Archive for April, 2012

Expect CMS Unannounced Visits after Filing the Revalidation Application

Monday, April 30th, 2012

Do not be surprised if a CMS representative visits your agency after you apply for revalidation. Leaders are identifying that the visitors are taking pictures of the agency building and signage; taking pictures of the state license; as well as requesting copies of agency business documents.

Administrators and owners have cited the CMS representatives presenting CMS badges.  Some have termed themselves as revalidation inspectors, site inspectors, and Medicare representatives while others termed themselves as Medicare Fraud Inspectors. Be certain to obtain a business card and look at the CMS badge closely. But, if you have recently sent a revalidation application, do not be surprised at the visit.

In order to be compliant with the Patient Protection and Affordable Care Act (PPACA) Section 6401, all new and existing providers must be reevaluated under the new screening guidelines delineated in the Act. These new procedures are expected to reduce fraud and abuse. For some providers, the new screening procedures will be more intense, involving the unannounced site visits, fingerprinting, and owner background investigation. For others, such as publicly traded providers, site visits are not designated.

Three Levels of Risk Assigned

In early March, 2011, CMS began basing the above interventions on a rated level of risk. There are three levels of risk per CMS; “limited,” “moderate,” and “high.”

Limited -risk providers, such a physician practices. Because there will be verification that the provider is in compliance with Federal and State guidelines, such as current licensure verification and periodic database checks prior to and following enrollment, the practices are rated limited-risk.. Also, included in the limited -risk category are ambulatory surgical centers, Indian Health Service Centers, mammography screening centers, and rural health clinics.

Moderate – risk providers, can anticipate unannounced visits. This level of provider includes community mental health centers, hospice organizations, and comprehensive outpatient rehabilitation facilities (CORFS). Home health agencies had been placed in this category however,  CMS has recommended this group to be moved to the high risk category.

High – risk providers will be expected to have unannounced site visits as well as fingerprinting and thorough background reviews. Providers in this category include new DME companies and new home health agencies.

Limited and moderate risk providers can be moved to high-risk under various conditions including: allowing one provider to use another provider’s identifier within the CMS program or if a provider has had their billing privileges denied within the last 10 years.
Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) CR 7350 provides the complete list of these three screening categories, and the provider types assigned to each category, as well as a description of the screening processes applicable to the three categories  and procedures to be used for each category. Have your state license posted. Make certain signage is clear.  Demonstrate your compliance with regulation.

We have all read about the stated recent fraudulent activities involving 78 Texas agencies and a physician who, allegedly bilked hundreds of millions from CMS. This new regulation is an additional attempt to minimize the risk of that type of fraud and abuse

To learn more about this new rule, visit: http://www.cms.gov/MLNMattersArticles/downloads/Se1126.pdf.

Tags: , , , , , , , ,
Posted in Affordable Care Act (ACA), CMS | No Comments »

ICD-10 CM is Delayed but NOT for Long Because We Cannot Wait

Monday, April 30th, 2012

HHS proposes a one-year delay of ICD-10 compliance date.

On April 17, 2012 the Department of Health and Human Services (HHS) published a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

Per the CMS website, “The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).”

HHS states that covered entities must be in compliance with ICD-10 on October 1, 2014. The statement was made that providers required the extra year to be adequately prepared for the transition.

Providers have outgrown the present ICD-9 CM system. That system is over 30 years old, implemented in 1979 and has no more room to handle needed codes for new medical conditions or technological advances. It is not always precise or unambiguous. Because the classification system is organized with specificity, each three-digit category can have only 10 subcategories and most of those numbers already have assigned diagnoses.

The ICD was developed in the late 1800s to collect data regarding mortality causes and rates. It is an international classification system endorsed by the World Health Organization (WHO) in 1994 and started to be used by WHO members in 1994. The WHO updates the classification usually every 10 years and is looking to beta test ICD- 11 next year.

ICD-10 is already being utilized in Asia, most of Europe and all of Canada and Australia enabling those 99 nations to share public health data. Implementing ICD-10 effective October 1, 2014 allows the USA to be aligned with those nations. ICD 10 is also available in 36 languages including English, Chinese, Arabic, Russian, and the Romance languages: French and Spanish. Improved clinically coded data is essential in this modern era.

Uses of the Clinically Coded Data

  • Benchmarking and quality measurement: to improve quality and effectiveness of patient care
  • Making clinical, financial, funding, expansion, and education decisions
  • Healthcare policy
  • Public health surveillance (increase ability to track and intervene if global health threats)
  • Reimbursement
  • Research- code analysis is crucial to research
  • Increased specificity in data means more robust design of algorithms to predict outcomes and care
  • Increased coding detail offers capability to find previously unrecognized relationships of diseases and variables

Why ICD-10-CM

  • Bring US in alignment with worldwide coding system
  • Greater coding specificity and accuracy with “full code definitions”
  • Increased capability to measure healthcare quality, safety, and efficiency.
  • Lower Costs through increased efficiencies
  • Decreased reduction in additional information sent to payors
  • Synergistic effects with the Electronic Health Record (EHR)
  • Clearer recognition of medical advances
  • Clearer recognition of technological advances

ICD-10 and better data for QI

  • Decrease in complications and improved patient safety
  • Improved patient outcomes
  • Improved ability to reassure outcome efficiency and costs

There is also improved capability to determine disease severity for audit risk adjustment.

Benefits of ICD-10 CM

Organizational Monitoring

  • Administrative efficiencies
  • Cost containment
  • More accurate trend and cost analysis as well as analyze trend and cost data

Improved coding accuracy and productivity

Reimbursement

  • Increased accuracy
  • Fairer reimbursement
  • Improved justification for medical necessity
  • Fewer errors and rejected claims

Reduced opportunities for fraud

  • To handle the complexities and shear size of the number of codes ICD-10

requires expertise in

anatomy,

physiology, and

diagnostics

  • Besides moving from 13,000 codes to 68,000 available codes
  • ICD-10 allows laterality and bilaterality

ICD-10 specificity improves coding accuracy and richness of data for analysis

The Coding specificity is far greater than ICD-9-CM and the need to better understand A&P and diagnostics is vital. Improved education for coding specialists is necessary.

A Sample Coding Preparation Plan: Phase 1

  • 2012-2013…Assess for coder gaps

as to body system anatomy 15 hrs

as to body system physiology 15 hrs

as to diagnostics/pathophysiology 20 hrs

as to diagnostics/pharmacology 20 hrs

as to medical terminology 10 hrs

A Sample Coding Preparation Plan: Phase 2

  • Organizational leaders need to assess their

– Organizational readiness: forms, clinical software, documentation readiness

- Billing/Support system needs

- EHR system

- Support systems

- Case management processes

- Disease management

- Compliance software

A Sample Coding Preparation Plan: Phase 3

There needs to be:

  • Testing of Coding by parallel Coding  ICD-9 and ICD-10 CM
  • Testing of Billing System for smooth transition
  • Look for misinterpretation by auditors/payors

Be certain everyone has past training goals i.e. understands documentation of medical necessity to code

Sample Coding Preparation Plan: Phase 4

  • Go Live
  • Evaluate processes
  • Evaluate Coding
  • Evaluate Billing

In Phase 1 there is a need to fully review each body system.

  • Choose 2-3 body systems for assessment of need such as:
  • Cardiovascular System

Identify the Anatomy and Physiology of the heart. Prepare pre/post tests.

Identify the Anatomy of the circulatory system and the role of each vessel type

Review categories 100-109 in ICD-10-CM Chapter 9, “Diseases of the Circulatory System.”

  • Explain ICD-10-CM terminology related to diseases of the circulatory system
  • Create scenarios and have coding team gatherings where learning can be fun

These scenarios will allow you to assess gaps and needs

  • Consider use of webinars
  • AHIMA or like courses
  • Online self study may fit certain lifestyles better
  • Have videos/PowerPoints of body systems available

Look at workshops, seminars, lunch and learn sessions

Each body system should be reviewed, such as below:

  • The Heart
    • Has three layers:  endocardium, myocardium, and epicardium
      • Endocardium – membrane lining interior wall
      • Myocardium – thick, middle, muscular layer
      • Epicardium – thin outer layer
  • Pericardium – 3 layer sac that surrounds and protects the heart
  • Route of Blood Flow Through the Heart
    • Blood enters the right atrium from the inferior and superior vena cavas (veins)
    • Blood leaves the right atrium to the right ventricle through the tricuspid valve
    • Blood leaves the right ventricle through the pulmonary semilunar valve to the pulmonary artery to the lungs

Unoxygenated blood

  • Route of Blood Flow Through the Heart
    • Blood leaves the lungs via the pulmonary veins to the left atrium
      • Oxygenated blood
  • Blood leaves the left atrium through the mitral valve to the left ventricle
  • Blood leaves the left ventricle through the aortic semilunar valve out to the body
  • A series of 20-30 slides could be developed to review the Cardiovascular System

These types of reviews could be excellent resources also for specific component answers such as Cardiac conduction

  • Route of Blood Flow Through the Heart
    • Blood leaves the lungs via the pulmonary veins to the left atrium
      • Oxygenated blood
  • Blood leaves the left atrium through the mitral valve to the left ventricle

Blood leaves the left ventricle through the aortic semilunar valve out to the body

  • Cardiac Conduction
    • Sinoatrial node (SA node, called the pacemaker of the heart) à Atrioventricular node (AV node) à Bundle of His à right and left bundle branches à Purkinje fibers

SA node (pacemaker) is located in the upper part of the right atrium below opening of the superior vena cava

  • Discuss disease processes such as:

CAD

CHF

Heart Failure

Use specific terms and processes in the discussions

  • Discuss diagnostic and intervention procedures as well as pharmacology
  • Have teams participate in establishing education plan after gaps have been identified
  • Make certain some kind of training takes place each month, even if it is only a memo about a specific aspect of ICD-10

Keep ICD-10 in front of everyone. Remember, you only have until 2014. Let’s get started!

Tags: , , , , , ,
Posted in CHF, Compliance, Home Health, ICD-10-CM Coding, ICD9-CM Coding, Medicare | No Comments »

The Surveillance and Utilization Review Subsystem (SURS)

Thursday, April 26th, 2012

Predictive Analytics or Provider Profiling? Call it what you want, is your agency being monitored by CMS and/or state Medicaid etal? And, have you directly triggered an alert? Or, are physicians that sign orders for your agency patients being investigated?

Should you be aware that your agency could trigger a PPS RAC, MAC, or Z-PIC audit and that a related party or a referral source under review could trigger an audit of your agency? Yes, that could be a reality.

CMS and related agencies are using predictive analytics to identify aberrant care delivery and utilization patterns for PPS. At the time the claim is dropped, an assessment of multiple patient factors is conducted. These factors may include diagnoses, frequency, and disciplines involved in care. Your agency practice patterns are now being compared to peer groups and may include a comparison to validated benchmarks. Physicians who refer to your agency may be having their practice patterns monitored also, especially if the payor source is Medicaid.

The Surveillance and Utilization Review Subsystem (SURS) is responsible for monitoring claims process for Medicaid, seeking indicators of fraud.  They look for duplicate, inconsistent, or excessive visits in relation to diagnoses and visits provided in State systems.

Section 456.25 of Title 42, Code of Federal Regulations writes that “States are required to have a post-payment review process that allows State personnel to develop and review: (1) recipient utilization profiles, (2) provider service profiles, (3) exception criteria; and (4) identifies exceptions so that the agency can correct misutilization practices of recipients and providers.”

No two state Medicaid systems are the same, thus, there are a variety of post- payment review SUR systems. Some state systems are routinely using tools that can statistically use random sampling with extrapolation for provider reviews. This allows the auditor to identify a current trend and apply the findings retrospectively for a specific past time point. Recoupment dollars can add up quickly using this methodology.

The SURS are also using tools that flag inconsistencies and over-utilization of visits in relation to care delivered at those visits. At times, they may be focusing on specific discipline practices.

States have different practices.  Personnel in the New Hampshire Surveillance and Utilization Review Subsystem (SURS) monitor financial claims for the NH Medicaid plan. SURS review provider claims for fraud, waste or abuse and may refer cases under suspicion to the Medicaid Fraud Unit of the State Attorney General.

The unit also recovers overpayments by using predictive analysis algorithms that search its data warehouse for aberrant claim information. “In addition, SURS in New Hampshire also conducts reviews to determine if recipients are inappropriately using certain types of medications.” This can trigger other areas of investigative need.

Some states are querying relational databases which provide flexible and easy access to years of paid claims and the ability to query real time data along with trending patterns and profiles.

The SURS also use exception profiling as a starting point for case development. Ranked reports can quickly identify outliers. A sample profile might include the following elements:

-Average patients per agency

-Average reimbursement per agency

-Average disciplines per patient

-Average diagnoses per patient

-Average number of patients with labs

-Average number of patients with injections

-Evidence of upcoding

-Evidence of downcoding

Medicaid is monitoring payment for care and now closely monitoring physician practices. Agencies need to be certain that they strictly adhere to the regulations for care provision. A physician who is being monitored now can bring review and audits to those for whom he or she may provide referrals.

Compliance risks have always existed. But now, agencies need to expand those risk mitigation practices to their referral sources as well as their marketing departments. Be certain you and your referral source philosophies are similar.

Quality oriented physicians are also seeking agencies with like philosophies. They too want to improve the patient transition of care.  The bad press regarding 78 Texas home health agencies and the linked Texas physician has raised some physicians concerns nationally re this industry.

Showcase your agency quality programs and excellent outcomes.

  • Work to improve bi-directional communication flow.
  • Establish points of accountability for sending and receiving patient information.
  • Increase the use of case management and professional care coordination.
  • Develop performance measures that encourage better transitions of care that are well documented.
  • Let it be known that your agency supports a strong regulatory culture that offers accountability and effort toward solid patient outcomes.

That well-stated philosophy and agency culture exhibited through employee conversation, patient care, and marketing materials tells all stakeholders involved that your agency strives to be a quality-oriented care delivery provider.

Tags: , , , , , , , ,
Posted in CMS, MACs, Medicare, MICs, RACs, SURS, Z-PICs | No Comments »