previous articles, no longer is “A visit made, a visit paid”. This applies to the new G-code system and billing refinements as the Home Health model continues to evolve and refine.
The HHSM Nursing Newsletter is written by Kimberly A. McCormick, RN/BSN, Consultant of HHSM. Her expertise is based on sixteen years of homecare experience.
HHSM Newsletter Corrections
Thanks to readers who helped identify in-correct numbers included in the latest HHSM Newsletter; Part Two: Elements of the 2011 Final Rule. The 60-day episode rate decreased from 2312.94 (2010) to 2192.07 (2011); a 5.23% decrease. The Non-Routine Medical Supplies Conversion factor decreased from 53.34 (2010) to 52.54/51.50 (2011).