There are so many clinicians new to home health and there are so many things to know—PPS, OASIS, coding, coverage, just to name a few. There have been many misunderstandings about the role of dialysis in home health. What to do with your patient on dialysis? Do you document the dialysis catheter? Can you take care of it? How do I code it and do I need to code it? What about OASIS?

Coverage

Dialysis-related services are not a covered service under the home health benefit. The Code of Federal Regulations, Section 409.49 (e), dated December 20, 1994, specifically excludes services which must be provided by an End Stage Renal Disease (ESRD) facility. “Services that are covered under the ESRD program and are contained in the composite rate reimbursement methodology, including any service that is directly related to that individual’s dialysis, are excluded from coverage under the Medicare home health benefit.”

Dialysis related services are not covered under the home health benefit. Any and all dialysis-related services are the responsibility of an ESRD facility.

Dialysis-related services that are not covered:

·  Treatment of an infected shunt site

·  Epogen injections

·  Venipuncture for dialysis-related labs

·  CAPD/PD

·  Hemodialysis

Renal-related services that may be covered include:

·  Treating an abandoned shunt site

·  Medical treatment not related to the dialysis, i.e., decubitus wound care

·  Teaching the administration of non-dialysis related medications

Dialysis-related services that are not covered should not be included as part of your Plan of Care, i.e., they require no interventions. In the past, there were consultants that would inform agencies that the agency should not document that the patient was on dialysis or include the dialysis catheter in the assessment for fear that the home health services would be denied. This instruction is not correct. A complete assessment should include the presence of dialysis catheters. The initial assessment includes the baseline assessment of your patient and should reflect all of the findings. Omitting documentation reflecting the presence of the catheter makes the assessment incomplete. There is little danger in documenting the presence of the catheter or that your patient goes to a dialysis center three times a week, as long as your documentation also reflects the services that the home health agency is providing. There should be no doubt that you are not providing dialysis-related services that could be denied.

Coding It

There are two codes to consider in indicating dialysis services. The first is the V56 category (Encounter for dialysis and dialysis catheter care). This code indicates that the agency is providing the dialysis or the dialysis catheter care. The use of codes in this category indicates that the agency is providing services that are not covered by the home health benefit. The agency will be at risk for denial of services.

If, on the other hand, you are trying to indicate the patient is receiving dialysis, then the code is V45.1 (renal dialysis status), which indicates that there is an arterial venous shunt present or the patient is receiving hemodialysis, but the agency is not providing the services. The code, V45.1, is a better choice of codes for your patient who is on dialysis, however, because V45.1 is a status code, code it only if it is pertinent to your plan of care.

Answering OASIS

The dialysis catheter is treated just like an implanted venous access device or central line in answering the OASIS M0 data items. A dialysis catheter of any kind is considered a surgical wound for OASIS purposes. (See Q.106 in Category 4b of the OASIS Q and A). Even if no care is being provided regarding the dialysis catheter, the assessing clinician should answer ‘yes’ to M0440 ‘Does this patient have a skin lesion or an open wound?’ and answer ‘yes’ to M0482 ‘Does this patient have a surgical wound?’ Case mix points are available for the dialysis catheter on M0488 ‘Status of Most Problematic (Observable) Surgical Wound’ if early/partial granulation (7 points) or not healing (15 points) is checked. The Q and A states that the dialysis catheter can never be better than fully granulating because the device keeps the wound from healing completely.

To answer M0488, the wound must be visualized. If a dressing covers the peritoneal dialysis catheter or AV shunt, is it removable? If it is not removable, then the wound is nonobservable and no points are available. If the dressing is removable, the clinician should assess the wound for its size, status, drainage, edema, etc., answer M0488 and document the findings. No further care will be provided other than including it in your assessment of the skin on subsequent visits and OASIS assessments.