Accurate coding with the highest level of specificity is required if an agency wishes to remain compliant and to retain revenues received.  Creating and maintaining a strong code of conduct sends a powerful statement to employees, customers, and business associates.

A strong code that is aligned to corporate values and ethics sends a message of comfort to those committed to those principles. Fraud in healthcare is being uncovered at a rising rate. RAC, MAC, and Z-PIC audits as well as HEAT raids have uncovered hundreds of millions of dollars of false claims filed. Because of an increasing mistrust of provider ethics, taking a strong stand is necessary.

The OIG had announced that in 2009 Medicare-Medicaid paid over $54 billion in improper payments. There have been 2500 persons/entities from Federal health care programs. There have been 625 criminal actions with 399 civil actions including actions involving the False Claims Act. There are another 2400 investigations pending. The GAO has reported that improper payments due to fraud and abuse are escalating.

Dollars and processes have been approved to target areas of high risk. Monitoring that the principal diagnosis code accurately portrays the patient’s focus of care is a MAC missive. Probe edits are one such process expected by CMS from the MACs to achieve that goal.

Agencies should design a code of ethics that is easy to understand and tailored toward the business sector served, such as home health or hospice, that clearly delineates expectations. Senior leadership should define the agency mission and the employee expectations.

Be certain that topics such as confidentiality, care of protected health information (PHI), fraud, areas of high risk such as coding and claims management, and conflicts of interest are covered.

When discussing the agency code of ethics, identify processes and data capture that will support the areas of high risk. Coding and claims management is supported by complete documentation. Documentation deficiencies that expose an agency include the following:

Common Documentation Deficiencies:

¡  Repetitive clinical notes are frequently seen stating the same things over and over with no progress patient progress identified; how is it that the clinician is unable to teach a new med successfully within a visit or two?

¡  Notes from different disciplines reflect lack of plan coordination

¡  Visit notes do not substantiate orders and goals on Plan of Care/485.

¡  Clinical interventions without orders.

¡  If a chronic diagnosis is the primary reason for ongoing care, the skilled nurse should be VERY VERY clear as to why (s)he is still making visits.

¡  If visit notes do not EACH stand alone and justify care, the nurses visits are at risk.

The casemix co-morbidities; such as CHF, CAD, COPD, DM, Parkinson’s disease should be included in the diagnoses list. If they are standing alone, the nurse should carefully justify the skilled need because of the chronic disease.

¡  In justifying observation and assessment, note if:

¡  There is significant change in meds, treatments, or conditions

¡  There is teaching and training needed

¡  The condition or disease symptomology has exacerbated or changed in another way

NOTE: the SN care must tie to the POC and the discipline specific care plan as well as the ultimate outcomes.

¡  Teaching on new medications must include instruction or intervention on the related diagnosis.

The clinician providing injections such as insulin, require specific documentation to support the need; specifically why the patient cannot self inject the med such as tremors, impaired cognitive function, and no willing and capable caregiver.

One of the most common home health reasons for MAC claim denial is that the documentation does not support medical necessity. A Code of Ethics supports the CMS Conditions of Participation.

No matter if your agency deals with a RHHI or a MAC, high risk probes are on the rise. The intermediaries are mandated by CMS to monitor areas of greater risk. When they see trends of concern they will launch probes usually of at least a 100 records of several firms. Some of these high risk areas include revenue in relation to diagnoses in relation to visits, certain stand alone diagnoses or diagnoses in combination with certain numbers of episodes or number of visits.

A strong Code of Ethics suggests not only the mission, expectations, and regulatory compliance, but it requires an audit process to verify adherence to expected principles.

Claim Denial Potential

Various diagnoses run a great risk for denial because of probe edits and recertification. If the file is pulled and  there is not “Clear documentation that it is with considerable and taxing effort for the beneficiary to leave home, the episode or specific visits could be denied for lack of homebound status.  (74% of ADRs reviewed for lack of homebound status were denied).”

NOTE: Documentation of “short of breath” does not justify homebound status. Acceptable documentation would include “short of breath after ambulating 10 feet and requires rest period.”

See: The Home Health Industry and Insufficient Documentation/Medical Necessity: Meeting the Challenges of Quality Care and the RACs, MACs, and ZPICs etc at the Select Data Website (Part 1).

Claims can be denied if skilled nursing care is not intermittent.

To meet the requirement for “intermittent” skilled nursing care, a beneficiary must have a medically predictable recurring need for skilled nursing services…at least one every 60 days.”

Your agency corporate compliance audits should be monitoring clinical documentation.

Therapy is under scrutiny

If your agency offers therapy, realize that employees and contractors alike must adhere to documentation requirements to support revenue expected to treat.

Functional ability improvement is expected or why is therapy present?

Therapy may be covered if the patient or caregiver receive teaching that is  reasonable and necessary.

In 2008, claims chosen with 10-11 therapy visits and discharge in episode two had a 74% rate of denial essentially due to poor or insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment. The 2011-2012 changes are rigorous and denials are imminent if documentation is insufficient.

The therapy treatment plan must:

¡  Relate to the exact diagnosis that has required therapy intervention.

¡  Identify visit frequency and duration.

¡  Identify the present and prior functional level.

¡  State specifically the procedures, treatments, and/or exercises to be performed.

¡  Clearly list the reasonable and measureable goals to be achieved.

¡  Care must be specific, safe, and effective supported by the diagnoses according to accepted practice.

¡  Specify the rehab potential.

¡  Specify the discharge plan.

Additional Ways to Decrease Risk

Having a strong Corporate Compliance Program with a serious Code of Conduct can go far to mitigate risk. Audits of work products and processes can alert leaders to the plan’s effectiveness. Documentation must be reviewed routinely.

Adequate documentation begins with the correct diagnosis and being alert for edits. Besides agency PI projects, consider professional coding teams to decrease risk. Third party coding and auditing can provide the buffer needed to diminish risk and increase compliance. It is hard for one or two or a few in-house coders to not only keep up with the average 350 coding changes each year but to also locate the ever changing edits of each FI. The edits are usually disclosed AFTER the MAC probe results. At Select Data, we monitor the FI sites, newsletters, and alerts to dig for present edits so our clients are aware before claim submission.

If You Are Not Auditing, Know that CMS Auditors Are

The goal is to achieve better outcomes, better care, and cost reduction. Each working day Medicare pays over 4.4 M claims to 1.5 M providers worth $1.1 B. Reducing fraud and abuse is a part of the goal to provide the better care, achieve the better outcomes, and reduce cost.

That will be accomplished in a number of ways. The old way of chart sampling to determine care and identify fraud is less used, being replaced by elaborate algorithms in predictive analytics.  Predictive analytics is a combination of data mining and sophisticated statistical techniques concerned with prediction of future probabilities and trends. Patterns are sought in both historical and transactional data that identify risks. The models look at relationships (given a variety of factors; i.e. discipline of care compared to diagnoses and the frequency of care delivered). The risks are assessed within the conditions described.

Fraud and Abuse

Under the Health Care Reform Law, Section 6402d, a health care provider receiving an overpayment now has 60 days to repay the overpayment to the appropriate Federal or State contractor. Exceeding the days allowed for dollar return can trigger liability under the False Claims Act ranging from $5,500 to $11,000 per claim. The Fraud Enforcement Act of 2009 (FERA) expanded FCA liability to include a person improperly avoiding timely repayment of an overpayment whether a false claim was made or not.

Home health agencies should be auditing clinical records carefully to be certain that the clinical assessment supports the plan of care and that each visit supports the medical necessity of the care being provided.

Protecting justly due reimbursement starts with a proper Code of Conduct, proper data gathering, coding to the highest level of specificity with sufficient documentation, and dropping claims according to regulation.

The Code of Conduct is your first line of defense. Proper Coding paints the picture of your agency care. Are you painting a masterpiece or a disjointed scribble?