Archive for April, 2011

Part 4: Record Reviews/Home Visits/Analysis/Assigning Citations

Thursday, April 28th, 2011

As stated in Parts 1-2 of this series, CMS has released the new survey protocols, including new guidance as to what HHA surveyors will be expecting from HHA. It is believed the new protocols will provide more survey consistency. According to CMS, the revised survey process incorporated in the protocols is “data-driven, patient outcome-oriented and less structure and process-oriented.” This guidance is effective May 1, 2011.

The protocols focus on the 34 highest-priority standards that closely relate to care quality. During the CMS April 6, 2011 training for surveyors, Pat Sevast (a nurse consultant with the CMS Survey and Certification group) stated that just one finding related to the standards could merit a citation which is a significant move from the present behavior that is seeking non compliant trends at an agency; ie, one of five records or 20% of records reviewed yielded a specific ongoing trend.

With the new survey protocols, a surveyor could cite an agency if just one patient file reflected a patient care issue or a lack of one omitted supervisory visit.  Industry leaders expect an increasing number of condition-level citations. The new protocols allow for one standard level citation to trigger a partial extended survey. If that would occur, the agency would be evaluated against the level 2 standards thus increasing their risk for serious citations.

The training for surveyors included Ms Sevast noting that CMS expects surveyors to cite at a condition level the patient rights’ conditions of participation (CoP) if an agency is out of compliance with two of the highest-priority standards and one level 2 violation. That would trigger an automatic extended survey necessitating review of all CoPs.

So what should an agency do?

Agencies should review the new survey protocols and become familiar with the Home Health “G” Tags and Abbreviated Identifiers, HHA Survey Investigation Worksheets and Calendar, and HHA Survey Investigation Worksheets as well as the Revised Home Health Survey Protocols of February 11, 2011 and the advanced copy of Appendix B- Guidance to Surveyors.

Parts 1-3 of the Select Data article regarding Survey Protocols published in the March 30, 2011 ezine looked at the types of surveys, level 1 and 2 citations, surveyor prep for the survey as well as the new entrance interviews, and the entrance information with specific information gathering techniques.

This segment, part 4, looks at the clinical records and home visits.

The number of records reviewed is still determined by the unduplicated census of the prior year as well as the number of records and home visits necessary to assess compliance with the CoPs.  There is an increase in required home visits by the surveyor as the focus is essentially patient care oriented.

Home visits to patients should include those receiving high-tech care, home health aide services  as well as patients triggering “at risk” of Level 1 and Level 2 potentially avoidable events. Some of the areas the surveyor will be looking at:

  • storage of records,
  • the most recent plan of care and its specificity as to orders and goals,
  • when the patient was visited in relation to the physician’s order,
  • completeness of the comprehensive assessment,
  • evidence of “major decline or improvement,”
  • how coordination of services are met,
  • any evidence of the patient/caregiver contributing,
  • care provisions not in compliance with the law,
  • case conferences, informal conferences and telephone calls,
  • patient specificity of the plans and visits,
  • evidence of patients denied or not offered services,
  • patients hospitalized,
  • patients with LUPAs,
  • reconciliation of care provided to orders given by the physician,
  • inter-related factors of patients with co-morbidities and the care received,
  • therapy visits made at ordered frequency,
  • evidence that PTAs, COTAs, and LVN/LPNs were supervised appropriately,
  • evidence home health aide visits were made every two weeks,
  • if an RN or PT ever observed the aide’s provision of care,
  • evidence the aide careplan was specific to the patient,
  • evidence of consistent documentation of VS, insulin injections, B/P, pain frequency/ severity/interventions,
  • how corrections are made in the record,
  • evidence of discharge summaries in discharge records,
  • evidence of consistent assessment of patient status and progress over the visits.

The home visit and interviews.

Home visit probes will focus on “compliance related to patient rights, accepted professional standards of practice, coordination of care, and comprehensive assessment of patients, plan of care, services provided, and clinical records.” Though not all inclusive, consider the surveyor will be looking at:

  • any instances of personnel providing care that may not be in accordance with laws, regulations, state practice acts, accepted professional standards, or agency policies and procedures,
  • communication by providers with patients/caregivers,
  • evidence that care is delivered by accepted professional standards,
  • evidence that care providers follow CDC guidelines,
  • evidence the aide follows the plan as identified by written instructions,
  • evidence that “medications in the home are the same as those listed on plan of care, interim orders, and clinical record notes,”
  • and asking the clinical personnel “about instances of patient care noted in home visits or record reviews that deviated from the physician orders, accepted professional standards or agency policy.”

The surveyor will interview the patient caregiver to validate that care documented in the plan is the care that is provided, will ascertain if needs are being met by the agency, identify if caregivers are satisfied with the care, that medications presently taken are what have been prescribed (and will compare it to physician orders found in the clinical record), that there is participation by the patient/caregiver in the planning of care, and if they understand the process for handling a complaint. These are minimum areas of review and the agency should be aware that the surveyor may ask when visits occurred, did the clinician and care provider wash their hands, and did they bring their own towels? The surveyor may ask to see all medications taken, including OTC meds and engage the patient/caregiver in discussing when and how they take the meds.

It is important that agencies review processes that are in place to be certain that appropriate agency personnel understand policy and those procedures that support that policy. There needs to be consistency of statements when speaking with the surveyors, who will now have a greater number of interviews scheduled then documented.

The information analysis

This process requires surveyors to review the information gathered during the survey and exercise judgments about the effect of care upon patient outcomes, the degree of severity of any behaviors not fully in compliance, the frequency of the non compliance, and how the services were impacted.

Standard and Condition Level Deficiencies

Data Tags (G-Tags) are assigned to the standards in the interpretive guidelines. If a data tag is assigned to a condition it becomes a condition level data tag. If assigned to a standard level deficiency it is cited at a standard level tag.

If a Level 1 standard-level deficiency is identified, “the surveyor is required to move to a partial extended survey and the surveyor examines, at a minimum, the Level 2 standards under the same condition and any other standards the surveyor chooses to examine.” A review of all Level 2 standards that relate to a deficiency at  Level 1 standards is the minimum requirement.

Any condition level deficiency “requires a move to an extended survey which includes a review of all CoPs and the policies and procedures that resulted in the substandard care.” Substandard care is defined by CMS as “one or more CoPs out of compliance.”

Summary

The new survey process is data-driven and begins with the surveyor’s pre-survey preparation. The surveyor will be focusing on patient care and outcomes derived. The Appendix B of the State Operations Manual has been revised and all are encouraged to read about the new survey process. The definition of a standard survey has been revised to increase the survey’s focus on those standards most related to patient care. Surveyor worksheets are available online at the CMS worksite and provide insight as to the depth and path of the survey. CMS has established a special mailbox for questions related to the new survey protocols hhasurveyprotocols@cms.hhs.gov. Appendix B Guidance to Surveyors: Home Health Agencies of the State Operations Manual offers, in addition to the surveyor process, a full listing of the G-Tags and the interpretive guidelines allowing the agency to see the basis for the interview questions.

This survey process is believed to offer more consistency and focus. The new process complements the patient/outcome focus of OASIS and the drive for improved outcomes and quality patient care.  The surveyors training has been completed. It would be interesting to hear from agencies that experience the new process. Arm yourself with information. Let the new process begin!

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Posted in and Other Audits, Compliance, CY2011, Medicare, OASIS-C, Surveys, Teaching/Education | 2 Comments »

Educational Video: New Survey Protocols

Wednesday, April 20th, 2011

CMS New Survey Protocols Clinical Compliance

Surveyors will, more in depthly, prepare for surveys, using OASIS data. They will review any complaints, previous survey data, and reports generated from the OASIS data. Available OASIS reports can be generated for specific time periods, as requested, from the OASIS Coordinator’s office. These reports include case-mix, potentially avoidable events, risk adjusted outcomes based quality improvement (OBQI) or process measure reports.

More Videos

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Posted in CMS, Educational Videos, Medicare, OASIS-C, Patient Survey, Surveys, Teaching/Education | No Comments »

The Growing Importance of Revenue Cycle Management:

Friday, April 15th, 2011

Introduction to Decade’s Hottest Topic

by Ed Buckley 
with Tim Rowan

Lost revenue and poor compliance go hand in hand. They infiltrate a home health care agency together. 
Managing revenue cycle means improving compliance as much as it means ensuring complete and accurate billing processes and A/R follow up procedures. 

Compliance is the responsibility of all staff, especially those with clinical and financial responsibilities. In today’s Medicare environment — and it is not much different if a provider’s primary payer is insurance or the patient — mere automation is insufficient. Quality Revenue Cycle Management (RCM) processes are required today more than ever.

In fact, RCM is the number one key to meeting today’s home health compliance challenges. Considering the current regulatory environment, where we are seeing sharp increases in ADRs, the imminent rise of collection agencies such as Recovery Audit Contractors, and intensive, relentless MAC, MIC and Z-PIC audits, home healthcare processes and systems dare not fall short of the challenge.

RCM processes must build in compliance, not treat it as an afterthought or a luxury. Patient care is a complex proposition. Building in compliance requires that communication and interdisciplinary coordination are part of a plan of care that manages a patient’s medical needs. There are four key components to the process of building compliance into a plan of care:

  • technology
  • documentation
  • coding
  • billing

These four business pillars support RCM and form a foundation for compliance. Think of RCM as permeating the entire life cycle of a patient care episode, from referral to assessment to plan of care to patient record and finally to the revenue derived from that care. When a plan of care is carefully developed and managed through compliant systems and processes that all talk to each other, a complete management cycle results. When done right, the benefit of this cycle is that it provides the agency with a comprehensive, dynamic, profitable, accurate and compliant home healthcare business.

Most importantly, it results in the ability to provide the highest possible level of patient care, making the agency the first choice among doctors, hospitals and care planners.

Technology only part of the answer

In order to achieve compliance in the contemporary regulatory environment, home healthcare providers must employ more than just point-of-care technology and a centralized billing/coding system. It is imperative to utilize the RCM processes in order to verify assessments, review clinical processes and reconcile resulting data as part of compliant revenue generation. Incorporating RCM processes as part of an overall business strategy often results in improved reimbursement, bullet-proof billing compliance and stellar clinical outcomes.

Lost revenue and poor compliance go hand in hand because OASIS and coding errors are often the result of incomplete and incongruent assessments. Billing mistakes typically occur because visit activities vary from physician orders. Data errors are frequently triggered by hurried keying into point-of-care and EMR systems. A well-developed RCM system as part of operations, implemented in real time, can mitigate most of these costly mistakes. 

With compliance comes control and peace of mind. Compliance leads to more positive patient outcomes, fewer hospital readmissions, more retained revenue, greater efficiency and more predictable cash flow, while providing the business peace of mind that comes only when patient outcomes match plans of care. A home health agency’s business depends on the quality of patient care provided. Doctors, hospitals, and care planners need an agency they can trust to deliver quality care and outcomes, period. 

RCM begins with a complete data capture and error mitigation philosophy impacting every staff member and virtually every aspect of a healthcare provider’s business operations. This includes:

  • accurate patient assessments, the cornerstone
  • correct OASIS documentation
  • clean patient data
  • physician order monitoring
  • visit reconciliation
  • clinical coding with review
  • QI oversight
  • A/R management and collections follow-up

Systems must be designed into processes that identify errors prior to revenue generation. Catching up with after-the-fact chart audits is no longer an adequate process in today’s environment. Operations must have built-in processes that catch incongruence in real time while it is occurring…not after the bill has flown out the door. RCM systems monitor all administrative and clinical components that contribute to the capture, management and collection of patient service data.

The heart of the RCM process is a team of specialists charged with the responsibility of establishing and implementing policies, procedures, and performance measures and standards.

What RCM is and is not

RCM begins and ends with clinicians 
In order to obtain compliance within the RCM process, coding accuracy is indispensable. For the average home healthcare agency, however, achieving the necessary level of accuracy on a consistent basis is often an impossible dream. Among the most prominent roadblocks to coding success is the speed with which codes change. Dozens of alterations take place each year, seemingly in the blink of an eye. In 2009 alone, a total of 290 new codes were established. 

Coding errors create even more vexing challenges, the majority of which are related to documentation accuracy and completeness. Co-morbidities are missed during this phase, opening the floodgates to improper sequencing and inaccurate primary diagnoses. Clearly, RCM must begin with management’s confidence that assessments are accurate. Crucial to this phase are clinical tools. It is management’s responsibility to assemble the tools — especially comprehensive and ongoing training programs — that will properly channel the critical thinking skills required and expected of field staff.

Then, even with confidence in your staff’s coding and documentation skills, ensure excellence by assigning RN coding experts to review every assessment to see that every plan of care reflects best use of ever-changing codes and regulations. 

Accurate and compliant coding is not only the image of your standard of care that you broadcast to the community. It is the cornerstone of your ability to receive and retain revenue. Getting it right is the best way to grow your business and increase patient and doctor satisfaction with your plans of care. 

Cliché though it may be, there is a bottom line to consider here. Management’s focus on strong patient outcomes through compliance means greater revenue retention and the lowest audit risk. Clearly, effective RCM is a timely solution providing agencies with a foundation for a vigorous bottom line, a solid grip on financial activities, freedom to focus on priorities, and a welcome relief from compliance anxiety.

Ed Buckley is CEO of Select Data, a home care software and clinical services company based in Anaheim, California. He welcomes comments and can be reached at ed.buckley@selectdata.com

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The Face to Face Encounter – UPDATES

Wednesday, April 13th, 2011

On and after April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices to have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and recertification for Medicare hospice services.

There has been much discussion re the Face to Face Encounter required by the Affordable Care Act and a part of the CY 2011 Final Rule. (See page 296 of the Final Rule) What exactly is required? The Face to Face encounter document needs to be part of the physician certification. CMS has added the term “travels together” to describe the relationship between the two activities.
The new regulation requires a patient to have been seen by the certifying physician within 90 days prior to the Start of Care (SOC). If that is not achieved, the patient must be seen within 30 days of admission to the home health agency. The regulation went into effect January 1, 2011 for patients admitted to home health on that date or later. Enforcement began April 1, 2011.

CMS Q&A:
Q: Is the face to face provision applicable to Medicare Advantage Plans?
A. No. The Face to Face provision applies only to Medicare fee for service.

Keep in mind that many private carriers have even more stringent rules on Face to Face visits than CMS. It is becoming very common with many carriers to require physician visits every month while being under the care of a home health agency.

Per CMS, Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.
The physician is required to document on the certification how the clinical findings of the encounter support eligibility requirements as well as primary focus of home care. (See pages 498-500 of the rule). The certifying physician must document that they or a specified Nurse Practitioner had the required face to face encounter (including use of telehealth which is subject to requirements in 1834 (m) of the Act). Also see Publication b100-02 Medicare Benefit Policy 30.5.1 content of physician certification and 30.5.1.1 Face to Face Encounters 3/10/2011.

CMS Q&A:
Q. Can a resident conduct the face-to-face encounter?
A. Only the certifying physician or certain NPPs can perform the face-to-face encounter. Additionally, only Medicare-enrolled physicians can certify home health eligibility, per the Affordable Care Act.

“Since the F2F encounter is part of the certification for home health care, the resident would have to be eligible to certify. Therefore, he/she would need to be authorized by the State to practice medicine and enrolled in Medicare. If the resident met the criteria, it is possible that a resident could conduct this encounter” per NAHC.


The physician must document either on the certification form itself or as an addendum to it that the patient has a condition warranting home health involvement and that the patient is homebound, and has needs for skilled services.
Per the letter sent to physicians from CMS dated 12/10/2011,
• ”The face to face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. While the long standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition.”
• The new regulation effects Starts of Care initiated on or after January 1, 2011.

Q&As:
Q: Can the ER physician caring for a patient during an ER visit and who determines that a patient is in need of home health services and is homebound, and who establishes a plan for home care document the face to face encounter/certification?
A: Per NAHC, yes, with the same caveats as above (regarding a resident).

The physician who conducts and documents the F2F encounter must be the physician that certifies the patient. The referring physician from the hospital may not conduct the encounter and have another physician sign the certification. The F2F encounter and the certification go hand in hand. Another (different) physician may sign the POC.
The final Rule states that agencies may not use “standardized encounter language” on the face to face encounter form that the physician must sign. A “template” may be used that allows physicians to describe the patient’s condition and primary reason for the encounter and referral to home health.

Q&A:
Q. Given the most recent CMS Q&A which seem to indicate that physicians could use drop down menus built into their electronic medical records to document the F2F, does that mean a home health agency can create a form with several checkboxes re diagnoses/reasons for homecare?
A. Many home health agencies are asking CMS what the difference is between electronic drop down choices and checking a box next to the appropriate written selection. CMS has specifically stated that checkboxes can not replace the physician’s narrative.

As a service to our clients and other agency leaders, Select Data has prepared a sample Face to Face Encounter Form for your use. You will note that it meets the requirements of:
• Specifying the individual completing the face to face encounter
• Specifying the date of the encounter
• Specifying the primary medical reason/diagnosis/condition for the encounter
• Specifying additional clinical findings that support home health medical necessity
• Specifying the patient meets the CMS requirements of Chapter 7 Medicare Benefits Manual for homebound status
• Specifying findings of the encounter support the skilled services for home health; SN, PT, S/LP
• Physician signature and Date

CMS has required that the “certifying physician document show the clinical findings of the Face to Face Encounter that supports home health eligibility. The Rule references homebound status and skilled need. It also causes the physician to be certain the clinical findings identified are sufficient to support home health care. CMS Manual System: Pub 100-2 Medicare Benefit Policy Transmittal 139.

Please note the MLN website will have a special edition article which may be found at http://www.cms.gov/MLNGenInfo

Posted in CMS, Compliance, CY2011, Face to Face Encounters, Legislation, Medicare, Teaching/Education | 7 Comments »

Resources

Tuesday, April 5th, 2011

New Surveyor Protocols Effective May 1, 2011.

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Posted in and Other Audits, G Codes, Legislation, Medicare, OASIS-C, Resources, Surveys, Teaching/Education | No Comments »