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NEW PROPOSED CHANGES FOR HOSPICE- Changes Changes Changes: THEY ARE COMING!

Friday, May 24th, 2013

First…

The CMS proposed rule “Medicare Program; FY2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform.” was released April 29, 2013 and the questions have been frequent per CMS. Though the rule includes no proposed changes for payment reforms presently, it does outline the findings from ongoing data collection, analysis, and provides certain choices being considered for future consideration and review. One of the most frequently asked questions, per CMS, is “When will Medicare Administrative Contractors (MACs) begin returning to provider (RTP) hospice claims that have ‘adult failure to thrive’ or ‘debility’ as the principle diagnosis?” CMS has stated “Soon.”

New Proposed Rule: PAYMENTS ESTIMATED TO INCREASE?

For fiscal year (FY) 2014, CMS currently anticipates hospice payments to increase, on average, a net of 1.1 percent based on  the anticipated fiscal year (FY) 2014 hospital market basket update (currently projected at 2.5 percent), reduced by 0.7 percentage points due to reductions mandated by the Affordable Care Act (ACA).  Note that CMS reserves the right to notify the industry this summer of a potential re-estimation ofthe hospital market basket and the changes identified in the Affordable Care Act (ACA).

However, Hospices that failed to report quality measures required under the Hospice Quality Reporting Program (HQRP) earlier this year would have their market basket values further reduced by 2 percentage points

Old Rule Now Being Enforced

Hospices that attempt to submit more than one claim per hospice beneficiary per month will have claims returned beginning on dates of service July 1, 2013. This has been a requirement not reinforced, but will have increased reinforcement, per the January 31, 2013 transmittal

New Proposed Rule: LEVELS OF CARE Estimated Payment Rates

Both the Department of Justice and the OIG are monitoring hospices with long lengths of stay at a general inpatient (GIP) level of care. CMS has an even higher focus of care if GIP is provided in inpatient units of hospice.

Given this fact and many others, CMS included as part of the proposed rule estimated FY2014 payment rates for the four payment categories under hospice. Note the table includes the projected payment rates:

Proposed FY2014 Hospice Payment Rates

Codes Description FY2013 payment Rates Multiply by the FY2014 proposed hospice payment update of 1.8 percent FY2014 Proposed Payment Rate Labor Share of the proposed payment rate Non-labor share of the proposed payment rate
651 Routine Home Care $153.45 x1.018 $156.21 $107.33 $48.88
652 Continuous Home Care

 

Full rate=24 hours of care

 

$=37.99 hourly rate

  

 

 

$895.56

  

 

 

X1.018

  

 

 

$911.68

  

 

 

$626.42

  

 

 

$285.26
655 Inpatient Respite Care $158.72 x1.018 $161.58 $87.46 $74.12
656 General Inpatient Care $682.59 x1.018 $694.88 $444.79 $250.09

 

You can find the FY2014 hospice wage index values at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html.

Levels of care have been and will be an ongoing focus of scrutiny as seen by the CMS filing of a civil suit against one of the largest providers of hospice services, for “submitting false claims to Medicare for crisis care services that were not necessary, not actually provided, or not performed in accordance with Medicare requirements.”  Those requirements necessitate specific documentation. The old adage, “if you did not document it, you did not do it” has real meaning when an agency is attempting to defend itself in this kind of situation.

Old Rule Documentation Requirements.

Be cautious that your general inpatient levels of care (GIP) services documentation can withstand scrutiny:

Prior to transfer to an inpatient setting, ask if the clinical team documented all attempted interventions in the non-inpatient setting and be certain they were documented specifically. Were caregivers involved? Since pain assessment and care is scrutinized, was documentation complete as it related to inpatient care justification? Be specific. Does pain medication administration require skilled clinical intervention not easily or safely completed in the home; ie tubing change? Intensive clinical intervention for significant change in condition such as pathological fracture would require specific documentation but may justify transfer. Also, once admitted to an inpatient setting, initiate the discharge planning process and document the plan. Identify who assisted with the careplan, as well as the expected date of discharge. Again, were caregivers involved?

New Proposed Rule: PAYMENT REFORM DISCUSSION

Though the proposed rule DOES NOT propose payment reform changes at this time, CMS announced it will post the ABT Hospice Study Technical Report on the Hospice Center webpage.

The proposed rule does state future consideration of several potential options  for payment reform:

  • Use of the initial Medicare Payment Advisory Commission (MedPAC) proposed U-shaped model of March 2009 that oiutlined an increased payment at the beginning and end of an episode of care, with reduced daily payments in the center of the episode
  • A possible short-stay add-on to cover the higher costs of patients who are on service for a short time.
  • A possible tiered approach to payment with payment based on length of stay.
  • CMS is also looking at a potential case-mix based system. It is believed by some that is the reason for the stronger reinforcement of use of more than just a primary diagnosis stated on a claim. CMS stated a recent analysis showed that 4 of 5 hospice claims in 2010 only included the terminal diagnosis out of compliance with  ICD-9-CM coding guidelines. CMS has stated that “hospices need to use the ICD-9 coding guidelines when determining the principle diagnosis and all other diagnoses.” In hospice, as in home health, clear coding to the highest level of specificity paints a more complete portrait of the patient and their individualized needs.

A new edit is being considered, which would identify and reject claims without related diagnoses).

New Proposed Rule: REBASING OF ROUTINE HOME CARE

None proposed at this time

CMS RELEASED THE HOSPICE ITEM SET (HIS) draft- It is OASIS-like

Recently, CMS released the Hospice Item Set draft version of assessment forms it expects to be completed for patients on or after July 1, 2014. Section 3004 of the ACA authorizes establishment of a new quality reporting tool/program for Hospices. Per the Hospice Item Set,” For the FY2016 data submission requirements, CMS is proposing that beginning July 1, 2014, each hospice collect data using a n newly created data collection instrument, the Hospice Item Set (HIS).The data item set consists of elements, per CMS, “to collect standardized, pain level data for five domains of care: Pain, Respiratory Status, Medications, Patient Preferences, and beliefs and values.

CMS believes the standardized data collection instrument will allow a more uniform patient-level data collection for quality reporting purposes.

There will be two primary users of this Hospice QRP data; CMS and the public, as the data will all be made available on the CMS Hospice website.

Hospices will submit the data via the Quality Improvement Evaluation System (QIES) Assessment and Processing (ASAP) system for data submission, currently used by Inpatient Rehabilitation (IRFs), Skilled Nursing Facilities (SNFs), and Long Term Care Hospitals (LTCHs).

2014 LOOKS TO BE A VERY BUSY YEAR

There will be an updated OASIS instrument to be implemented. The date and changes are not finalized, but it must be ready for the advent of ICD-10CM which is effective October 1, 2014, which will significantly impact clinical, RCM, and financial processes. And just before ICD-10-CM, starting July 1, 2014, Hospices will be utilizing the new HIS instrument.

Home Health and Hospices will need to start planning NOW for 2014.

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Good Coding: Helps Your Agency Keep Its Revenue Bad Coding: Can Mean You Lose Your Revenue

Friday, May 17th, 2013

PPS has always meant that “close enough” isn’t good enough. A digit off can be costly. Coding to the highest level of specificity can be complex and confusing. CMS has published Coding Guidelines and the Coding Clinic remains the source document for any coding questions.   Per CMS and as per the Federal Register, “The  Coding Clinic by AHA is the US Official Clearinghouse for Coding.”

Agencies have hired coders, some are credentialed, some not.  All usually do not have audits of their coding compliance.  As a result, when asked, “Are you leaving dollars on the table?” most administrators pause.  Most acknowledge they believe their coding may be costing them at least $200-$400 per episode.  Why continue to lose dollars?

Agencies have usually decided to complete their coding themselves, but that is changing.  In the past, agencies have hired coders, certified or otherwise. Some coders are routinely reviewed and audited, most are not.  Most agencies rely on their coders. They put a portion of their financial welfare in the hands of unreviewed coders.  Lessen the worry regarding dollar loss and the quality of your agency coding by instilling specific processes. At the very least, contract for routine third party coding and billing audits.

If you were to use a third party coding firm, be certain they have external audits performed on their coding.  Quality third party coding firms should have quarterly internal audits and annual external audits completed in their firms. Who has audited them? What are the firm’s names?  Yes, the audits are an increase cost, but ar $e you losing 200-$400 per episode of care delivered? Are you flagging your firm for a RAC, MAC, or Z-PIC audit?

You should take a close look at the coding completed in your agency. Look at the use of case-mix diagnoses and at comorbidities. Down coding can be as costly as upcoding, just in different regulatory ways, if it brings on an audit. Have your ADRs increased? Do you know the number of codes used routinely in your firm? Do you know the top 10 diagnoses assigned?  How many of the present 16,000 codes are your coders using? How much will preparing for ICD-10 cost you?  Is a plan in place now? How strong is your coder in anatomy, physiology, diagnostics, and pharmacology? How many of the 68,000 codes will they use?

Experts know that much training is required for ICD-10. If you do not properly prepare, how much more will it cost you? Perhaps it really is time to consider a third party coding specialty firm.

Consider a firm that has experienced, highly credentialed coding specialists. Ask if they employ a full time coding internal auditor. Ask if they have weekly training sessions paid for by the coding firm to keep their coding specialists current. Ask if they have a full time Compliance Officer, a compliance committee, and have current program policies and procedures. Ask if the firms’ employees are required to annually attend corporate compliance and HIPAA inservices. Ask if the coding specialists are reviewed quarterly. Ask about internal and external audits of the coding teams’ work. Ask about their % of documented accuracy as stated by an independent auditor.  If the coding agency is under 97% accuracy documented by independent external audit, look elsewhere. All of the above items are costly to the coding firm but a top coding firm should be investing in quality.

And lastly, identify the coding firm’s indepth ICD-10 curriculum for their coding specialists. Also, identify their overall plan for ICD-10 implementation including their plan for parallel coding of ICD-9 and ICD-10.  Do not continue to lose dollars. Make a move now.

For more information, call 714.524.2500

ICD-9-CM Official Guidelines for Coding and Reporting

Effective October 1, 2008 http://www.ama-assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_full.pdf

The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S.

Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO).

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are includedon the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself.

The following are the CMS ICD-9 Site:

  1. CMS ICD-9 Site

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html?redirect=/ICD9ProviderDiagnosticCodes/

  1. Attachment D

http://www.oasisanswers.com/downloads/HHQIAttachmentD.pdf

  1. Coding Clinic

https://www.cms.gov/Medicare/Coverage/CouncilonTechInnov/downloads/InnovatorsGuide5_10_10.pdf

Operational coding advice and guidelines for ICD-9-CM are published quarterly by the American Hospital Association (AHA) in Coding Clinic for ICD-9-CM (Coding Clinic). The Editorial Advisory Board (EAB) for Coding Clinic consists of representatives of AHA, the American Health Information Management Association (AHIMA), NCHS, CMS, the American Medical Association (AMA), the American College of Surgeons, and other hospital coders and physicians. Four of those parties (AHA, AHIMA, NCHS, and CMS) are identified as Cooperating Parties for Coding Clinic. The Cooperating Parties must agree on the coding guidance before it can be published in the Coding Clinic. Anyone may send issues to AHA for EAB discussion.

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Billing Compliance, Q Codes, Edits and Audits: Compliance in the Home Health Industry an Update

Tuesday, May 7th, 2013

CMS revised the requirements on “April 19, 2013 to delete “and indicating whether services were added to the HH plan of care by a physician who did not certify the plan of care” from the Provider Action Needed” section of MLN Matters numberMM8136 Revised.

Implementation date remains: July 1, 2013

Please see the following updated article.

Statistical Data

Every time an OASIS is submitted to the state, portions of it may be parsed out to state, regional, and Federal groups such as the HEAT, MAC review groups, and Federal special projects in the DOJ and FBI. That means that when a review letter arrives, it may already be too late.

Each time a claim is submitted, it is being reviewed using sophisticated predictive analytics that review a number of indicators including: frequencies, certain HIPPS codes and now Q codes. Is your billing company or department aggressively assisting to protect you?

Each time a diagnosis code is assigned to a clinical record and attached to that patient claim, an audit can be triggered. Is your coding department aggressively assisting to protect you?

Alerts in billing, Q Codes, and with ICD-10 looming, are you prepared?

The Q codes

Recently, CMS issued Change Request 8136 that requests new data reporting requirements for Home Health Prospective Payment System (HH PPS) claims. It is to go effect July 1, 2013, Home Health Agencies (HHAs) must start reporting new codes indicating:

The location where services were provided

The location where services were provided should be reported along with the first billable visit in a home health PPS episode with one of three Q codes: • Small clarification in the wording, but it can mean a BIG difference. Q Codes will be required to identify where the services were PROVIDED not necessarily the place of residence. Note the difference in wording.

1.  Q5001  – Hospice oe Home Health Provided in a patient’s home/residence

2.  Q5002 – Hospice or Home Health Provided in an Assisted Living Facility

3.  Q5009 – Hospice or Home Health Provided in a place not otherwise specified (NO)

Further, changes in the location during an episode must be reported on the corresponding line to the first visit in the new location.

CMS’ requirement to report new Q codes and modifiers could cause claims denials and rejections for your agency. Industry leaders predict CMS auditors will use these new codes to target duplicate services for patients in an ALF.

The patient’s residence is where he or she makes their home. “This may be his or her own dwelling, an apartment, a relative’s home, a home for the aged, or some other type of institution. Refer to www.cms.gov/Outreach-and-Education/Merdicare-Learning-Network-MLN/MLNMatters/Articles/Downloads/MM8136.pdf.com for the entire update from CMS MLN.

These codes also can interrupt productivity if your agency does not have a process in place by July 1 for documenting these services and supplying your billing specialists with the necessary information. Select Data has been providing billing services to the home health and hospice industry for over 22 years. If we can assist, call us.

On another matter…EDITS

Per CMS, in a report released a while ago, the NHIC Corp Medical Review Department reviewed claims selected by three service- specific home health edits between July1 and December 31, 2012. The alert was entitled Home Health Prepay Results. These reviews have found continuing high error rates. The three edits are:

·         5ACO1- billing of the HHRGs 3AFK

·         5ACO2- billing the HHRG 1AFK

·         5ACO3- billing 5-7 visits for full episode

52% of the claims were denied. The top denial reason was 55H3A-skilled observation was not reasonable and necessary. This was the denial reason for 56% of the denials. They cite “CMS Publication 100-02, Medicare Benefit Policy Manual Chapter 7, Section 40.1.2.1 explains that nursing services for observation are covered when the patient’s condition is changeable. Once the condition stabilizes, the nursing services are no longer medically necessary.”

The next highest denial reason stated CMS. was no physician certification (about 15% of denied claims). “The face to face encounter must be documented by the certifying physician.” They referred to Publication 100-02, MBPM, Chapter 7, Section 30.5.1.

“Documentation not supporting the homebound status was the reason for denial in 14% of the denied claims. Reason code 55H2B is appended to the claim when the documentation does not support the patient is homebound.” This was the third most common denial. Homebound status should be one of the first things reviewed by the clinician and the first item reviewed by any coding specialist. If there is insufficient documentation to support homebound status or medical necessity, a coding specialist should not be coding this record as it does not meet Home Health regulations right from the start. Is this a requirement of your coding specialists? It is a standard at Select Data.

The fourth most frequent denial was “physician orders not signed timely.” Another reason found as a denial reason was that” therapy services were determined to not require a therapist.”

Agencies should be auditing records routinely for these errors as well as the completeness of the record. Consider developing or using a chart audit tool. A sample of such a tool can be found on the Select Data website. That tool may be modified for completeness to meet your agency specific needs.

The NHIC Corp Medical Review Department review of specific claims are not the only claims being reviewed. Palmetto GBA recently announced new medical prepay audits based on certain HIPPS codes that have the highest denial rates. While PGBA internally identified the top 20 HIPPS groupings that have the highest denial rate. Here are the two under specific review:

  • 2CGK*
  • 1BGP*

As an agency provider, you should be prepared for possible ADRs on claims with these HIPPS. When an End of Episode claim is submitted using one of the two above HIPPS groupings, Palmetto GBA may place the claims into ADR status and you will be required to submit additional documentation from the chart in order for a determination to be made on the claim either being paid or denied. If you have limited QA resources, these are the charts you may want to focus on.

PECOS is placed on Delay per CMS

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed.   These edits would have checked certain claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If this information were missing or incorrect, the following types of claims would deny:
• Claims from laboratories for ordered tests;
• Claims from imaging centers for ordered imaging procedures; and
• Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS.
• Claims from Part A Home Health Agencies (HHA)

CMS will advise you of the new implementation date in the near future. In the interim, informational edits will continue to be sent for those claims that would have been denied had the edits been in place.

Predictive Analytics for operations and clinical data

In home health care, predictive models are being used to exploit patterns found in historical and transactional data to identify risks and opportunities. The present models capture relationships among many factors to allow assessment of risk or potential risk associated with a particular set of conditions. The relationships should guide clinicians in their care plan decisions as well as care delivery. There are thousands of potential OASIS and coding combinations. Because of the patient profiles and patterns retained over the years, comparisons can be made readily. Add HHRGs and service information to the OASIS and diagnostic data and CMS can gather very significant data regarding your agency care delivery and outcomes. MANY analytic filters are utilized to screen the data.

The initial round of filters are termed MUEs (Medically Unbelievable Edits). These edits are the first predictors of fraud and can alert the Z-PICs of agencies that should be monitored. Auditors may monitor an agency for years, gathering data, analyzing data and patterns, and reviewing payments. The agency profile is completed.

This data and these pre-probe edits allow Z-PICs to have plenty of time to analyze data and monitor agency behaviors so that when they send a letter, they have already completed their initial audit and arrived at a solid conclusion.

Since experts state that 75-85% of all agencies are acutely unaware of business operations data and do not have necessary compliance rules built into or a part of their billing practices to protect them from wrongful claim submission. Agencies are at risk so questions must be asked. Who is auditing your clinical records and care, the ICD-9 coding, and the claim submission? Who is monitoring your data? Do you have clinical and operational benchmarks? In 2009, billing errors were found to have doubled. Be proactive now, because if your compliance rules and program are weak, you could be hearing from the Z-PICs soon.

If you are considering third party ICD-9 (soon to be ICD-10) coding or billing specialty services, consider Select Data, the Gold Standard in these services for over 20 years.  Call us at1.800.332.0555.

 

 

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ICD-9-CM and ICD-10-CM: Some Differences and Similarities

Tuesday, April 30th, 2013

CMS is stating they expect 10% of all claims submitted to be denied with ICD-10 initially. Selecting and assigning accurate diagnoses in the proper sequence must be performed in compliance with Medicare rules and regulations, Coding Conventions and Coding Guidelines. That remains the same.

The accuracy of this information contained in the clinical record is directly tied to payment and to justification for homecare services, so understanding how to select and assign accurate diagnoses is very important. This is the same but the specificity of the documentation becomes very very important. Increased specificity in data means more robust design of algorithms to predict outcomes and care by MACS, RACs, and Z-PICs.

ICD-10-CM presents an even greater challenge for documentation by the clinician. The word “documentation” is stated 72 times in the ICD-10-CM guidelines document.  Querying for additional information is noted 23 times in the same document. The instructions and conventions of the classification take precedence over guidelines which requires a keen understanding of the conventions.

ICD-10 requirements have raised the documentation expectations. Have your clinicians had an overview of ICD-10-CM? Here are just some observations.

  • Coding assignment will be based on the agency’s documentation of the relationship between the condition and the care that is planned.
  • Not all conditions that occur during or following surgery will be classified as complications
  • A cause and effect relationship must be present between the care provided and the condition clearly delineated within the documentation
  • Query for Clarification re documentation that supports codes assigned is expected
  • There will be specific documentation needed for specific codes and without the documentation, the codes may not be used
  • Code only those diagnoses that are relevant, unresolved, and impact the plan of care. Diagnoses that are resolved or have no impact on the plan of care should be excluded since they do not meet the criteria for a home health diagnosis
  • Code only those diagnoses that are supported by the medical record including diagnoses supported by the plan of care and the comprehensive assessment.
  • There are placeholders in ICD-10
  • There is laterality
  • There are sixth and seventh characters
  • ICD-10 requires expertise in anatomy, physiology, diagnostics, and pharmacology

Agency clinicians are expected to understand the patient’s clinical status and overall medical condition very well before approving/assigning diagnoses, so the comprehensive assessment must be ­completed in its entirety prior to the diagnoses decision. All coders should be properly educated on ICD-10-CM including how to use coding manuals properly. 50 + hours are being identified as necessary for each coding specialist to be properly prepared for ICD-10.

Your agency’s integrity and financial health could well depend on your preparation for ICD-10. Selecting and assigning accurate diagnoses must be performed in compliance with Medicare rules and regulations, in addition to ICD-10-CM coding guidelines.

You have choices; either prepare VERY VERY well for ICD-10 or consider third party experts for coding and remove that burden and concern.

Consider joining Susan Carmichael for a general overview of ICD-10CM Coding on May 7, 2013. Check the Select Data website for more details.

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Preparing to Be Surveyor Ready Always? 10 Steps to Success

Tuesday, February 26th, 2013

Educate clinicians to document for clear reading, substantive support for Coding, and to support reimbursement.  Expect QA team members to verify 10 key elements that can lead to successful surveys.

Documentation  Documentation  Documentation is the key:

Have a copy of Publication 100-2, Chapter 7, the Medicare Benefits manual available for every QA member. Use it as a basis for education for all field clinicians.

  •  § 20 – Conditions for Coverage of Home Health Services,
  •  § 30 – Conditions to Qualify for Coverage of Home Health Services,
  •  § 40 – Conditions to Cover Services Under a Qualifying Home Health Plan of Care
  •  § 50 – Conditions for Coverage of Other Home Health Services

1.Home Visit Documentation: To meet the conditions, each clinical note/home visit documentation must contain the following components:

a) Measurable progress towards stated goals listed on the plan of care / 485.

b) Skilled Service provided/Instructed to the Patient and or Caregiver:

CMS states, “A skilled nursing service is a service that must be provided by a registered nurse or a licensed practical (vocational) nurse under the supervision of a registered nurse to be safe and effective. In determining whether a service requires the skills of a nurse, the reviewer considers both the inherent complexity of the service, the condition of the patient and accepted standards of medical and nursing practice.”

NOTE: Every element of the plan of care is based on the assessment of the patient’s condition and must be addressed throughout the course of the home health care. Failure to document the completion or progress toward completion of the components of the care can result in a surveyor citation, as this has been a focus of updated surveyor education.

Remember, it is not quantity of goals listed in Locator 22, but it is the quality and relevance of the goals.

2. Homebound Status:

a). The clinician must identify considerable taxing effort is exerted to leave the home

b). The clinician must note the type of assistive devices utilized

c). The clinician must note caregivers providing assistance

d). The clinician must document type and frequency of skilled care provided

3. Reconcile Care Delivered to Care Planned

It is quality of the plan not the quantity of items on the plan that matters. The clinician must follow every item listed on the plan of care, and document specifically  to the Plan of care established. Note supplemental orders also.

4. Total body assessments

A total body assessment is to be performed and documented at each visit.

5. Note Change of Condition

Complete documentation of the patients change in condition must occur with corresponding change in care plan and any additional orders and goals. Changes must be clearly documented

for each visit as a move to clinical outcomes occurs.

6. Patient and Caregiver Teaching

  • Three Types of Teaching:
  • Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis
  • Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching
  • Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient has had prior instruction

The clinician should note patient/caregiver response/reaction to teachings/interventions in rough percentage of understanding, 20%, 25%, 50% as well as competency of the return demonstrations.

7. Caregivers

There are certain expectations to qualify as a caregiver. They must be willing to provide the care and perform the level of skill necessary and have the ability to perform required tasks. The clinician must document clearly if caregiver or patient refuses to participate in care and not the particulars such  as to why and the date of the refusal.

8. Appropriate and timely communication

Care Coordination with all relevant clinicians, with the case managers and physicians is required. The documentation must be clear and dated.

9. Specific definitive documentation of wounds

The clinician must document wound size, depth of tunneling and other descriptions as well as describing the treatment performed in specific detail at each visit. Wounds may be safely photographed as appropriate. Describe changes in the treatment regime and the ongoing progress communicated with the physician. WOCN consultation assessments as needed and be certain pain levels are noted as well as the patient’s response or lack of response to the medications and treatments prescribed. Do not forget to note alternative means of relief such as heat, ice, massage being utilized along with their effectiveness.

10. Appropriate and timely interventions to problems and deficiencies observed and reported.

Consider a Mock survey once to twice per year to keep everyone sharp, and to identify any incongruent and unnecessary processes that have crept into the everyday workflow. Be certain that when deficiencies are identified, a comprehensive plan of correction must be developed, the corrective actions need to be implemented and monitored to assure continued compliance with state and federal regulations.

Show the Surveyors the proactive plans of correction and your agencies march toward excellence. As you work toward demonstrating your agency value for ACOs, this proactive excellence plan works towards a positive survey, increasing agency value in collaborative efforts and of course, toward quality patient care.

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