Home Health Ordering/Referring Edits Effective, January 6, 2014

The Centers for Medicare & Medicaid Services (CMS) issued a revision to the Medicare Learning Network (MLN) Matters® article SE1305, which is available in this bulletin, announcing that effective, January 6, 2014, the Fiscal Intermediary Standard System (FISS) will implement the ordering/referring physician edits.  Billing transactions and adjustments for home health services with the “FROM” date of service on or after January 6, 2014, will be denied if the attending physician National Provider Identifier (NPI) and name do not exactly match the NPI and name that is on the Provider Enrollment, Chain and Ownership System (PECOS) file. 

NOTE: The edits will compare the first four letters of the last name.  When submitting home health billing transactions and adjustments, include the first and last name as it appears on the ordering and referring file found at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html on the CMS website.  Middle names (initials) and suffixes (such as MD, RPNA, etc.) should not be listed in the ordering/referring fields.

Please review the following to learn how Requests for Anticipated Payment (RAPs), final claims, and adjustments will process in the Fiscal Intermediary Standard System (FISS) and how to prevent denials for this reason. 

Requests for Anticipated Payment (RAPs)
If the attending physician NPI and name submitted on the RAP does not match the NPI and name in PECOS, the RAP will process with zero payment.  If this occurs, you may either:

• Cancel the RAP and resubmit a new RAP with the correct attending physician NPI and name to receive the RAP payment; OR
• Submit the final claim with the correct attending physician NPI and name to receive the full episode payment. 

Final Claims and Adjustments
Final claims and adjustments will deny when the “FROM” date is on or after January 6, 2014, AND:

• The attending physician National Provider Identifier (NPI) is not found in the eligible attending physician file from PECOS; or

• The attending physician NPI is found in the eligible attending physician file from PECOS but the name on the claim/adjustment does not match the name in the PECOS file; or

• The specialty code is not a valid eligible code to order and refer.

Appeal Process
If the final claim or adjustment is denied, to receive Medicare payment, you must follow the appeal process by submitting a redetermination.  To avoid administrative costs that providers experience with filing an appeal, take action now to develop an internal process to prevent such denials. 

How to Prevent Denials

• Check the “Ordering Referring File” at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html to ensure that the physicians and non-physician practitioners from whom you accept orders and referrals have current Medicare enrollment records, and are of a type/specialty that is eligible to order or refer in the Medicare program.

• Review the “Ordering Referring File” to ensure the information that you submit exactlymatches the information as it appears in the file. 

• Review your billing transaction before submitting to Medicare, to ensure there are no typos. 

Please note the following clarifications.

• HHAs should not use the NPPES web site at https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do to verify the physician’s information

• HHAs should use the “Medicare Ordering and Referring File” at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html to verify the physician’s NPI, last name and first name reported on the home health billing transaction.  Once again, the attending physician NPI and name that you submit must exactly match the NPI and name that is on the PECOS file and displays in the “Medicare Ordering and Referring File.”

• The CGS Home Health & Hospice Customer Service Representatives cannot assist with physician enrollment issues, since we do not process their enrollment applications.  If it appears that your referring physician is not enrolled in PECOS, please ask the physician to contact his or her Medicare Administrative Contractor regarding the appropriate steps to follow.  Refer to the CMS interactive map at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html for Medicare contractor contact information. 

Medicare Learning Network (MLN) Matters® Articles

• SE1305 - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf
• MM6856 - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM6856.pdf  

Obtained from: http://cgsmedicare.com/hhh/pubs/mb_hhh/2013/12_2013/index.html#001

CGS Initiates a Widespread Home Health Probe on Face-To-Face Encounter Documentation

As a result of numerous errors identified by both CGS and the Comprehensive Error Rate Testing (CERT) contractor related to home health face-to-face (FTF) encounter documentation, CGS will be initiating a widespread edit for all home health providers.  The topic code for this review will be 52xxT (‘xx’ denotes various numbers) and the edit will select start of care home health claims equally across the provider community.  Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity compliance with all CMS coverage guidelines, correct billing and coding.

In addition, beginning July 8, 2013, CGS will begin requesting the initial certification face-to-face (FTF) encounter documentation is submitted with all home health claims selected for Medical Review. The Centers for Medicare & Medicaid Services (CMS) clarified the “face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes.” (CMS FAQ # 44)

The previous was from CGS website: http://bit.ly/18czZ7g. Site goes into additional details of examples of what should be included and what would be considered insufficient within FTF documentation. The site also recommends actions for agencies to prepare for this edit which will come in the form of an Additional Documentation Request (ADR) letter. They recommend:

1. Checking for claims in the Additional Development Request status/location in the Fiscal Intermediary Standard System (FISS) at least weekly.
2. Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency.
3. Mailing your documentation for claims selected to CGS by day 30.

CMS Issues ICD-9 to ICD-10 Transition Claims Instructions

CMS published a special MedLearn Matters article addressing ICD-9 to ICD-10 transition claims instructions. The article SE1325, addresses institutional provider which includes home health and hospice providers. Providers will be required to split claims so that all ICD-9 codes remain on one claim with Dates of Service (DOS) through September 30, 2014 and all ICD-10 codes placed on the other claim with DOS beginning October 1, 2014 and later. While the processing requirements for hospice should be clean because they bill on a monthly basis, home health has several challenges and issues to clarify.

Since home health does episodic billing, will all Medicare and Medicaid patients be required to be discharged and readmitted at their first billable visit on or after October 1, 2014? Under important details in the article, Note 1 states that “creating multiple/interim claims on a single encounter is not a new concept and that these instructions will apply to relatively few claims that span this single implementation date (October 1, 2014) will be impacted.” This could impact 1/6th of all claims for 2014 impacting over 1 million Medicare episodes alone, so this would not affect a “relatively few claims”.

There is a potential that CMS would fall back to the logic stated in Note 2 and treat the episode as a single service; however not likely because of the problems this causes. If an episode starts before October 1, 2014 and the resumption of care is completed after, which code set would you use? ICD-10 should be used, then the diagnosis data will not be consistent across the episode. If ICD-9 is used, then agencies will be required to code certain claims under each of the ICD data sets during an extended period. This would result in increased confusion amongst coders and potential errors.

CMS also needs to clarify which OASIS data set (M item), is tied to the DOS; M0030 (Start of Care (SOC) Date) or M0090 (Date Assessment Completed). CMS has implemented different program changes based on each item depending on the circumstance. M0030 makes sense except in the case of recertification, since that is not used. M0090 can be beneficial, as it allows a few days of wiggle room around the October 1st implementation date. In the case of SOC, this would allow for SOC to be completed as early as September 27th, considering that October 1st will occur mid-week. This could be helpful especially if all Medicare and Medicaid patients will need to be discharged and readmitted.

Either scenario would not be pleasant. Ideally, there should be a 60 day window on either side of October 1, 2014 to allow for entering ICD-9 or ICD-10 codes. This would put the burden on the government. The agencies would have the ability to do what is best for their staff and the patients. The government would need to handle processing both types of claims during this time.  This would decrease the burden on the agencies.  There has not been any talk of this and it does appear the burden will fall onto the agencies.



 

Home Health PPS Rate Update for CY 2013

Changes to OASIS Field M1024

On July 6, 2012, CMS announced proposed changes to the Medicare home health program for 2013 that, as they noted in a press release, “would foster greater efficiency, flexibility, payment accuracy and improved quality.” 

We wish that were the case. 

As many of you know already, by law CMS has to update the payment rate every year. While many of the primary focuses of the proposed changes are expected, and in fact will do some good, there are a few major items that are receiving very little attention and should be of concern to home healthcare agencies and their patients and families. Specifically, we are very concerned about proposed changes restricting the use of OASIS field M1024. While on the surface the rule would appear to simplify coding of this section, if implemented there is going to be a significant case mix (CM) decrease, with unintended results affecting patient care. 

The proposed rule addresses what CMS sees as an overuse of diagnoses assigned to M1024. Basically, M1024 is an additional optional area of the OASIS form where codes are put in to help with payment calculation. Its use should only be used on a limited basis, but because of poor direction and management from CMS in the past, plus ongoing issues with EMRs, home healthcare agencies (HHAs) have been inconsistent on how they have used this field over the years.

 

CMS also states in the proposed rule that many HHAs are not complying with the guidelines of “Attachment D” which was published in December 2008. It is true that adoption of Attachment D by the home healthcare industry has been spotty. But CMS is also not acknowledging its lack of proper implementation of Attachment D. First of all, they published these guidelines 11 months after the PPS changes went into effect which these guidelines covered.  When they were first published, they were full of errors and the examples that they had within the document did not even follow their own guidelines. They later revised these guidelines but, as industry experts will tell you, they still continue to provide confusing and conflicting guidance. In 2010, HHA switched to OASIS-C, however, Attachment D still uses the language of OASIS-B (i.e. M0246). 

 

How does CMS expect an industry to follow the guidelines when they are riddled with errors, offer conflicting guidance and are out-of-date?

Other ongoing issues have also contributed to the use of M1024 that CMS fails to address in this rule. Many EMR systems, for example, are not setup properly and require every V code to have a corresponding code in M1024.  In the past, CMS has told agencies that this is “okay” as they are limited by their EMR system, instead of demanding that the EMR system fix the problem.

Lastly, if there is a coding error, and it is the difference between a clinician and a coding specialist, CMS has stated in the past that they would rather have incorrect coding from a clinician rather than proper coding from a trained professional. Yes, you read that correctly. [See Quarterly CMS Q&A question 44.1 from category 4 located here on page 29 ]

With this proposed rule, CMS is taking an extremely narrow worldview and wants to limit the CM diagnosis categories to fractures only. One example where an agency is at significant risk is in the case of a status post-mastectomy patient who is not receiving additional treatment for cancer. Typically, an aftercare code would be used in M1020/M1022 and the Breast Neoplasm code would go in M1024. This would add CM points and non-routine supply points to the episode. Based off the proposal, these patients would receive less reimbursement. This may be an oversight of CMS or it could be intentional to lower the overall CM average.

Bottom line, this rule will affect reimbursement for a significant population of patients within the industry and there has been no discussion of it. Instead of legislating, let’s take a step back and offer a sensible solution that fixes the problem, not make it worse. We call on CMS to…

• Fully implement what “Attachment D” was meant for and not restrict diagnoses codes limited to M1024 other than what is the intention of Attachment D.
• Form a committee of homecare industry experts to fix Attachment D. Mandate that only CM codes are placed in M1024 and not allow EMRs to allow otherwise. Have MACs audit for accuracy.
• Acknowledge the use of certified coders in homecare. Give them the ability to correct inaccurate coding by clinicians. Allow them to make the change, with specific documentation on what was corrected and why. 

Read the entire rule published in the Federal Register on July 13, 2012 here.CMS will accept comments on the proposed rule until Sep. 4, 2012. We are already working on ours.

Its Almost Time for the Annual NAHC Financial Management Conference: July 15-17 in Dallas, TX

We can’t believe its already time for the NAHC Financial Management Conference; where has the first half of the year gone?

If you’re attending this year’s show in Dallas, Texas July 15-17th, we hope you’ll take a minute (or two) to stop by our booth (#304). We’ll be giving out free Custom Coding Cost Analysis’s to show how you can improve efficiencies and your bottom line. Our analysis will include how ICD-10 will influence your organization’s productivity and bottom line. For a more in-depth analysis of your coding expenses and efficiency recommendations, please email Carie Wright for a specific meeting time.

We understand folks are uncertain about how their organizations will adapt to regulatory changes like ICD-10, and we know it’s becoming harder and harder to stay profitable. That is where our team can help. Our goal for this event is to help attendees improve their bottom line by making home healthcare coding as pain-free as possible.

For those attending, we look forward to seeing you in Dallas and discussing how using a professional coding team can save your organization money while remaining 100% compliant. And if you can’t make it, stay tuned here and on Facebook or Twitter for updates during and post-show.

How to Help Ensure Adequate Supervision of Home Care Staff in Order to Avoid Negligence and Allegations of Fraud and Abuse

By: Elizabeth E. Hogue, Esq.

Home care is different from institutional care in a number of ways.  One crucial difference is that field staff members are essentially working without direct supervision on a routine basis.  The cost of providing direct supervision for staff as they provide services to home care patients is prohibitive.  Consequently, providers are vulnerable to claims that they failed to adequately supervise staff.  These claims may include allegations of negligence and fraud and abuse. 

Perhaps the greatest risk involves staff members who say they made visits that they really did not make.  Changes in patients' conditions may not be addressed when visits are missed.  Visits that are claimed, but turn out not to have been made after all, are also a common basis for allegations of fraud and abuse.

In view of inherent limitations on agencies to directly supervise field staff, what is the applicable standard of care that must be met?  Generally speaking, appropriate supervision means that agencies must make reasonable efforts to ensure that field staff meet applicable standards of care.  Reasonable efforts to ensure adequate supervision may include the following:

-        New employees may be required to make several visits with experienced employees with proven track records so that any deficiencies in abilities or practices of new staff can be determined as quickly as possible.  The results of these visits must, of course, be documented.

-        Agencies should develop and implement a policy and procedure that requires random supervisory visits.  Thereafter, managers should make "unannounced" supervisory visits to patients' residences at all hours of the day and night so that employees understand that they may be directly supervised at any time without notice.

-        Managers may also wish to investigate commercially available systems for tracking the arrival and departure of field staff members at each patient's home.  These systems may require staff to place a telephone call that registers in a computer when they arrive at patients' homes and again when they depart. 

               

Of course, these systems are not foolproof.  Instances have been reported in which staff members paid patients and/or family members to call in for them as though the worker arrived and departed patients' homes.  To the extent that the use of such systems makes it clear that agencies are using reasonable means to help verify that services were actually rendered, even if the system is circumvented, it helps to ensure that agencies have adequately managed risks associated with visits that are not made as scheduled.

-        Agencies should also develop and implement policies and procedures that require patients and/or someone else present in patients' homes when visits are made to sign a document verifying that services were provided.  If the patient cannot sign and no one else is present to sign, staff should be required to provide a detailed explanation for missing signatures.

-        Quality assurance staff should conduct retrospective audits to make certain that signatures from patients and/or family members verifying services are routinely obtained.  When there are a number of instances in which specific staff members failed to obtain signatures as required, despite the presence of a written explanation, further investigation must be conducted to determine why signatures are missing on multiple occasions.

-        Agencies should continue to use patient satisfaction surveys to assist them to satisfy their obligation to monitor workers.  Agency staff members sometimes correctly observe that most of the surveys returned by patients fall into a category that can best be described as: "We love our nurse!"  Nonetheless, valuable information can occasionally be gleaned from surveys.

For example, a patient of an agency responded to a survey by saying that he was quite pleased with the care provided, but wished that the agency would not send a different nurse every day.  The staff was initially quite puzzled by this response since their records showed that the same nurse had visited the patient each day.  Following further investigation, however, the staff was astounded to learn that the agency worker was "subcontracting" the care of the patient to members of an extended family so that, indeed, the patient was being cared for by a different "nurse" each visit!

It is impossible for agencies to duplicate the supervision provided by institutional providers.  Nonetheless, reasonable efforts to supervise field staff will work in agencies’ favor when workers' performance is scrutinized.

©2012 Elizabeth E. Hogue, Esq.  All rights reserved. 

No portion of this material may be reproduced in any form without the advance written permission of the author.

Call Congress: Home Health Care Cuts

Congress is about to cut billions of dollars in funding for Medicare home health care services. Home health cuts and co-payments will have a devastating impact on millions of Americans, including some of the poorest and sickest Medicare beneficiaries. Such changes may also cause many patients to leave their homes and instead seek treatment in costly hospitals and nursing homes.

A Home Health Copayment:

• Would Disproportionately Impact Poor and Sick Seniors
• Would Shift Seniors to More Costly Settings
• Would Increase Medicare and Medicaid Costs
• Was Repealed by Congress in 1972 and Remains Unpopular Today 

Please Protect Seniors from a Home Health Copayment. Join the Partnership for Quality Home Healthcare and contact your U.S. Representative today.

How to Work With Us

Daymarck is Pain-Free Coding

We want to make it easy for you to work with us. This is why we have established simple methods to help with your coding needs. Read below to find out what we need from you to ensure accurate and efficient coding.

What we need
To ensure accurate ICD-9 codes to be assigned, the following information is required: 

1. Referral information (i.e. why patient was referred to homecare)
2. OASIS/Comprehensive Assessment 
3. Care Plan (it can be a draft) 
4.  Medication list at the time of the assessment

Additional Information that helps us accurately code: 

1. History and Physicals
2.  Hospital Treatment Notes
3.  Discharge Notes 
4. Therapy Evaluations

It is also very important to NOT send irrelevant information such as maps, driving directions, and blank pages. By eliminating those types of non-pertinent information, we are able to maintain a quick turnaround time and keep your costs low.

How we get the data

The quickest and most cost effective way, as far as time, fees and production, is one pdf file uploaded for each patient or case that needs coded. But we know that isn’t possible for every agency or situation. Talk to us and we can come up with a solution that works for you.

Here are a few ways our clients send us the data:

• Run a few reports and put them together using Adobe Acrobat Pro or Standard or similar pdf creator.
•  Scan the paper and bind it together in one pdf file with the reports they ran out of their system.
•  Give Daymarck remote access into their electronic system via VPN or other remote access methods and we run the reports and create the patient document (additional fees do apply).
•  We accept faxes. Agencies who are on paper or prefer to print everything can then fax us patient documentation and it drops right into our system.
• And, lastly, some agencies use a mix of both methods - they fax us a couple pages with a cover page and then we can remote in and get the info out of their system.

Question 2: Medicare home health patient who drives

Determining homebound status is not as easy as it seems. This is in part to CMS's broad and non-specific definition. Most people within the homecare industry can recite that Medicare homecare patients have to have the condition "that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort." After this, there is definite discrepancy in what this exactly means.

As far as driving, this fact does not automatically exclude a patient from home health services. CMS answered a Q&A in 2008 to this effect. The bigger picture has to be looked at.

Question 2 does not indicate if there is a considerable and taxing effort to leave the home thus the correct answer would be not enough information to make a decision.

Should HIPAA Business Associate Agreements be Modified to Comply with HITECH?

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

Many providers have asked whether they should modify their business associate agreements to comply with the HITECH Act. There is, in fact, ongoing discussion and debate in the legal community about this issue. It seems fair to say that business associate agreements should be modified to comply with requirements of the HITECH Act regarding notification of breaches, since final regulations have been published implementing these requirements.

On August 19, 2009, the Department of Health and Human Services (HHS) issued an interim final rule entitled “Breach Notification for Unsecured Protected Health Information.” This rule describes how healthcare providers must notify patients when the security of their protected health information has been breached. Providers were required to comply with these new requirements beginning on September 23, 2009. Providers are also required to revise their internal policies to include these requirements.

OIG on RAC Fraud Referrals

This was a report received thru the OIG Public Affairs.

Recovery Audit Contractors' Fraud Referrals (OEI-03-09-00130)

We found that between March 2005 and March 2008, recovery audit contractors (RAC) referred two cases of potential fraud to the Centers for Medicare & Medicaid Services (CMS). However, CMS reported that it received no potential fraud referrals from RACs during this period.

Care Plan Oversight

As I mentioned last month, Senator Collins (R-ME) and Senator Conrad (D-ND) introduced senate bill 2814 on November 20, 2009. This bill would allow for advance practice providers other than physician to order and monitor home care services for patients. Despite several State laws that already allow this, it is not allowed by the Federal Government so it is prohibited under federal reimbursed payment systems such as Medicare and Medicaid.

At the time I last blogged about this issue, it was not clear if this would allow for Advance Practice Providers to bill for care plan oversight. I did receive a letter from Senator Conrad stating that it would not allow for this provision. This is a shame. The Senate needs pressure from its home health constituents to pass this senate bill and add a provision for care plan oversight. I would take the bill as is but if Advance Practice Providers like Nurse Practioners are doing the equability work of a physician they should be reimbursed for that.

This bill still remains in the Senate Finance Committee for review. I would be interested in your feedback.

Month one of OASIS-C

Irrational rational

Illogic logic

Just a plain, what were they thinking?

I’m a big fan of the OASIS assessment because of the practical, efficient applications that result from the data collected; PPS calculation, quality measures and a standardized tool that every agency has to use. It intrigued me to learn the relationships of the specific questions and the complex calculations which either resulted in payment calculations or risk adjusted outcomes.

Learning these relationships over the years, we have learned small but critical improvements that were needed. M0700 ambulation/locomotion needed to be more specific in order to show the improvement a patient makes from using a walker to a single hand cane. Certain questions that were nonspecific and difficult to answer were eliminated, like M0280 Life Expectancy - likely hood a patient was going to live more than 6 months. For these details and other evidence based practices learned over the decade OASIS-C was created.

Guest Post: When Are Patients “Unsafe” for Home Care?

Daymarck Home Care Thought Leader Guest Posting

When Are Patients “Unsafe” for Home Care?

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

Discharge planners/case managers are likely to encounter instances in which home care, hospice, and home medical equipment (HME) providers state that they cannot accept patients because they are “unsafe” at home. The use of this term may be confusing to discharge planners/case managers. What is it about patients’ homes that make it “unsafe” for them to receive services there? Aren’t all patients appropriate for home care?


First, discharge planners/case managers may not have provided services in non-institutional settings. If so, it may be difficult to make a crucial distinction between institutional care and home health services.

New Day, New Programs

With the implementation of OASIS-C Jan 1st, agencies have the ability to do an extreme makeover and position themselves for Pay for Performance (P4P). Yes, P4P will still come despite all the other changes that are occurring. The Demonstration project ended in December. Findings will be published in the near future.

April will be the last Caspers report until this fall. Home Health Compare will also not update for 6 months. What is done with OASIS-B is done. Quality reports are going to be wiped clean and the first full OASIS-C episodes will begin your new quality report tallies. Some quality measures will remain, others will be added.

So what should agencies focus on? Continue to do business as usual. Defiantly not! Agencies need to take a step back and look at their operations to see what is working and what is not. Are you a proactive agency or a reactive agency? Proactive agencies foresee the problems as they arise and put checks and balances in place to prevent rework and poor outcomes. Reactive agencies are always looking hindsight and trying to figure out what went wrong. They are so busy looking backwards they do not see the opportunities going forward.

Advance Practice Providers Ordering Home Care

Senator Collins (R-ME) and Senator Conrad (D-ND) introduced senate bill 2814 on November 20, 2009. This bill would allow for advance practice providers other than physician to order and monitor home care services for patients. Despite several State laws that already allow this, it is not allowed by the Federal Government so it is prohibited under federal reimbursed payment systems such as Medicare and Medicaid.

This legislation is way overdue. Not clear is if it will allow for these advance practice providers to bill for Care Plan Oversight. This should be allowed due to the regulatory requirements for reviewing and communicating with the home health agency.

OASIS Surgical Wound Score

I have been on a mission to either get better understanding or change the CMS guidance on OASIS surgical wound score related to venous access devices. With the implementation of OASIS-C, there is better guidance as far as staging surgical wounds. However there is significant confusion on how to score M1340 related to central venous access devices and the WOCN guidance did not cover this issue.

Previous guidance from CMS states that central venous access devices are always considered surgical wounds. I believe the original intent was that the skin break (surgically created) which the access device was placed into the body is actually the surgical wound. CMS has taken the original written guidance to mean that the actual device is the surgical wound. Previous guidance states that when a venous access device such as a mediport is in place, even if not used, it will always be considered a surgical wound. This is confusing the homecare industry.

With the new OASIS guidance which states, "For the purpose of this OASIS item (M1340), a surgical site closed primarily (with sutures, staples or a chemical bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has been present for approximately 30 days, unless it dehisces or presents signs of infection. After 30 days, it is generally described as a scar and should not be included in this item." 


Industry consultants and CMS representatives state that venous access devices fall out of this guidance although the official OASIS-C guidance manual does not state this. They say that this is because WOCN stated in the past that a central venous access device is always considered a surgical wound therefore CMS has taken that stance.

There needs to be clarification from the WOCN on how to score venous access devices. Here are my suggestions:

***These guidelines are not approved by CMS or WOCN. These are just my suggestions for what they need to change. ***

First, the term of venous access devices needs to be broken down into two subcategories; implanted venous access devices and other central venous access devices.

Implanted venous access devices (i.e. mediport)

When scoring M1340 such as a mediport, the clinician will assess the surgical implantation site wound. If the wound has been epithelized for greater than 30 days, the clinician will mark No.

If the site is epithelialization is less than 30 days then M1340 would be marked 1 or 2. If 1, then score M1342 accordingly.

Other central venous access devices (i.e. central lines)

As the access device is keeping the original surgical wound open, M1340 would be answered 1 and then M1342 would be marked non-healing. Once the access device is removed, the surgical would then be scored accordingly to the WOCN guidelines. Once the site is epithelized for greater than 30 days, it is no longer considered a surgical wound.

***These guidelines are not approved by CMS or WOCN. These are just my suggestions for what they need to change. ***

These suggestions have been submitted to CMS and the Chairperson from the WOCN OASIS-C Committee. We will see if common sense prevails or not.