File this one under “lesson learned…the hard way.” Incorporate it into your next staff training. This agency properly followed the government’s appeal procedure after receiving a notice of payment denial. Excerpts below show that the administrative law judge did not find the provider’s care lacking, just its paperwork. That is correct, it is not merely an old cliché. The job is still not finished until the paperwork is done…and submitted.
After studying descriptions of the patient assessment and care plan, try to determine why payment for this episode was denied by the RHHI and why both QIC and ALJ agreed.
Patient Background
- One HHPPS episode provided, 59 days, to 72-year old female.
- Diagnoses: osteoarthritis of lower let, difficulty walking, diabetes type II uncontrolled, hypertension, esophageal reflux and hypothyroidism.
- History of falls without injury
- Functional limitations: endurance, ambulation, shortness of breath on moderate exertion, poor vision.
- Patient oriented, forgetful, anxious.
- Referral made by primary care physician due to exacerbation of osteoarthritis and increase in knee pain. Physician prescribed Celebrex and ibuprofen.
- Son/daughter available to assist with all activities of daily living, monitor blood glucose level.
Care Background
- SN for observation, assessment and education on new medication regimen.
- Physical therapy evaluation determined patient needed assistance to walk at home. She could walk 25-30 feet with a cane and stand-by assistance and displayed an unsteady gait.
- PT provided therapeutic exercise, transfer therapy, gait training, balance training, ultrasound and muscle re-education.
- SN provided education on disease process and assessment for medication compliance and response.
- Patient missed or canceled last three scheduled weekly SN visit appointments and was discharged, one week after the final cancellation, with goals met.
- At discharge, blood pressure and blood glucose levels were stable.
The ALJ Decision
- Celebrex and ibuprofen do not constitute a change in the patient’s treatment regimen requiring SN services.
- Skilled nurse provided nothing more than observation of a chronic condition.
- Patient, with daughter’s help, was able to monitor her own blood glucose levels.
- Three successive canceled visits indicates SN was little needed.
- “The record does not support the medical reasonableness and necessity of the SN services provided.”
- “The record does not indicate a functional decline requiring the skills of a PT.”
- “Physical therapist checked a box at each intervention but provided no description of the specific interventions provided. Thus, it is unknown if the skills of a therapist were required.”
As can be seen, the ALJ made no determination as to whether the patient had shown some improvement over the course of the episode. No judgment was made that the provider did not provide necessary services. Neither the skills of the nurse nor the therapist were called into question. The judge does not even specifically state that the care itself was not reasonable and necessary.
This judge referenced the condition of participation known as G-tag 161. “Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration.” To quote from the judge’s final conclusion, with emphasis added, “The record does not establish the medical reasonableness and necessity of the services provided…”
In this case, it is the lack of comprehensive, compelling documentation that is the primary driver for payment denial. To clinicians who say, “I may not write it down well but I provide excellent care,” ALJ’s are beginning to say, “if you expect to be paid for your excellent care, you had better learn to write it down well.”
