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4/20/2009
Medic<strong>are</strong> Coverage Guidelines Part IV
Don’t letM&Ebecome
an En.em.y
Diane Taylor, BSN, RN, COS-C
Selman Holman & Assoc
Identify at least 2 situations when management
and evaluation is the absolute right thing to do
Verbalize the necessary steps to provide
excellent oversight of the patient’s complicated
unskilled plan of c<strong>are</strong>
Identify at least 3 key points to consider when
deciding if management and evaluation is
necessary
Clinicians will be able to identify the most
important points for writing an M& E note to
assure reimbursement (Hint: documentation,
documentation, documentation).
Patients that <strong>are</strong> on service for Management
& Evaluation must meet all criteria for
homebound status
◦ Experiences a considerable taxing effort due to
physical condition and/or physical limitation
◦ Psychiatric illness which manifests in a refusal to
leave the home
◦ The need for supportive devices or assistance does
not necessarily render the patient homebound
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Frequent absences from the home when the
reason to leave is to receive medical
treatment
Brief and infrequent absences from the home
for non medical reason (i.e. hair c<strong>are</strong>, walk
around the block, etc.)
Religious services
Attendance at an Adult Day C<strong>are</strong>
Frequent
absences from
the home for
◦ Social reasons
◦ Shopping
◦ Business purposes
◦ Attends adult day
c<strong>are</strong> for non
medical purposes
The patient to be under the c<strong>are</strong> of a
physician that is able to sign the Plan of C<strong>are</strong>
◦ Medical Doctor
◦ Osteopath
◦ Podiatrist
◦ Psychiatrist
Remember…as of May 24, 1996 psychiatric services
may be ordered by an MD. The psychiatric services
need to be rendered by a qualified psych nurse.
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Medically reasonable and necessary to the
treatment of a patient’s illness or injury
Nursing need must meet the definition for
intermittent
The terminology “Skilled Management and
Evaluation” should be included in the orders
Requires that the beneficiary is:
Requires that the beneficiary meets the
Requires that the beneficiary meets his/her
obligation towards
Skilled Observation
and Assessment
Teaching and
Training
Administration of
Medication
Diabetic C<strong>are</strong>
Wound C<strong>are</strong>
Psychiatric Nursing
Therapy
UGS
Management
& Evaluation
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4/20/2009
Skilled nursing or physical therapy visits for
management and evaluation of the
beneficiary’s c<strong>are</strong> plan <strong>are</strong> reasonable and
necessary w<strong>here</strong> underlying conditions or
complications require that only a registered
nurse or physical therapist can ensure that
essential non skilled c<strong>are</strong> is achieving its
purpose.
Palmetto
Management and evaluation of a patient’s c<strong>are</strong> plan.
Skilled nursing visits for management and
evaluation of the patient’s c<strong>are</strong> plan <strong>are</strong> also
reasonable and necessary w<strong>here</strong> underlying
conditions or complications require that only a
registered nurse can ensure that essential non-skilled
c<strong>are</strong> is achieving its purpose. To be reasonable and
necessary the complexity of the necessary unskilled
services that <strong>are</strong> a necessary part of the medical
treatment must require the involvement of licensed
nurses to promote the patient’s recovery and medical
safety in view of the patient’s overall condition.
UGS
To justify Management and Evaluation the
beneficiary’s c<strong>are</strong> plan has to be complex.
1. Management of the unskilled services being
provided
2. Evaluation of the effectiveness of the unskilled
services,
3. Oversight to avoid complications
The unskilled services must be part of the
medical treatment plan
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4/20/2009
1. Plan of C<strong>are</strong> (POC): Orders received from
and signed by the physician. The plan of c<strong>are</strong>
may include medication regimen, medical
treatments, frequency of visits for each
discipline, etc.
2. C<strong>are</strong> Plan: Developed by RN or PT so that
non skilled staff have direction to provide
c<strong>are</strong>. Goals/outcomes <strong>are</strong> stated in
measureable terms so that RN/PT is able to
assess the effectiveness of the c<strong>are</strong> plan.
Patient’s Condition
+ Medical Needs
+ Treatment Regimen
+ Potential for Serious Complications
+ Complexity of
Non Skilled C<strong>are</strong> =
Supportive documentation for the skill of
Management and Evaluation
Management & Evaluation is the skill to use
when a patient’s c<strong>are</strong> plan is unstable.
That’s difficult for us
◦ It’s not a ‘tangible’ skill
◦ M & E is so automatic to nursing
• However, you need to take credit (DOCUMENT) for
what you do
Nursing or PT is involved to ensure the safety
and effectiveness of the home health plan of
c<strong>are</strong>.
It is this unstable c<strong>are</strong> plan that must be
presented in the documentation to assure
coverage by Medic<strong>are</strong>.
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4/20/2009
1. What would happen to this patient if the plan
of c<strong>are</strong> is not implemented correctly?
Would the patient be a risk for:
• Hospitalization?
• Exacerbation?
• Premature placement in a LTC
facility?
2. What makes the ‘unskilled’ part
of the patient’s plan of c<strong>are</strong> so
complex that oversight by an
RN or therapist is necessary?
Multiple physicians involved with POC and no one
physician is taking the lead responsibility
Many unskilled tasks necessary to ensure good
outcome(s) for the patient
GT Feedings
Frequent Turning
Titration of Medications
Skin inspections
Pro active in general!!!
Multiple family members assisting with
c<strong>are</strong>
Multiple unskilled providers/aides
assisting with c<strong>are</strong>.
Patient does not have stable living
conditions
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4/20/2009
OASIS assessment
M0340 Patient Lives With ( Mark all that apply)
0350-Assisting Person(s) Other than Home C<strong>are</strong>
Agency Staff (Mark all that apply)
360 Primary C<strong>are</strong>giver taking lead responsibility
for providing or managing the patient's c<strong>are</strong>,
providing the most frequent assistance, etc.
(other than home c<strong>are</strong> agency staff)
Just to name a few
Patient has history of multiple re
hospitalizations---Define multiple…
C<strong>are</strong>giver Behaviors that may be a concern…
M0360 Primary C<strong>are</strong>giver
M0380 Community Services involved
M0520 Urinary Incontinence
M0540 Bowel Incontinence Frequency
M0780, 790, Management of Oral / Inhalant
Meds
M0810 Patient management of equipment …
Functional Score
M0800 Management of Injectable
Medications: Patient's ability to prep<strong>are</strong> and
take all prescribed injectable medications
reliably and safely, including administration
of correct dosage at the appropriate
times/intervals. Excludes IV medications.
If this is a concern the patient would qualify
for home health under the medication
administration benefit.
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4/20/2009
Or
Right Here
Assessment
Diagnosis
Plan
Evaluation
Project outcomes
patient may
experience without
POC oversight
Unstable C<strong>are</strong> Plan
Provide the skill of
Management &
Evaluation
Revise accordingly
For those of you that didn’t get it……
That was a BLAST from the past!!!!
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4/20/2009
The entire OASIS
assessment
should be
utilized to
support the
need for M & E.
◦ Living
Environment
◦ C<strong>are</strong>givers
◦ Therapies Rec’d
@ Home
◦ Cognition
◦ Clinical Status
◦ Functional Status
◦ Management of
Medications
◦ Management of
Household Duties
Develop a standard “Intervention Statement”
to be listed on the 485.
“Intervention Statement” will need to be
individualized for each patient.
Be sure to address the skills that will be
performed that <strong>are</strong> specific to M & E.
1. RN required for skilled management to meet
the patient’s medical needs, promote
recovery and ensure medical safety
2. Evaluate dietary compliance and response,
including nutrition and hydration status
3. Evaluate mental/cognitive status for
behaviors and risks to safety
4. Evaluate patient/C/G understanding of
complications to report
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4/20/2009
5. Evaluate for increased risk or potential
complications due to the complexity of the
disease process or treatment regimen
6. Evaluate medication compliance and/or
instruct on any new/changed medications
7. Evaluate functional limitations and the
patient’s mobility
8. Evaluate the patient’s risks of immobility and
for falls
8. Coordinate and manage multiple and/or
complex unskilled services in the home
Patient will receive adequate c<strong>are</strong> to promote
recovery, ensure safety and prevent
hospitalizations and emergent c<strong>are</strong> for the
next 60 days
Goals must be individualized for each patient
The Plan of C<strong>are</strong> is being implemented as
ordered
The patient’s medical needs <strong>are</strong> being met
The patient’s environment is being monitored
to ensure medical safety and to promote
recovery
This will be part of your supportive
documentation necessary for M & E.
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4/20/2009
Date of Last Inpatient Stay
Type of Facility
Any updated information that may be
pertinent
t
Functional Limitations
Unusual Home/Social Environment
What medical conditions/
exacerbations is the patient
currently experiencing?
◦ What did the RN/PT do about
the stated issues?
◦ What were the outcomes?
Clearly state what the RN/PT did to
reduce the risk of a negative outcome
for the patient:
◦ What was done to reduce risk of
exacerbation of disease?
◦ What was done to ensure the patient’s
safety and health status?
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4/20/2009
Does the management of the
situation ti require an RN or PT?
Why can’t the patient’s
neighbor manage it?
Patients with multiple medical problems
Require high frequency of HHA for
assistance
May require other skilled services
Complications that may result <strong>are</strong>
considered as high risk issues and/ or
safety concerns
Multiple medications/High risk medications
Multiple or very restrictive functional
limitations
Cognition deficits that contribute to the
complexity of the patient’s c<strong>are</strong>
Deficits of some type that render the
patient in need of assistance with
◦ Social concerns
◦ Personal c<strong>are</strong>
◦ Community resources
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4/20/2009
T<strong>here</strong> is no set frequency to utilize
when providing the skill of
Management & Evaluation
A patient may utilize their Medic<strong>are</strong>
Home Health benefit to access
assistance with M & E as long as it is
warranted
It is up to the clinicians to present the
need for M & E through accurate and
thorough documentation
Let’s
look at
a few...
Sal Slaphappy, RN has been assigned to
admit Mr. Brooks to service. Sal returns to
the office and states, “T<strong>here</strong>’s nothing to get
this guy admitted. He doesn’t need any
services that we provide.”
You ask Sal to give you report.
Sal states, “Well, he’s on about 50 meds—all
spread out all over the house. All of the
meds <strong>are</strong> PO—you know we can’t go just to
pop pills in his mouth. The guy lives alone,
I think he’s starting to ‘slip a little’, if you
know what I mean.”
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4/20/2009
He’s got all kinds of people helping him out.
Someone helps with his personal c<strong>are</strong>,
someone else helps him with getting his
groceries. Of course he was complaining about
how they never show up and how they don’t do
what they <strong>are</strong> supposed to do.” “He has 3 kids
that all want to be in charge.”
The kids were all t<strong>here</strong> when I was trying to
admit him. I asked which one gets his meds
refilled and they all said, “I do!!”. I wanted to
ask, “If all of you order the meds then why <strong>are</strong>
4 of them empty??, but, I didn’t.”
“Anyway, the whole situation is a disaster. I
just don’t know what we could do for him.”
Management & Evaluation due to his unstable
Plan of C<strong>are</strong>
◦ Coordinate c<strong>are</strong>givers’ efforts to assure the c<strong>are</strong>
plan in place accomplishes the Plan of C<strong>are</strong> as
ordered by the physician
• Coordinate the purchasing of medications
• Communicate with physician(s)
i • Update Plan of C<strong>are</strong> PRN
• Monitor issues as related to memory disorder
• Coordinate c<strong>are</strong>givers to assure
• Necessary tasks <strong>are</strong> accomplished
• Services <strong>are</strong> not being duplicated and t<strong>here</strong>by wasted
Mary Taylor has been on your service for
3 recerts. She has had therapy and a
home health aide. Mary has
progressed well and has met all of the
goals that she and the therapist had
set. The therapist states that she will
need to discharge Mary at the end of
this cert. The therapist is concerned
about Mary living alone without the
assistance of home health. The
therapists reports that Mary is:
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Unable to coordinate the community
assistance that she receives as
evidenced by:
◦ Refusal to accept the meals that <strong>are</strong>
delivered to her home. Mary gets
confused and forgets that she
receives the meals everyday.
◦ Failure to contact agency that
provides an attendant to assist with
personal c<strong>are</strong> when attendant is a ‘no
show’.
◦ Calling the DME company to request that
they come and get the walker that they
‘must have mistakenly left at her house’.
◦ Preparing spoiled food for meals 4 times
within the last 2 weeks.
Unable to manage her medications
without assistance.
◦ Cannot order meds from pharmacy, cannot
fill pill pack as ordered.
Mary does not have anything that needs
to be
Observed and Assessed
Mary does not have the cognitive ability
to be
Taught or Trained
Mary does not have any medications
that would qualify for Medication
Administration under the home health
benefit
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4/20/2009
Mary’s not a diabetic so, she doesn’t
need
Diabetic C<strong>are</strong>
Mary doesn’t have any wounds that
would require
Wound C<strong>are</strong>
Mary does not have the cognitive
ability to benefit from
Psychiatric Nursing
Mary has progressed as much as she
will progress with
Therapy
Enlist the skills of management that
make you a professional!!
Manage the c<strong>are</strong> plan to assure:
The plan of c<strong>are</strong> is carried out as the
physician has prescribed
Essential non skilled c<strong>are</strong> is achieving
its purpose
Unskilled tasks necessary to achieve
good patient outcome(s) <strong>are</strong>
accomplished
M0110
M0230
M0250
M0390
M0420
M0450
M0460
M0474
M0488
M0490
M0540
M0650
M0660
M0670
M0680
M0690
M0700
M0800
M0826
M0240 x5 (possible)
M0246 x6 (would be
some crazy coding
but, possible)
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4/20/2009
M0110
M0230
M0240
M0250
M0300
M0360
M0380
M0520
M0540
M0780
M0790
M0810
Functional Score
questions
M0110 Episode Timing: Is
the Medic<strong>are</strong> home health
payment episode for which
this assessment will define
a case mix group an
“early” episode or a “later”
episode in the patient’s
current sequence of
adjacent
Medic<strong>are</strong> home health
payment episodes?
1 - Early
2 - Later
UK - Unknown
・NA - Not Applicable: No
Medic<strong>are</strong> case mix group
to be defined by this
assessment.・
M0110 Can be
used as
supportive
documentation
for M & E as
during the early
episodes as the
Qualified
Clinician works
to manage and
organize the
patient’s plan of
c<strong>are</strong>
M0230—chief reason for providing home
c<strong>are</strong>
M0240—include not only conditions actively
addressed in the patient’s plan of c<strong>are</strong> but
also any comorbidity affecting the patient’s
responsiveness to treatment and
rehabilitative prognosis, and outcomes even
if the condition is not the focus of any
home health treatment itself. Avoid listing
diagnoses that <strong>are</strong> of mere historical
interest and without impact on patient
progress or outcome.
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4/20/2009
The reason(s) why the patient is being
admitted could be supportive
documentation for M & E. The
clinician would need to consider other
factors as well.
‣Memory Disorder
‣Progressive/Degenerative Disease
‣Acute Illness
‣Chronic Illness
1) Intravenous or infusion therapy
(excludes TPN)
2) P<strong>are</strong>nteral nutrition (TPN or lipids)
3) Enteral nutrition (nasogastric,
gastrostomy, jejunostomy, or any
other artificial entry into the
alimentary canal)
4) None of the above
How will the patient coordinate and
manage these efforts?
Is patient or c<strong>are</strong>giver knowledgeable
with administration but, need
assistance with managing and
coordinating efforts of unskilled
disciplines to assure positive
outcomes?
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Current Residence:
□1 -Patient's owned or rented
residence (house, apartment, or
mobile home owned or rented by
patient/couple/significant other)
□2 2 -Family member's residence
□3 -Boarding home or rented room
□4 -Board and c<strong>are</strong> or assisted living
facility
□5 -Other (specify) ___________________
This question could be the basis for the clinician
to begin thinking about
M & E
or not!!
The clinician will be looking at the patient’s
complete situation
‣ positive aspects
‣ negative aspects
1-Lives alone
□2 -With spouse or significant other
□3 -With other family member
□4 -With a friend
□5 -With paid help (other than home
c<strong>are</strong> agency staff)
□6 -With other than above
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4/20/2009
Think about these answers….what
category would you list them in?
1. Skilled C<strong>are</strong>giver(s)
2. Unskilled C<strong>are</strong>giver(s)
3. Uhhhh…category??
M & E = Management of unskilled
c<strong>are</strong>givers to assure the c<strong>are</strong> plan is
carried out according to the
physician’s orders in the plan of c<strong>are</strong>
Mark all that apply
□1 -Relatives, friends, or neighbors living
outside the home
□2 -Person residing in the home (EXCLUDING
paid help)
□3 -Paid help Includes community-based
programs like Meals on Wheels (59)
□4 -None of the above [ If None of the above,
go to M0390 ]
*□UK -Unknown [ If Unknown, go to M0390 ]
**
* At discharge, change M0390 to M0410.
** At discharge, omit "UK - Unknown."
□0 -No one person [ If No one person, go to
M0390 ] *
□1 -Spouse or significant other
□2 -Daughter or son
□3 3 -Other family member
□4 -Friend or neighbor or community or church
member
□5 -Paid help
□UK -Unknown [ If Unknown, go to M0390 ] **
* At discharge, change M0390 to M0410.
** At discharge, omit "UK - Unknown.“
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1—ADL assistance
2—IADL assistance (meds, meals,
housekeeping…
3—environmental support (housing, home
maintenance)
4—psychosocial support (socialization,
companionship, recreation)
5—advocates or facilitates patient’s
participation in appropriate medical c<strong>are</strong> (dr
visits, refills)
6—financial agent, power of attorney, or
conservator of finance
7—health c<strong>are</strong> agent, conservator of person,
or medical power of attorney
UK
These questions could carry a lot of weight in
the supportive documentation category.
Results in effective
Management of POC
‣ M0560 through M0590, M0610, and M0620
address the patient’s neurological and
mental status.
‣ The objective of this portion of the patient
assessment is to determine those mental
processes or thoughts that interfere with
the individual’s d ability to reach optimal level l
of function. IMPORTANT FOR OUTCOMES!!
‣ M0570, M0580 and M0590 <strong>are</strong> questions
that look beyond 24 hours preceding the
assessment—Day of assessment and recent
history
‣ VERY IMPORTANT TO CONSIDER THIS
INFORMATION WHEN CONSIDERING
Management & Evaluation
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4/20/2009
‣ Functional Assessment includes OASIS
items (M0640 through M0820) and
addresses the patient’s functional status.
‣ Functional ability is an indicator of the
patient’s ability to remain in their home
setting.
‣ Functional ability typically requires
coordinated effort among disciplines to
achieve functional goals.
Management of
Medications...
consider all routes
of administration
M0780- Management of Oral Medications:
Patient's ability to prep<strong>are</strong> and take all
prescribed oral medications reliably and safely,
including administration of the correct dosage
at the appropriate times/intervals. Excludes
injectable and IV medications. (NOTE: This
refers to ability, not compliance or willingness.)
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M0790 Management of Inhalant/Mist
Medications: Patient's ability to prep<strong>are</strong> and
take all prescribed inhalant/mist medications
(nebulizers, metered dose devices) reliably and
safely, including administration of the correct
dosage at the appropriate times/intervals.
Excludes all other forms of medication (oral
tablets, injectable and IV medications)
M0800 Management of
Injectable Medications:
Patient's ability to
prep<strong>are</strong> and take all
prescribed injectable
medications reliably and
safely, including
administration of correct
dosage at the
appropriate
times/intervals. Excludes
IV medications.
Assess the
compliance or non
compliance with the
prescribed
medication regimen
If non compliance is
an issue how could
this be corrected?
Management &
Evaluation
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4/20/2009
Follow the prescribed c<strong>are</strong> plan as ordered in the
plan of c<strong>are</strong> to achieve
Management &
Evaluation
Lisa Selman-Holman
Selman-Holman & Associates, LLC
214.550.1477
Diane@selmanholman.com
www.selmanholman.com
l
Diane Taylor, BSN,RN, COS-C
940-300-9974
diane.taylor8491@yahoo.com
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