Medicare requires that all home health agencies create a comprehensive Plan of Care, also known as the CMS 485 form. This plan of care is required to contain information regarding the diagnoses treated, the medications patient takes, the frequency and duration of all services being rendered, and interventions and goals planned by the home health agency for the episode. More than a required document, the Plan of Care is literally a document outlining what the agency is going to do to get the patient well. This document also shows Medicare that the planned care is a 鈥渞easonable and necessary鈥� covered service under the Medicare benefit.[1]听According to the Office of the Inspector General (OIG), 听home health agencies are required to,鈥� assume that the adequacy of care beneficiaries receive is indicated, in part, by the extent to which their plan of care is appropriately developed and implemented.鈥�[2]
Although it is easy to create plans of care, all too often agencies lose the patient-centered vision and end up with 鈥渃ookie cutter鈥� plans of care. These care plans often have the same visit frequencies, vague interventions and un-measureable goals. They often also contain diagnosis codes that are not properly sequenced, and appear unrealistic. For example, I recently reviewed a plan of care for a patient whose primary diagnosis was COPD, unspecified, with an exacerbation date that was not supported by documentation in the notes nor on the Recertification OASIS assessment. The Plan of Care also showed a skilled nurse visit frequency of once a week for nine weeks (1w9). The plan of care had over 50 nursing interventions listed, which were vague, lengthy and not measurable. I was left wondering how the home health nurse was going to cover 50 interventions in 9 visits, and how the goals would be measured.
So how does an agency or clinician create a comprehensive, patient centered plan of care?
Start with a comprehensive admission assessment that is patient centered. Take time to get to know the patient鈥檚 听situation. This may require a little more investigation, querying the physician for more specific diagnoses, and focusing on the patient鈥檚 safety and knowledge deficits. Does the patient know the names of the medications he or she is taking? Is the patient knowledgeable about the side effects of these medications? Do they know what foods are allowed or disallowed on their therapeutic diet? What about the disease process s/s, what to report? If you find deficits, how do you address these on the plan of care?
It is not uncommon for clinicians and/or agency staff to create a plan of care with specific interventions. For example, we may use, 鈥淪N to teach on cardiac diet鈥�. The plan of care will be better suited and more patient specific if this intervention reads, 鈥淪N to instruct patient on rationale for following a cardiac diet, and 10 foods allowed and not allowed on this cardiac diet鈥�. 听Another example could be that the patient understands the action of his furosemide tablet, but doesn鈥檛 understand about the symptoms of low or high potassium( a side effect of the medication), which can occur as a result of taking furosemide. The 听care plan should be specific, and could be worded as, 鈥淪N to instruct patient on possible S/E of hyper or hypokalemia and 5 symptoms of each that require immediate reporting to health provider to prevent further complications鈥�.听 Goals should likewise be specific, such as, 鈥淧atient will verbalize 5-10 symptoms of hyper and or hypokalemia that require intervention by health provider by end of episode鈥�.
Patient frequencies should likewise be patient specific, and should show that we are planning to discharge the patient. When a patient comes home from the hospital, has a larger knowledge deficit, or has an unstable status, it is difficult to justify to Medicare that a 1w9 frequency is not a cookie cutter frequency. It would be better to increase the patient visits for a few weeks, provide extensive teaching and assessment, and then decrease the visits to show that you are planning to prepare the patient for discharge.
When adding therapies, be sure that documentation demonstrates why the care is indicated. Rather than saying, 鈥淧T TO EVAL AND TREAT鈥�, you could say, 鈥淧T to EVAL AND TREAT due to left hemi paresis with poor understanding of need to use walker and increased fall risk鈥�. Be sure the therapy plan of care is also comprehensive, specific, and documentation supports the interventions and goals as planned.
Finally, be sure you code to the highest specificity when possible. This may require querying the physician to get documentation on diagnosis. According to M. Therese Rode, querying should be performed, 鈥渨hen documentation is illegible, conflicting, incomplete, or ambiguous; when clinical indicators of a diagnosis (are noted) but no documentation of the condition or there is no cause and effect relationship between two conditions or organism鈥�[3]. If enough information is not available to code to a specific degree, ask the physician and clinician for more information, so that you can code correctly and appropriately.
Per Medicare guidelines[4], the condition requiring the most care or the focus of care given should be coded as primary, followed by the other diagnoses for which the agency will be performing interventions. We are also required to add co-morbid diagnoses that may affect the plan of care. Home health agencies must however be sure that these diagnoses are sequenced properly, and that each of the top 6 payer diagnoses are addressed in the plan of care. Medicare wants to know what you are going to do about these diagnoses, as well as how you are going to keep the patient out of a hospital and get the patient to an independent or supported independent status by discharge.
By being thorough and comprehensive, you can show Medicare that you have a plan, what the plan is, and how you are going to execute this plan. 听The ultimate rewards are that you will help your patient achieve the goal to remain independent and healthy, as well as ensure payment for the services provided.
REFERENCES:
[1],6 Medicare Benefit Policy Manual, Chapter 7, Home Health Benefit, Rev 142, 4-2011
[2] Department of Health and Human Services, Office of the Inspector General, 鈥淢edicare Home Health Agency Survey and Certification Deficiencies鈥�, June Gibbs Brown, Inspector General, October 2000.
[3] M. Therese Rode, RHIT, Senior Home Health Coder, Inova VNA Home Health, Fairfax, VA.-2012
[4] Medicare Benefit Policy Manual, Chapter 7, Home Health Benefit, Rev 142, 4-2011