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Creating a Medicare Compliant, Patient-Centered Plan of Care

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 “reasonable and necessary” covered service under the Medicare benefit.[1] According to the Office of the Inspector General (OIG),  home health agencies are required to,” 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.”[2]

Although it is easy to create plans of care, all too often agencies lose the patient-centered vision and end up with “cookie cutter” 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’s  situation. This may require a little more investigation, querying the physician for more specific diagnoses, and focusing on the patient’s 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, “SN to teach on cardiac diet”. The plan of care will be better suited and more patient specific if this intervention reads, “SN to instruct patient on rationale for following a cardiac diet, and 10 foods allowed and not allowed on this cardiac diet”.  Another example could be that the patient understands the action of his furosemide tablet, but doesn’t 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  care plan should be specific, and could be worded as, “SN 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”.  Goals should likewise be specific, such as, “Patient will verbalize 5-10 symptoms of hyper and or hypokalemia that require intervention by health provider by end of episode”.

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, “PT TO EVAL AND TREAT”, you could say, “PT to EVAL AND TREAT due to left hemi paresis with poor understanding of need to use walker and increased fall risk”. 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, “when 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”[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.  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.

[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, “Medicare Home Health Agency Survey and Certification Deficiencies”, 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


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