Archive for May 7th, 2016

May 7, 2016

Palmetto GBA: Local Coverage Determination (LCD) Updates: Home Health and Hospice

Won the Battle and the War?

Looks like we won the battle, but lost the war. Losing the war in the end may be better for our patients so all we have to do now is get the physicians to cooperate.

Palmetto just released their revised medical policy on the requirement to have a recent HbA1c on a diabetic’s chart. Agencies have run into problems getting physicians to order the HbA1c. The new policy still requires a HbA1c, but the big change is that if the patient is stable, the requirement is only twice per year. (That’s the battle we won.)

Here’s the language:  “Reasonable and necessary home health plans of care for Medicare beneficiaries with Type II diabetes must therefore include the monitoring and reporting of not only intermittent capillary blood/serum glucose levels but also quarterly (and no less often than 120 days) HbA1c levels. Performing the HbA1c test quarterly in patients whose therapy has changed or who are not meeting glycemic goals is supported by the American Diabetes Association Standards of Medical Care in Diabetes – 2016 (ADA Standards).

Palmetto intends to keep the quarterly  (and no less often than 120 days) HbA1c frequency for the home health beneficiary population “whose therapy has changed or who are not meeting glycemic goals”.

For those that have met treatment goals in the Plan of Care (I want to know whether they mean our PoC or the physician’s, but I have a feeling what they will say), the HgbA1c is required twice per year. So what does that mean? Stable glycemic control is defined as two consecutive HbA1c results meeting the treatment goals specified in the plan of care.

I’ve heard that at a recent Palmetto educational offering that it was suggested to leave diabetes off the Plan of Care. Warning: Diabetes is one of those conditions that has the potential to affect the PoC and rehab potential. In addition, the coding guidelines indicate that we should code what the physician states. It’s a difficult argument to make that diabetes does not have the potential to affect the PoC, being a chronic disease that affects multiple body systems.

Myths I’ve heard:
1. This policy only applies if diabetes is primary.
2. Drop diabetes out of the top 6 diagnoses and the policy doesn’t apply.

Both of those statements are false.

If type 2 diabetes is listed on the claim, the policy applies.

So here’s where we are:
If the patient has type 2 diabetes, you must communicate with the physician regarding treatment goals for the patient and expected HgbA1c results. You must have information regarding the last results and you must have a plan to attempt to stabilize the patient and monitor. You either need to get an order for venipuncture or you need to ensure you get the physician’s results on your chart.  The hope is that the patient will have fewer adverse consequences requiring emergency room treatment and decrease the probability of other complications of diabetes.

Link to article:

If you need assistance with medical review or audits, please call Selman-Holman & Associates, LLC. We’ve had over 20 years (100s of combined years)  experience with documentation requirements and medical review. 940.383.2130 or 940.300.9974.