Archive for February, 2012

ACOs and Patient Centered Medical Homes: Home Health, Have You Prepared?

Wednesday, February 29th, 2012

CMS has, for years, suggested to healthcare providers across the care continuum that they must refine old and create new methods of providing care. Providers are expected to collaborate and coordinate to minimize the fragmentation in healthcare. They need to work together to improve care delivery, efficiency, and effectiveness. Home health care providers should be aware of the new Chronic Care Management Models that include Accountable Care Organizations (ACOs) (see Select Data ezine, January, 2012 ) and Patient Centered Medical Homes (PCMH).

Through collaboration amongst stakeholders, with coordination of expensive chronic care, and with partnership developments, strategic alliances are being encouraged. Is your home health agency ready? What specific programs do you have in operation? Are they evidenced-based? What have been the outcomes? Do you have reliable statistics?

As stated in the January, 2012 ezine:

“Home health agencies should be paying VERY close attention to the latest requirement for home health found in the Affordable Care Act. The Act encourages development of Accountable Care Organizations (ACOs) and provides for “incentives to enhance quality, improve beneficiary outcomes and increase value of care.” (CMS Q&As Section 1899 of Title XVIII)  The ACO becomes a type of managed care organization that may use fee-for- service or capitation payment, and is accountable to patients and the third party payor for the quality, appropriateness, and efficiency of the care provided. Because of the Affordable Care Act, CMS must have an ACO in place by January, 1, 2012.

Some home health agencies have begun aligning with physician offices, hospitals, rehabilitation facilities, and long term care providers to coordinate care across the health care continuum. Home health agencies are becoming members of hospital teams in both general and specialty areas. Agencies which cannot seem to form the alliances may find themselves with declining referrals in the near future. Home health needs to demonstrate their personalized approach to care so they may be appealing to the PCMH team.

Home health agencies should be encouraging discussions among provider leaders of all levels of the care continuum. Patient ultimate outcomes should be shared by all providers. Establishing those mutual patient outcomes is a primary step in a strategic alliance between ACOs and PCMHs.

Hospitals know that the bundled payment pilot begins January, 2013. It is expected that hospitals will be responsible for the patient three days prior to hospitalization, during hospitalization, and 30 days after hospitalization. They will more likely want to work with agencies with proven hospital reduction programs, quality care clinical programs, and positive patient outcomes. Agencies with those types of programs are already aligning to form care transition models to be ready to bill the new CMS ACO.” (Select Data ezine, 1/2012)

Hospitals are also expected to be working closely with primary care practices which have the PPC- Patient Centered Medical Home Recognition. Many practices approved using the 2008 Standards have now applied to meet the 2011 National Committee for Quality Assurance (NCQA) Standards.

The PCMH is defined by NCQA as an innovative program for improving primary care using clear and specific criteria centered around patients and their care needs, working in teams coordinating and tracking care over time. The PCMH program is for practices that “provide first contact, continuous, comprehensive, whole-person care for patients across the practice.” (NCQA, 2011)

Per the NCQA:

“The Patient Centered Medical Home is a health care setting that facilitates partnerships between

individual patients and their personal physicians, and when appropriate, the patient’s family. Care is

facilitated by registries, information technology, health information exchange and other means to assure

that patients get the indicated care when and where they need and want it in a culturally and linguistically

appropriate manner.”

The PCMH is being touted as an excellent way to improve healthcare in this country by “transforming how primary care is organized and delivered. The Agency for Healthcare Research and Quality (AHRQ) defines the PCMH as a model of the organization of primary care that delivers the core functions of primary health care.”

The Patient Centered Medical Home must encompass five core functions and attributes:

  1. Comprehensive Care: The PCMH is accountable for meeting “the large majority of each patient’s physical and mental health needs, including prevention and wellness, acute care, and chronic care.” To meet required standards, comprehensive care must include a patient-centered team that may include physicians, nurses, PAs, pharmacists, social workers, and care coordinators. Large primary practices may have large teams while smaller practices may “link themselves and their patients to providers and services in the community” (NCQA, 2008).
  2. Patient Centered: The PCMH must provide “primary care that is relationship-based with an orientation toward the whole person.”  The standards require a partnering with patients and families that demonstrates an understanding of their unique needs, values, and preferences. The PCMH primary physician and team are expected to assist patients to manage and organize their own care.
  3. Coordinated Care: Care is required to be coordinated across “all elements of the health care system.” This care is considered critical during transition between levels of care with clear and open communication.
  4. Accessible Services: The PCMH is expected to deliver care in shorter timelines with individualized hours of care and 24/7 phone or electronic access to a member of the PCMH team demonstrating responsiveness to patient needs.
  5. Quality and Safety: The PCMH is committed to quality and quality improvement with ongoing evidence-based medicine and “clinical decision-support tools to guide shared decision making with patients and families.

CMS believes that for too long patients have been provided care by disparate systems; a hospital here, a home health agency there, and yet long term care over there. An ACO (created by health care reform law) is expected to include a broad network that will share responsibility for providing care. The ACO must be able to show they can provide care better than the singular services. Home health agencies should consider establishing patient populations of mutual interest and present evidence-based practice interventions that are likely to improve quality, diminish decline, and improve patient satisfaction not merely in one level of care but across that continuum.  NCQA released its ACO Accreditation Standards in 2011.The NCQA approach to ACOs emphasize patient-centered primary care; use of measurement techniques that improve health care, and high standards for care coordination.

The CMS ACO initiatives were launched January 1, 2012, but ACOs were already being explored not only for Medicare but for other payor sources as well.  ACOs, theoretically, would make the providers jointly responsible for care and offer incentives to achieve quality outcomes yet, make a profit. There would need to be a seamless way to share information.  They would encourage standardizing care to reduce variable clinical practices. It is expected that those who would achieve the quality and financial goals would retain a portion of the savings.  The amount or percentage is yet to be determined.

To work together with agencies with like values, goals, and evidenced-based processes could challenge present regulation. Would this mean the regulation regarding the hospitals discharge policy involving a referral list of local agencies would be changed? It would seem that would be needed since the hospital would be working with agencies that were a part of their ACO. Also, under a hospital led bundled payment, hospitals it would seem, would want to transition patients to agencies with specific programs in place to prevent readmissions. Agencies should be developing programs NOW that can significantly reduce emergent and inpatient care. Outcomes will play a larger role as to which agencies will be chosen as ACO members.

NCQA views primary care as the foundation of the health care system. The primary care physician/team is frequently the first point of contact. The NCQA new standards require a patient survey to help drive quality improvement. It also requires involvement of patients and family in quality improvement. In addition, tracking care over time is necessary. Reducing fragmentation, involving patients and families actively, while transitioning through levels of care is a primary goal of the PCMH and the ACOs.

Home health agencies should be prepared to statistically present outcomes and be ready to participate actively in devising a plan for sharing information. The need to dramatically alter home health care delivery is upon us. Agencies need to be prepared for this change. Be open and receptive to collaborative practices. Be prepared to assist in standardizing teaching and discharge planning instruction. And one other point: CMS is subtly suggesting that discharge planning will soon evolve into transitional planning as the patient moves from one level of the care continuum to another. Be prepared for that transition or face the potential consequences.

Before and after home health care could well be the PCMH. Home health agencies may need to blend into that model. No matter what, data, statistics, and analytical analysis will be vital and an integral part of any Chronic Care Management Model. Are you prepared…or preparing?

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Auditors are Making Their Presence Known: Prepare for RACs, MACs, and Z-PICs

Wednesday, February 29th, 2012

Because we have received calls asking about RAC audits, we have included a PowerPoint regarding RACs and suggested below preparation you may consider doing NOW. We are also re-releasing segments of a prior ezine.  Click here to view PowerPoint slides

Below are some questions that you may already know, but of course, need to know about your agency and delivery of service:

What are your agency case mix averages by admission?  by clinician? by diagnosis?

Do you know your top five diagnostic patient profiles?

How do you set visit frequencies? Formula-based or just “what seems right” or a formula plus reflective clinical assessment?

Are you making visits that have no impact on patient outcomes?

Are you auditing for homebound status?

Are you auditing documentation for medical necessity?

What is your cost per visit by discipline?

What is your recertification percentage?

Do you know your supply utilization per patient?

Does supply usage have adequate supportive documentation?

Do you know what coding, operational, or billing edits you are routinely triggering?

How are you applying the data collected to your business processes?

The RACs, MACs, MICs, and Z-PICs are now in place. The auditors are expected to perform. They have been chosen based upon performance.

Algorithms and Matrices are in place using Predictive Analytics.

Per Wikipedia, predictive analytics “encompasses a variety of statistical techniques from modeling, data mining and game theory that analyze current and historical facts to make predictions about future events”.

CMS is using predictive models to identify patterns found in transactional data gathered to identify risks and potential future behaviors.  They are looking at diagnoses in relation to visit frequencies and recertifications. They are looking at HIPPS scores compared to visit frequencies and durations. They are looking at predictive models that capture relationships among many factors to allow assessment of risk or potential associated with a particular set of assessment/care frequency/payments expected. In other words, what are the guiding decision-making factors for agency transactions? This is one reason why there needs to be rhyme and reason for visit frequency and patient diagnoses and care needed.

Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future. That behavior is then compared to other agencies’ behavior in order to calculate risk, then encompasses models that seek out subtle data patterns that  answer questions about that agency’s overall  performance. These analytics quickly become fraud detection models.

The MACs are using predictive models to perform calculations during live transactions to evaluate the risk or opportunity of a given agency transaction, in order to guide a decision. Individual agency modeling systems can simulate likely human behavior or reaction to specific situations.  The new term for animating data specifically linked to an individual in a simulated environment is avatar analytics. Hopefully, CMS is not there yet but gaming experts ARE employed by CMS.

The government is serious about attacking fraudulent behavior. The danger that exists is that some agencies not intending to commit fraud, but who are not auditing their data submitted, may be triggering alerts. Home Health Agencies can no longer afford to provide care without auditing the assessment, the care predicted, and the care provided.

The RACs have also identified that insufficient documentation for medical necessity will be one of the first area of focus for their audits. But, no agency should believe that only therapy documentation will be scrutinized. Skilled nursing with observation and assessment O/A continues to be high on the list for visit and episode denials.

What happens if compliance measures are not employed? Targeted Medical Reviews (TMRs)/(ADRs) Additional Documentation Requests will rise. There will be claim denials and Medicare audits.

CMS has Unleashed the Auditors

Annually, CMS receives 1.2 billion claims. That breaks down to 4.3 million claims per work day, 574,000 claims per hour, and 9,579 claims per minute. Fraud and abuse are on the rise and the pressure is on.

CMS has unleashed the age of the auditor with the advent of the RACs, MACs, CERTs, MICs, Z-PICs, and now, the HEAT.

RACs- The contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, mostly due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, these auditors are expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only 22 cents for every $1.00 recovered. They are now in place and ready to go at measure. Certain RACs have been held back until all MACs were in place. That is now completed.

MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There are 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for over payment estimation of claims (current and prospective focus). MACs have power and Congress is encouraging them to use it.

Z-PICs – Zone Program Integrity Contractors will perform Medicare Program integrity functions for CMS. They will interact with each MAC to handle fraud and abuse issues within their jurisdictions. ZPICs are seen to consolidate the work of present CMS Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) and are divided into 7 zones.

The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time.  That power can cripple or financially devastate an agency.

CMS states that their mission includes, “providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and the private sectors.”

Can Audits be Prevented?

Maybe not, but exposure for paybacks can be limited by enacting solid compliance measures.

Prepare now. Be aware of what other providers have faced with auditors.

Be certain a clinical documentation chart audit is available for all disciplines for clinical records.

The following items should be included in every clinical note:

Homebound status: Identify what taxing effort was exerted if a patient left the house since the last clinical visit. Be certain all assistive devices are listed and/or the caregivers needed, the purpose for leaving the home, and if this was expected and/or a part of the careplan.

Identify what skilled the visit. If teaching was conducted, was it initial teaching, reinforcement teaching, or was it re-teaching? Identify in objective terminology measureable progress towards goals; ie for the psych nurse, what evidence toward cognitive structural behavior was identified? For physical therapy, how many feet were walked since the last visit and where does this relate to the plan? For the SN, did the patient identify at least two key side effects for their medications? Does the patient know what their medication is for and what it is expected to do for them? Do they know how to safely take their medications?

Compare the Visit Notes to the POC: Compare the visit note to the plan of care that is developed by the clinician based upon the assessment. Have physician orders or notification for changes in condition. Note all change of condition clearly.

SN should be reviewing the body systems noting VS and pain assessments.

When Teaching: Note if the teaching is New, Reinforced Teaching, or Reteaching of the same subject to, perhaps, another caregiver. Note the caregivers willingness and capacity to learn and carry out the learning skills. Note the patient and caregiver’s learning in percentage; ie 10% or 70% or 80%.

Interdisciplinary communication: Comments to the physical therapist or the home health aide or other disciplines should be clearly noted. The visits should show the progress of the care in relation to the plan of care.

Specificity of wounds, skin conditions, falls risk, depression, and the focus of care are necessary. Auditors look for detail; for reasons that support skill. No skill can mean denial of visit payment.

For Diabetics Receiving Insulin

Be certain homebound status is clearly and adequately documented.

Skilled Visits must have skill identified such as specific instructions.

Return demonstration responses by the patient or caregiver should be documented. Note the patient or caregiver’s ability to follow their diet. Give examples to support diet and meal planning learning.

Caregiver willingness and availability should be specifically noted on each visit.

More Strategies

Review all claims against known edits prior to submission.

Have a system that prevents claims from being submitted without a signed physician order.

Counsel and hold clinicians accountable for accurate, complete, and concise documentation that matches the planned care expectation.

Clinicians must now be aware that surveyors are looking at their assessments, discipline specific plan of care, the overall plan of care, the visit documentation outlining care provided and patient response, and the outcomes at the episode conclusion. The diagnoses listed in M1020/M1022 must be compliant with ICD-9 coding guidelines, be unresolved, must read as the table of contents for the clinical record, and must be supported by the clinical documentation.

RAC auditors use clinicians and coders on their team to provide more specific auditing. Ask your clinicians: could their visits withstand that kind of auditing review?

Consider peer review sessions at your agency. Proud clinicians want their peers to think highly of them. Peer Review audits can be an excellent defense against a RAC audit and can be enlightening to clinicians as to what is expected as well as a motivation for excellence.

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Posted in Home Health, MACs, Medicare, MICs, OASIS-C, RACs, Z-PICs | No Comments »

Bulletin: ICD-10 is Still Coming. The question is WHEN.

Friday, February 17th, 2012

Yes, it is true that on February 14, 2012, CMS Acting Head, Marilyn Traverner, told the press that CMS will “reexamine the timeframe” of implementation of ICD-10 CM. She stated the timeframe will be examined through the rule making process, but no word as to when that process will begin.

The AMA lobbied hard for the delay of the ICD- 10 morbidity classification. On the other hand HIMSS (Health Information Management Systems Society) stated that ICD- 10 is “the very basic foundation of healthcare change”.

As we all are aware, ICD-10 will replace a 30 year old system that has not kept up with modern terminology and clinical practices. ICD- 10 offers detailed information on the patient’s condition through specific diagnoses. It is expected to allow upgrading of current data analysis of both diagnoses and procedures with improved care management for patients/clients as an outcome. It has increased capability allowing for far greater detail of the patient’s illness.

Because of increased specificity, the expectation is that interventions for chronic diseases will occur sooner. ICD-10 will allow tracking of disease severity and progress measurement as well as design educational programs for disease clusters identified. It is also expected to identify disease groupings that “may merit special attention” as well as the designing of new care management programs. It allows the US to work more closely with other countries.

The new system gives a much greater granularity to classifying disease and injury.  For instance, ICD- 9 still includes categories for injuries rarely seen, such as accidents in chicken coops and opera houses. It also has only 5 digit codes with no room for expansion.

HIMSS believes that there is “achievable value in the adoption of ICD-10″ by the original deadline, the group said in a 2/10/2012 press release.”The use of this more robust and upgraded data classification system, with the capacity to include current medical knowledge and 21st century patient procedures, will improve health care.”

Many healthcare experts believe that, at best, the ICD- 10 system is delayed for a short time only. The system has real merit, is needed for the specificity and accuracy required, and the US, in order to work with most other industrialized nations, must recognize that other countries are already using ICD 10.

As America considers when to implement ICD-10, ICD-11 is already in the works. The WHO, (World Health Organization) which already hosts an alpha-draft on its website, hopes to have a public beta this spring and a working version up in 2015.

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Posted in CMS, CY2012, ICD-10-CM Coding, ICD9-CM Coding, Medicare, MICs, OASIS-C, RACs, Z-PICs | No Comments »

CODING 2012: ICD-10-CM is Upon Us Next Year

Friday, February 17th, 2012

Agency leaders know that now more than ever, coding is driving payment and is a focus of audit by RACs, MACs, and Z-PICs. It is imperative that the primary diagnosis, primary secondary diagnosis, and sequencing of all codes clearly delineate the picture of the patient and his/her condition. The codes are the Table of Contents in the home health chapter of the book known as the patient clinical record.

Agency leaders want appropriate payment and compliance. Equally important, they want to retain that payment received. At VNAA’s 30th Annual Meeting In early May, 2012 preparing for ICD-10 will be discussed in depth, but what are some of the general concepts and constructs that differ from ICD-9 CM? To prepare for this grand change, what should you do? Commit to learning about ICD-10 CM. It impacts more than just the coding department. Everyone in your agency will be impacted.

CMS is preparing. While Home Health Agencies were focusing on new CY 2011 regulations and plenty of changes last year, agency leaders were aware that there was a change to Version 5010 for handling electronic claims. CMS will still accept Version 4010 claims for a short period. This billing change was necessary in preparation for ICD-10 CM scheduled for October 1, 2013.

The ICD-9 CM Coordination and Maintenance Committee

“Recognizing the ICD-9-CM as a dynamic statistical tool that must be flexible to meet expanding classification needs, the ICD-9-CM Coordination and Maintenance Committee was created as a forum for proposals to update ICD-9-CM.  A representative from the National Center for Health Statistics (NCHS) and one from the Centers for Medicare and Medicaid Services (CMS) co-chair the ICD-9-CM Coordination and Maintenance Committee meetings.  Responsibility for maintenance of the ICD-9-CM is divided between the two agencies, with classification of diagnoses (volumes 1 and 2) by NCHS and of procedures (volume 3) by CMS”. (http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm).

The ICD-9-CM Coordination and Maintenance Committee’s role is advisory. The Director of NCHS and the Administrator of CMS make all final decisions. Final decisions are made after the December meeting and become effective October 1 of the following year. Official code revision packages, which are referred to as addenda, are available from this site.

The transition to ICD-10 is a major change for the industry. To better effect that transition as well as the Version 5010 to handle electronic claims, the ICD-9-CM Coordination and Maintenance Committee proposed and accepted a partial freeze. This freeze identifies:

  • The last regular annual updates to ICD-9-CM and ICD-10-CM were made October 1, 2011
  • Limited updates to ICD-10 CM for October 1, 2013 (ICD-10-CM is expected to be fully in use in Home Health by 2013)
  • Full regular updates to ICD-10 CM to be reinstituted October 1, 2014

What is ICD-10 CM?

  • ICD-10 CM is the US “Clinical Manifestations” of the World Health Organization (WHO) ICD-10 Code Set.
  • ICD-10 PCS is a US creation for procedure codes only that will essentially be used in the acute care setting.
  • ICD-10 CM brings the US in alignment with the worldwide coding system.
  • ICD-10 CM offers greater coding specificity and accuracy.
  • IVD-10 CM offers increased capability to measure healthcare quality, safety, and efficiency.

Transaction version changes (X12 version 5010) must be in place to handle the new codes and its seven digits, thus the changes for billing this year.

CMS states, ICD-10 is markedly different from ICD-9 and they expect adjustment reaction to cause slowing in payment. Many coding experts believe that, with proper planning, that need not be the case.

“ICD-10 requires changes to almost all clinical and administrative systems. It requires changes to business processes.”  Per CMS

Why Must We Change to ICD-10?

  • ICD-9-CM is over 30 years old.
  • ICD-9 CM has no more room to add new codes or keep pace with current classification of Medical conditions or technological advances.
  • ICD-9 CM is not always precise or unambiguous.

US mortality data is being reported in ICD-10 thus making comparison of mortality and morbidity difficult.

ICD- 10 CM offers:

  • Lower Costs through increased efficiencies
  • Synergistic effects with the Electronic Health Record (EHR)
  • Clearer recognition of medical advances
  • Clearer recognition of technological advances

What are some of the Differences between ICD-9-CM and ICD-10-CM?

ICD-9-CM

17 chapters and V and E code chapters

13,000 disease codes plus V and E codes

3,000 procedure codes in Volume 3

3-5 digits in disease codes

Essentially numeric system

Codes usually do not indicate timing                                                                                            encounters

No differentiation between left/right

ICD-10-CM

21 chapters- V and E codes in disease chapters

68,000 disease codes, including V and E codes

87,000 procedures codes in ICD-10-PCS

3-7 digits in disease codes

Alphanumeric system

Codes specify initial and subsequent encounters

Differentiates between the right and left

Solid understanding of  anatomy, physiology,  and diagnostics will be a must.

In May, come to the session:  Start Preparing NOW for ICD-10 CM Coding and receive a plan for your coding teams’ educational preparation needs with examples of how to review anatomy, physiology, and diagnostic essentials.  It may seem like ICD-10 is far away but, an additional 55,000 diagnostic codes, a change in chapters, and required increased coding specificity to the 7th digit means increased risk for payment and more importantly, increased risk for payment retention. If your payment retention becomes in question, can the MACs, RACs, or Z-PICs be far behind? Could you survive what is coming with the coding preparation you have right now?

This article was written by Susan J. Carmichael MS, RN, CHCQM, COS-C, FAIHCQ, Susan is the Executive Vice President, Chief Clinical Officer and Chief Compliance Officer for Select Data, a national firm providing Revenue Cycle Management services, software, and process solutions to the home health industry for over 20 years. Susan has held C Level positions for nonprofit, and publicly traded home health firms. She has taken agencies to both the American and NASDAQ Stock Exchanges, has grown multi-state Medicare-Medicaid/Private Duty/Staffing agencies by both acquisition and native growth, and is credited with growing one firm from billing $114.00 (first week) to $515,000 per week in less than five years. Susan’s latest publication was The Remington Report, July/August, 2010Recovery Audit Contractors (RACs): Seven Major Changes to the Permanent Program and in the September/October issue: The RAC Attack: How to Prepare and Manage the Audits. Susan is a frequent requested speaker at state association conferences on industry topics, including OASIS, Coding, RACs/MACs/MICS/Z-PIC audits, and Corporate Compliance program essentials.

VNAA is proud to have Select Data as an Associate Member and Member Update Sponsor. Please support our sponsors like Select Data that support VNAA by visiting their Website and checking out their services.

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Posted in CMS, CY2012, Home Health, ICD-10-CM Coding, ICD9-CM Coding, MACs, Medicare, MICs, OASIS-C, RACs, Z-PICs | No Comments »