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Practical and Succinct Solutions to Coding: Obstacles Facing Home Health Coding Accuracy

Wednesday, December 26th, 2012

The Forces are Coming Together for 2013:

  • Changes in Case Mix Dollar Payment
  • Coding Changes
  • Survey Sanctions
  • Increased Audits
  • Confusion re newer requirements; ie F2F and Therapy
  • New Chronic Care Models
  • Affordable Care Act
  • And Everything starts with Solid Coding


Changes to 1024

  • Significant loss of payment expected: The inability to assign resolved conditions such as skin ulcers could cost 6-12 points. The latter could cost as much as $700 per episode.
  • If Agencies cannot report conditions resolved through surgery
  • Presently case-mix points are garnered  with use of these diagnoses
  • CMS proposes that only fracture codes to be placed in M1024

What does this mean? This means a loss of casemix and dollars so documentation must be stellar and every other code must be accurate.
The Coding Specialist is the one who can verify adequacy of initial documentation for the codes assigned, but more importantly, that means: verifies the reasons for the episode of care.
If your coder is not challenging documentation adequacy and specificity, raising questions for the clinician and the physician, and asking for H&Ps and other data, you may be at risk.

  • Is your coding team looking at the functional scores of M1800?
  • Do your clinicians understand how to answer that question? Clinicians may mark “0” as default answer just because the patient lives alone or does not have a caregiver. “0” or “1” is to be used when the patient has a high level of functionality

Incorrect answers mean increased audit risk. This M question supports reimbursement and is a focus for audits

Proper Coding Sets the Scene for Improved Outcomes

  • Coding is not just assigning a code to a diagnosis. It is so much more!
  • The clinical assessment must be complete enough to drive and justify a plan of care  for 60 days prospectively
  • Auditors look at OASIS answers
  • They look at the diagnoses code because those codes tell them about the patient and their needs

The frequency and duration must be in sync with the diagnoses assigned
The Coding Specialist should be asking the questions that prompt the precise documentation required.
Precise Coding means Increased Coding Specificity.

  • Diagnoses and the ICD-9 codes reported on each and every claim must match the diagnoses reported in M1022
  • The OASIS, POC, and the UB-04, must all match

Added to that is the primary reason the physician ordered home health care. Let’s discuss F2F.

  • M1016  refers to diagnoses requiring Medical or Treatment Regimen changes within the past 14 days prior to the SOC
  • The diagnoses of the past 14 days prior to the SOC must be listed

Are the coder s requiring completion of M1016 by the clinician? Surveyors can ask who is completing the OASIS questions. Remember the regulations, only one clinician completes the OASIS integrated assessment. This is NOT to be completed by a coder or clerk.

  • M1020a/M1022b/M1024a-f
  • Must be cautious as to risk of up-coding and down-coding
  • Sequencing must be reflected by specific documentation

Record must reflect homebound status and medical necessity or it can not be coded. Is that verified first?
Has the coding specialist assessed that there has been a review of each medication?
The coding specialist must be certain substantive documentation exists to support each and every code assigned or the code must be omitted or documentation must be obtained.

Does Your Agency Employ a Skilled Internal Coding Auditor?

  • Do you employ an internal auditor sampling coding monthly for accuracy?
    For instance, have you audited wounds and useage of the correct aftercare code? There is a significant number of codes This is an audit focus.
  • Frequently, audits reveal the coder was unaware that aftercare for traumatic fractures is excluded from V58.43 and should instead be reported with codes V54.10-V54.19 (Aftercare for healing traumatic fracture).

This is one of, at least 10 areas that should be audited.
There should be a review checklist for the OASIS, the POC, the UB-04, Codes must match on all three documents
The documentation must substantiate the codes chosen
The codes can significantly impact reimbursement and result in under or up coding. Can you afford the Risk?

  • The coding specialist is seeking clarification of medical necessity, viewing clearly defined goals, and proper diagnostic codes

Therapy Documentation

  • 6/30/11 large firm had to settle with DOJ:

Price $65 million dollars! This was related to primarily therapy overutilization not justified by assessment or plan of care. That was expensive lack of documentation.

  • If 781.2 Abnormality of Gait is used to justify PT care, PT needs specific documentation to support gait and balance and strength e.g. TUG or Tinetti Test Tools. Gait training should be specific with objective measurement progress. The gait should be described specifically and graphically; ataxic, spastic, staggers with increase in ambulation of ___feet this day. Lack of documentation specifics means the coding team must request more detail.

Is your coder verifying the detail of the therapy documentation?

  • If 719.7- Difficulty in walking is coded, the therapist should be clear that this is due to e.g. degenerative and chronic joint disease. This code is used for e.g. gait deficiencies due to lower extremity joint stiffness or effusion. If this is not documented the visit is at risk as is the plan.

Is the coding team requesting documentation to support the diagnosis?

  • If muscle weakness 728.87 is coded, there should be manual muscle strength tests indicating weakness. The therapeutic plan should have specific exercises and goals related to the weakness. NOTE: Absence of a specific exercise plan can jeopardize visit payments.
  • Who is challenging therapy for the SPECIFIC documentation needed?

Do you have Matrixes for M questions? They are needed for consistency.

RACs, MACs, Z-PICs: The Auditors are Unleashed

  • What are your agency case mix averages by admission: clinician: diagnosis?
  • Do you know your top five diagnostic patient profiles?
  • How do you set visit frequencies? Formula-based or what seems right?
  • Are you making visits that have no impact on patient outcomes?

Are you auditing for homebound status?

  • Are you making visits that have no impact on patient outcomes?
  • Are you auditing for medical necessity?
  • Does supply useage have adequate supportive documentation?

Do you know what coding, operational, or billing edits you are routinely triggering?
Are you auditing documentation for medical necessity?
What is your cost per visit by discipline?
What is your recertification percentage?
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 Matrixes are in place using Predictive Analytics.

  • CMS is using predictive models to identify patterns found in transactional data gathered to identify risks and potential future behaviors.  Auditors 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?

  • Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future. Poor coding performance places an agency in jeopardy.
  • 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.

  • 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.

  • 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 per the OIG as new fraud and abuse countermeasures are put into place.

  • 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. An increasing number of agencies are seeking outside expertise.

Retaining Your Dollars

  • Be certain a clinical documentation chart audit is available for all disciplines for clinical records, documentation must be consistent, complete, and defendable..
  • 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. Initially, this is reviewed by coding.
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 Visits to the POC: Compare the visit to the plan that is compared to 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 Re-teaching 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 70% or 80%.

  • 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. Recertification requires significant specific documentation
  • 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.
  • This information is reviewed by the coder for recertification.

Survey Sanctions begin in 2013
Getting a citation is never pleasant, but in 2013, it could also become expensive if your agency is not in compliance with CoPs, has repeat deficiencies,  and if the patient is placed in jeopardy.

  • The  rules  place much more pressure on a home health agency requiring  excellent documentation of care following a careplan that is consistent with  the needs identified in the patient clinical assessment.
  • It will require coding to the highest level of specificity.

If outcomes are not achieved because needs were not appropriately identified, visits were missed, or care was not appropriately delivered, an agency could face sanctions.


Does your Coding Team challenge the adequacy of the documentation to support each diagnoses?

  • Care should be modified for Patient Response
  • Decrease frequency as safety and learning is achieved
  • Well established care, properly coded prompts outcomes

Eliminate missed visits, poor compliance, patient and caregiver disconnect

  • Looking for Responsible Reasonable Rehab services as well as general care delivery
  • Contractors are the agency responsibility
  • Are orders and goals tracked and updated?

Does the Recertification process require a review of the prior episode coding? Will your recertification reflect real Need?


Are You Planning for ICD-10?

  • You should have a Solid Plan in Place NOW!
  • “ICD-10 requires changes to almost all clinical and administrative systems. It requires changes to business processes.”CMS
  • ICD-10 is one of the most significant events   planned for the industry.

   It impacts all Home Health departments.
Training needs exist for Coding, Billing, Nurses,
Therapists, Office personnel, IT, and others

  • 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
ICD-10 Codes provide greater detail in diagnoses and procedural description
Greater number also. 16,000 to more than 68,000 codes. Use of combination codes
ICD-10 codes have up to 7 digits and more alpha characters. The first digit is alpha. A code will be considered invalid if not coded to full number of characters (3,4,6,7)
Systems will be required to accommodate ICD-10 codes

  • Injuries are grouped by anatomical site rather than injury category

Post operative complications have been moved to procedure in the specific body system chapter

  • ICD-9-CM   Digits 2-5 are numeric
  • ICD-10-CM  Digits 2 and 3 are numeric, digits 4-7 are alpha or numeric
  • ICD-9-CM  Decimal point after 3rd digit
  • ICD-10-CM Decimal point after 3rd digit
  • ICD-9-CM  Dummy placeholder? NO
  • ICD-10-CM  Dummy placeholder? YES
  • ICD-9-CM 17 Chapters and V/E code chapters
  • ICD-10-CM  21 Chapters- V/E codes in disease chapters
  • ICD-9-CM 13,000 disease plus V and E codes
  • ICD-10-CM 68,000 disease codes, including V and E codes
  • ICD-9-CM  Codes usually do not indicate timing encounter
  • ICD-10-CM Codes specify initial and subsequent encounters
  • ICD-9-CM   No differentiation between left/right
  • ICD-10-CM  Differentiates between right and left
  • ICD-10 Requires expertise in anatomy, physiology, and diagnostics

The Coding specificity is far greater than ICD-9-CM and the need to better understand A&P and diagnostics is vital.

  • Billing and Eligibility Transactions
    • New codes mean greater specificity
    • Means detailed documentation

CMS states there will be increased rejections, denials, and pends as both plans and providers get accustomed to the new codes.


Technology Impact Includes

  • Modifications to Field sizes
  • Alphanumeric Composition
  • Decimal Use
  • Redefining Code Values
  • Edit and Logic Changes
  • Table Structure Modifications
  • Forms Interfaces

Business Ops

  • Modifications to Field sizes
  • Alphanumeric Composition
  • Decimal Use
  • Redefining Code Values
  • Edit and Logic Changes
  • Table Structure Modifications

Time for an Important New Year’s Resolution

  • If You are Comfortable that your coding Team can be educated fully and completed in time and be trained economically- Start your Transition Plan NOW!!

Include Anatomy, Physiology, Pathophysiology, Diagnostics, Pharmacology training for Coders and Clinicians. Accent the specificity needed.
Get the entire plan for all departments in place. Verify your clinical software provide, billing clearinghouse, and billing software vendors have a strong plan in place and care share with you when you will be able to parallel coding.
If you are already concerned about reimbursement and cannot afford to not only send your coding team for the over 50 training hours experts say are necessary but must also incur the cost of a replacement team to code and incur the costs of parallel coding (ICD-9 and ICD-10 simultaneously months prior to October 1, 2014, then you should consider third party expertise.

Posted in HEAT, Home Health, ICD-10-CM Coding, ICD9-CM Coding, MACs, Medicare, RACs | No Comments »

Billing Compliance and Proposed Survey Sanction: Two Looming Issues for the Home Health Industry

Thursday, September 13th, 2012

Issue One: Looking at 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. Since we are aware that Predictive Analytics are employed, correct complete data must be submitted.

Predictive Analytics

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 upon 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’s 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, andreviewing 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. 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.

Issue Two: Look at Clinical Data

CMS has proposed strong regulations establishing hefty intermediate sanctions to be imposed on home health agencies not in compliance with CoPs. Agencies must read the survey regulations carefully, implement precise policies and procedures, and audit utilization of those policies and procedures to be certain they meet processes as intended by the agency compliance program.

Proposed provisions include:

Monetary sanctions of $8500.00-$10,000.00 for condition level deficiencies that place a patient in immediate jeopardy.

Fines of $8500.00 per day for repeat deficiencies

Fines of $2500.00-$5000.00 per day for other deficiencies not placing a patient in jeopardy.

The monetary sanctions can be applied for the number of days the agency is out of compliance and they can be increased or decreased after the application of the penalty. The sanctions may be per day or per instance. They could not be applied simultaneously for the same deficiency. Please go to the CMS website to review the proposed rule.

Monetary sanctions are not the only sanctions that CMS may impose. CMS can chooses to terminate a provider agreement.  If an agency is unable or unwilling to correct deficiencies. Additional alternative or additional sanctions include suspension of payments for new admissions and new episodes of care, temporary management of care, mandated directed inservices and training, as well as the  emporary management of deficient agencies including making personnel changes and providing necessary interventions to assist the agency back into compliance.

The proposed rules would place much more pressure on a home health agency requiring  excellent documentation of care following a careplan that is consistent with  the needs identified in the patient clinical assessment. If outcomes are not achieved because needs were not appropriately identified, visits were missed, or care was not appropriately delivered, or a patient was placed in danger, an agency could face sanctions.

Agencies are expected to audit care, audit data, audit employee performance and be attuned to levels of care delivered to the patients of the agency. Agencies must clearly accept responsibility for care delivery and the outcomes derived from that care. It is clear from the proposed rule that

If the proposed survey sanctions are passed, agencies must be concerned they have excellent processes in place such as a “built-in, self regulating quality assessment and performance improvement system to provide proper care, prevent poor outcomes, control patient injury, enhance quality, promote safety, and avoid risks to patients on a sustainable basis that indicates the ability to meet theCoPs and to ensure patient health and safety ( Fed Register Vol 77 #135, Friday, 7/13/2012 Proposed  Rules, p 41582 col 3). or the financial consequences could be devastating.

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Posted in CMS, HEAT, ICD9-CM Coding, MACs, OASIS-C, Patient Survey, Surveys, Z-PICs | No Comments »

Proper ICD-9 CM Coding and an Effective Code of Conduct: Both are Essential in Home Health Care Today

Thursday, March 29th, 2012

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?

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

Educational Videos: RACs, MACs, Z-PICs, Part II of IV

Thursday, January 19th, 2012

RACs, MACs, Z-PICs, Part II of IV

CERTS – (Comprehensive Error Rate Testing) To better calculate the performance of the FIs and MACs, as well as to look at the reasons for their errors, CMS decided to look at a number of additional rates. The additional rates include

—   provider compliance error (how well providers prepared claims for submission)

—   paid claims error rates (measures how accurately FIs and MACs make coverage, coding, and other claims payment decisions). CERTs randomly select a sample of about 100,000 claims each reporting period.

—  CERTs review the claims for proper Medicare coverage, coding, and billing rules, and if not in compliance, they assign an overall error rate.

CERTs also identify if providers received overpayment letters or notices of adjustments to be made for claims that were overpaid and underpaid. CERTs are considered the Quality Improvement specialists who track and trend the performance of fiscal intermediaries and Medicare Administrative Contractors.

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.

HEAT –This auditing body is considered the more aggressive investigator of essentially DME and Home Health.  There has been expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay and as recently as September, 2011, they have struck, arresting 91.

The HEAT is the technologically oriented auditing body using state of the art analytics to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector.

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.”

Clearly, with all of the auditing bodies, CMS is making a bold statement; fraud and abuse will not be tolerated.. Unfortunately, in this kind of environment, innocent casualties can occur. Agencies need to take action now.

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Posted in CMS Guidelines, Compliance, Educational Videos, HEAT, HIPAA, HIPPA HITECH, Home Health, MACs, Medicare, MICs, OASIS-C, RACs, Z-PICs | No Comments »

Educational Videos: RACs, MACs, Z-PICs, Part I of IV

Thursday, January 19th, 2012

RACs, MACs, Z-PICs, Part I of IV

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.

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Posted in CMS Guidelines, Compliance, Educational Videos, HEAT, HIPAA, HIPPA HITECH, Home Health, MACs, MICs, OASIS-C, RACs, Z-PICs | No Comments »

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