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Observation and Assessment: When Will Medicare Pay?

presented by Annette Lee, RN, MS, HCS-D, COS-C

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Disclosure Statement:

Financial— Annette Lee is the owner of Provider Insights Inc and receives compensation from MedBridge for the production of this course. There are no other relevant financial relationships. Nonfinancial— No relevant nonfinancial relationship exists.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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Accreditation Check:

Did you know that Medicare's most prevalent skill paid for in home health is observation and assessment? CMS has provided a manual to describe what services are paid for and under what circumstances. This manual, the Medicare Benefit Policy Manual, has a chapter for home health: Chapter 7, which describes the circumstances under which CMS would pay for nursing to provide observation and assessment. This course will discuss how this skilled service can be provided in "real life" circumstances, yielding positive outcomes for patients and ensuring payment will be secured.

Meet Your Instructor

Annette Lee, RN, MS, HCS-D, COS-C

Annette is a registered nurse who has been practicing since 1990, with the majority of her nursing experience being in public health care. She has a master's degree in health care administration. In 2000 she joined the home health intermediary Cahaba GBA, where she became an instructor, providing education to home health and hospice providers…

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Chapters & Learning Objectives

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1. What Is Observation and Assessment per CMS?

This chapter will provide a clear definition of O&A per CMS. We will discuss the vital difference between “skilled” and “billable/covered,” and where to find these definitions in writing. This understanding is mandatory for home health nurses because it is up to each clinician to determine eligibility, both at the Initial Assessment and ongoing throughout care.

2. Clinical Indications and Exceptions for Assessment

CMS provides a list of circumstances in which they feel assessment would be a covered service. We will discuss these “clinical indications,” along with the counter-balance of the exceptions rules that CMS also provides.

3. Assessment Examples

This chapter uses both “real life” and “Chapter 7” examples of when CMS would pay for assessment, and when there would be risk for denial. These examples include everything from simple wound care to hypotension.

4. Documenting the Skill

Lastly, the documentation must show the level of skill, plus the medical necessity of this service. This chapter will discuss ways to ensure that your payment is protected with proper documentation of this service.

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