Posted by: Robert Markette
December 07, 2006

Let me start by apologizing for my infrequent posts the last few weeks. But with the holidays and work being exceptionally busy this time of year (and not a lot of new developments in the world of home health) I have had limited time and material. However, this week, I have noticed an upswing in questions relating to the HHABN. It seems that now that people have settled in with the HHABN, they are discovering unusual scenarios or reevaluating their use of the HHABN in an effort to lessen the number of HHABNs they are issuing.

Frankly, I am not surprised. In part, once the home health community implemented their HHABN system and became comfortable with it, it was only a matter of time before they began to realize that in many cases, they may have erred on the side of caution. The other issue is that providers have had a few months to have unusual cases come up. If you have read the HHABN transmittal, you will notice that for all of CMSs efforts, there are many situations for which the answer Do I need to issue an HHABN is not obvious.

For example, a recent question I received from a seminar viewer involved the need to issue an HHABN after a one time unplanned nursing visit. This could come up in a number of ways, but the main point is issue leading to an additional nursing visit during week that exceeds the POC frequency for the week. There is no change to the POC as a result and the next week the visits remain as in previous weeks. For example, HHA patient suffers from a slip and fall at home. Because it is apparently a minor slip, not requiring a 911 call, patient calls agency asking if she needs additional care. Agency sends nurse out to the home to check on the patient and make sure patient is ok. (Many of you are probably saying, we just tell them to call 911, this may be a good idea, but the point of this post is how would such a situation affect your need to issue an HHABN.) The patients POC calls for 2-3 vists per week and this visit happens to be number four for that week. As a result of the visit, there is no change to the POC or any other action taken.

Obviously, the additional visit does not require an HHABN, because it is an increase in care. Increases in care are one of the express exceptions to the HHABN requirement. However, the next week you effectively have a decrease from 4 visits to 3. Reductions in frequency are reductions in care that, in most cases, require an HHABN.

Most providers would react to this situation by issuing an HHABN, but lamenting the waste of time and paper. However, in this case, you do not need to issue an HHABN. The unplanned alteration in frequency is a minimal change. There is not alteration of the underlying plan of care and the visit itself was an unplanned visit. The Court in Lutwin specifically said that certain de minimus or minimal alterations to a POC would not require an HHABN. (Of course, I will not touch on whether this is the appropriate way to respond to the slip and fall, as opposed to calling 911)

CMS has not adopted a specific minimal change exception, but instead adopted exceptions for the specific minimal examples provided by the Court sick employees, missed visits, etc. This one time visit is a similar example of a minimal change. It also happens to fit into the concept of an unplanned or emergency visit. However, it is the nature of the visit patient calling for the agency to check on them after an in home incident that makes this an unplanned visit. (Of course, you should consider advising the patient to call 911 if the patient thinks it is an emergency.)

If the visit resulted in an alteration of the POC that led to a reduction in care, an HHABN would be necessary. You should not understand the minimal change concept to be a broad exception, but to be a very narrow exception.

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