In September and October, the ezine and nation-wide teleconference presented by Select Data will focus on Documentation and Compliance. Check the Select Data website for dates for the teleconference:  Documentation Requirements for Compliant Billing.

This week’s article:
Documentation, Edits, and Auditors, Are You at Risk?

Let’s Talk Documentation and Edits

Medicare has been called the “largest wasteful program in the Federal government.” With the expanded overpayment recovery mechanisms and stiffer penalties for those who commit fraud, the Affordable Care Act is committed to increased audits, deterring waste, and stopping those individuals who perpetrate fraud.

CMS will now disallow payment for illegible signatures and lack of documentation to support need or skill. There are widespread edits to AUTOMATICALLY reroute claims at risk for payment errors, for review prior to payment consideration, and to verify that care was appropriate to the plan of care submitted.

The Auditors

We have all heard the acronym auditing groups. They are real and because of the Affordable Care Act they now have more momentum.

¡  RACs- contingency motivated recovery audit contractors (retrospective focus). They are now in place and working closely with the MACs and ZPICs.

¡  MACs (Your Fiscal Intermediary) – can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for overpayment estimation of claims (current and prospective focus).

¡  CERTs- described as the “QI for MACs“ looking at claims payment accuracy.

MICs- described as the RACs of Medicaid

¡  Z-PICs- primary goal is to identify cases of fraud, develop the investigation, and refer to the OIG. If you receive a Z-PIC letter, one can presume they believe they have grounds for pursuit.

¡  HEAT- The more aggressive investigator of essentially DME and Home Health. Using state of the art technology to expand the CMS Medicaid provider audit program. Their raids result in convictions.

¡  Expansion of DOJ/CMS/HHS Inspector General Medical Strike Forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay. Raids in these cities are as recent as September, 2011.

NOTE: Fiscal Intermediaries reviewing denials May 28, 2008- October 31, 2009 identified lack of medical necessity and homebound status unsupported in the medical record. In addition, ADRs were not received in a timely manner.

¡  CMS expects that the patient’s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home.

NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1

The Edits

There are a growing number of widespread edits including diagnosis in combination with related factors or by itself, changes relating to utilization and skill, number of episodes and number of visits.

Are you monitoring the following:

• Parkinsons Disease 332.X > 60 days or more with 10 or no therapy visits.
• Trauma wounds 870-879.
• COPD Long-term 496 with two episodes or more.
• Long-term use of Anticoagulants V58.61 with no therapy ordered.
• 5 Visits in an episode comprised of 1 SN and 4 of any therapy.
• 5 Visits including 1 MSW.
• Hypertension 401.X with 3 episodes or more.
• Daily SN visits with no therapy exceeding 1 episode.
• Chronic diseases as primary diagnosis two episodes or more.

Claims are Denied When

• A matrix shows suspected reasonableness substantiated by lack of documentation
• Orders and plan of care cause alerts
• Homebound criteria not met every visit
• SN visit care is not intermittent
• HIPPS code billed is not validated by documentation
• CAHABA denied more claims in 2009 and 2010 for lack of proper documentation than any other reason.
• Long term claims show lack of documentation for reasonableness. The longer term the care, the more redundant the documentation.

Longer Term Care Edits Triggered

• Parkinsons Disease 2 plus episodes with no therapy.
• Primary Diagnosis COPD 2 episodes or more.
• Hypertension 3 plus episodes.

Skilled Nursing

Skilled nursing coverage is clearly identified in the Medicare Benefit Manual Chapter 7.40.3. If the G Code indicates observation and assessment, then documentation of the patient’s change of condition is necessary and nursing is required until the condition is stabilized. There is a need to note the abnormal symptoms of change such as VS, weight changes, pulse ox and respiratory changes, and/or mental status. There is also a need to document the plan modification and the skilled intervention on each visit. Just observing and assessing without clear intervention will not allow for ongoing payment.

Physical Therapy is a Target

Physical therapy remains a target because therapy documentation frequently remains inadequate and the therapy visits seem to adjust to payment regulation changes. This has triggered the new regulations for 13^th and 19^th visits requirements and 30 day reassessments. Scrutiny of therapy is acute.

In homecare, observable functional ability improvement is expected. Documentation should be clear and concise with objective measurements. To justify therapy for non direct hands-on treatment, therapists must be clear what was taught to a caregiver to qualify it as a necessary treatment. Services provided must be consistent with the severity of the illness originally assessed.

CMS states, “therapy services are provided with the expectation of the beneficiary’s rehabilitation potential that the condition will improve materially in a reasonable and predictable period of time. The term “materially” means having real importance to consequences, to an important degree or perceivable in material form (objectively).”

Diagnosis must illustrate the focus of care. Diagnoses codes must be updated for each episode. The documentation must support the diagnoses, the plan of care, and the treatments.

Diagnoses Edits

Diabetes primary with CHF secondary is downcoded when DM is incorrectly listed as the primary dx. It can only be listed in M1020 when it truly is the focus of care. The documentation must clearly and consistently reflect this focus.

Hypertension as a primary diagnosis for two or more episodes is a clear flag. A clinician must ask, “if the hypertension is unstable for over 180 days, could there be another problem?”

Schizophrenia is questioned when that diagnosis and the corresponding care are not consistent. An injectable med must be supported by adequate need. Why is it required vs the like oral medication?

Daily visits will be at high risk for audit review. They must have documented support with a finite, predictable, and reasonable endpoint. If BID insulin is being administered, an agency would be wise to have clear documentation, each episode, by a Medical Social Worker who investigates and find no willing, able, reliable caregiver to administer the insulin.

Watch out for LUPAs. Your agency should be monitoring the reasons for LUPAs. Trends such as specific physicians or diagnoses should be monitored. Your LUPA level is being monitored by CMS.

One SN visit with 4 therapy visits is an alert. The MACs look for the medical necessity of nursing. If one nursing visit was ordered then there was no plan for intermittent care thus SN will be denied. It will appear to an auditor that the RN opened the case for a therapy only case.

Minimizing  the Risk of Denials

Educate personnel as to how auditors are reviewing claims. Also, make the clinicians aware that auditors are now looking at the clinician as well as the agency.  If the documentation does not support medical necessity, the question becomes, why is the clinician stating the care is needed when the documentation does not support that fact.

Agency internal review should show why the QA/QI clinician concurred with the plan of care and visit documentation provided. Conduct routine audits and find issues before CMS summons you.

Be certain that ADRs are answered promptly. RACs auditors find that one reason they have had such success is because requested items were not provided timely.

In 2011 and 2012, CMS has required that the MACs not only consolidate fiscal intermediary edits but have them uniform throughout their jurisdiction. Agencies should stay current with MAC Alerts and Newsletters. Consider attending MAC workshops and ask that the edits be made available to providers.

References:

CMS Medicare Benefit Policy Manual, (CMS) Pub 100-02) Chapter 9.

www.cms.hhs.gov/Manuals/IOMlist.asp

OASIS Implementation Manual Chapter 3