Archive for the ‘Home Health’ Category

OASIS and Coding Go Hand in Hand: Reinforcing Clinical Understanding: Part 6 and Final Section of the Series

Tuesday, September 24th, 2013

In Part 6, we will conclude the review of OASIS and its impact on the required accuracy needs of coding. Agencies must improve their assessment and coding skills now in preparation for the indepth requirements of ICD-10-CM and the many changes required for the OASIS C1 data set.  

In Part 1, we had discussed, in general, the case mix adjustment model, case mix diagnoses, garnering case mix points, and the Initial and the Comprehensive assessment. 

Part 2, we reviewed each OASIS Convention that must be followed. When coding, the coding specialists presume coding conventions are followed. If incongruent documentation or inadequately supported documentation is observed, coding specialists should question any discrepancies and seek clarification.

Part 3, the Coding Expectations and Challenges in Home Health were openly presented including documentation required, the Coding Clinic, and OASIS C Guidance Manual as well as the Medicare Benefit and Claims processing manual. We also explored the three types of teaching.

Part 4, we presented a scenario, identified functional OASIS scores, assigned ICD-9-CM codes, listed Clinical, functional, and severity points, and noted the reimbursement. This section of the series received many favorable comments and was the most openly stated as being of real assistance to agency supervisors.

In Parts 5 we reviewed OASIS more indepthly up to Cognitive function items to assist the clinician with the specific OASIS requirements as well as application of specific OASIS Conventions.

Let’s look now at the OASIS Conventions that focus on ADLs. When the clinician performs the OASIS Comprehensive Assessment the time period under review is essentially the day of assessment. Convention states there should be no reference to prior assessment.

When the clinician is scoring each of the data elements, (s)he must consider the patient’s ability not how well they want to perform a function and how that ability relates to patient safety. In scoring consideration, looking at how well the majority of tasks are completed is a must. The patient’s compliance or motivation should not be confused with ability. The clinician must also assess the reasons for non compliance, such as whether or not noncompliance is due to impairment or choice.

Safety is primary and should be assessed through direct observation. Look at the assistive devices in the home as well as potential barriers to outcomes. Devices may include sliding boards, wheelchairs, canes, walkers, and crutches. Be certain to ask about devices used and/or ordered by prior physicians .

Clinicians should understand the specific M questions as to what is specifically to be assessed. Do not consider the caregiver when determining patient ABILITY. In looking at the grooming tasks, remember that washing one’s hair, taking a bath, or performing toilet hygiene is not included in M1800.

When assessing how well patients can dress themselves, consider prosthetics, orthotics and even TED hose as part of the patient’s apparel. Observe how the patient completes dressing. Look at the type of devices and apparel worn. If the device is to be permanent, then that must be considered when assessed.

The ADLs

Bathing can be dangerous. The clinician must focus on the ability to access the tub or the shower, ability to transfer in and out of the tub or shower, and the ability to reach needed items.  Remember that drawing the bath water and washing ones hair is not a part of the M1830 question. It certainly should be a part of the integrated assessment separate from OASIS. For those patients who cannot safely bathe in a tub and instead use the sink, the clinician must look at the level of independence.

M1840 Toilet Transferring does not include Toilet hygiene, which is addressed in M1845. The latter question requires focusing on the ability of the patient to access all supplies needed to manage their hygiene where the toileting takes place. Completing the majority of tasks is not applicable as a convention in answering this M question.

The ability to transfer can be influenced by medications. Look at medication impact on ambulation, climbing stairs, as well as the location and surface for sleep. Ambulation includes safety on a variety of surfaces. For an assessment time frame, the clinician must use the “usual status greater than 50% of the time” convention, unless the patient is chair or bedfast.

The Medication Review

The Conditions of Participation state the Comprehensive Assessment must include a review of all medications currently being taken by the patient. That assessment must include review of all meds as to drug expectations, med reactions, potential adverse effects, drug interactions, duplication of meds and patient noncompliance with medications. The clinician has from the time of the assessment to the end of the next calendar day to contact the physician and communicate any issues. The issue reconciliation must be proposed by the physician within 5 days of the Start of Care.  Remember, when answering M2020 Oral Medication, use response ‘0” if the pharmacy provides special packaging, such as easy-open containers or pre-filled medi-planners, that enables the patient to administer their own meds. In assessing Management of Injectable Medications, if the physician orders the RN to inject a med, score  “unable” to administer injectable medications. Be certain to include all meds even if not administered that day of assessment.

M2100 Types and Sources of Assistance requires the clinician to consider the fact that if more than one response in a row applies, they must choose the one needed the most. Consider ability over willingness.  Include reminder calls under supervision and safety.

Emergent Care and the Plan of Care Synopsis

M2200 Therapy Need is meant to identify the total number of therapy visits planned for the episode. Remember, the Assessment must be congruent with the proposed number of therapy visits.

Emergent Care M2300, means assessing the entire period  included since the last OASIS Assessment,  and M2310 requires inclusion of all reasons the patient sought and/or received care at the ER.

Pay special attention to M2250  Plan of Care Synopsis.  CMS has stated that a physician ordered POC means the patient condition has been discussed with the physician and there is agreement between the agency and the physician as to the patient’s POC.  Notice that for the diabetic foot care section there requires at least two orders: “monitoring for the presence of skin lesions on the lower extremities” as well as” educate patient/caregiver regarding proper foot care.”

Notice the falls risk section of M2250 requires falls prevention, pressure ulcer, and depression interventions. Document those interventions carefully.

Specificity has become the buzz word. The industry is seeing specificity required with the face 2 face. It will be demanded with ICD-10-CM coding and it is and will continue to be challenged with OASIS. Accuracy is a must.

Your agency needs assertive expert coding specialists now more than ever. Your coding specialists must verify Homebound status and Medical necessity before coding and OASIS review even begins. Then, an OASIS review and a review of other assessment data must be conducted so coding to the highest level of specificity is achieved.

In a future ezine article, let’s look at what is in a full OASIS Review as well as a modified review. Do you have matrixes for each PPS M question? In that article we will share some of those with your team. Select Data has specific review processes not only for the M questions but for integrated data elements also. Auditors are now looking at specific diagnoses groups. They are looking at comorbidities and sequencing. Auditors are also gearing up for ICD-10. Are you ready?

OASIS and Coding Go Hand in Hand: Reinforcing Clinical Understanding Part 3 of 6

Wednesday, August 14th, 2013

Part 1 – We discussed, in general, the case mix adjustment model, case mix diagnoses, garnering case mix points, and the Initial and the Comprehensive assessment. 

Part 2 – When coding, the coding specialists presume coding conventions are followed. If incongruent documentation or inadequately supported documentation is observed, coding specialists should question any discrepancies and seek clarification. We also discussed non routine supplies (NRS) and the conditions and OASIS questions that impact supply points.

Part 3 – Coding Expectations and Challenges in Home Health

In the home health setting, assigning ICD-9-CM codes presents unique challenges. Since home health agencies usually do not receive all of the information needed regarding the patient’s medical condition, clinicians must develop and /or hone strong communication skills, as they will be calling physician and other resource offices frequently.  Coding Guidelines and Conventions require specific information for ICD-9-CM Coding. ICD-10 is even more demanding and the specificity is even more stringent.

Unlike the inpatient setting where the present and prior medical record, labs, diagnostic reports, summaries, and history and physicals are readily accessible, home health is dependent upon the referral source, as well as the physician and his/her office. It is also dependent upon the sophistication of the technology systems for efficiencies.

The home health clinician must seek the H&P, pertinent lab reports, discharge summary, and necessary home health admission orders. She/he must complete the Comprehensive assessment, identify high risk areas, such as falls, nutrition, skin breakdown, and mental health risks, and establish a prospective plan of care that complements the assessment, collaborates with the patient and other team members and achieves the identified goals. The clinician must review all medications, including over the counter preparations the patient and/or his caregiver may be purchasing. The clinician must also review the diet as it relates, not only to nutritional needs, but as it impacts medication synergistic effects, antagonistic effect, or any other contraindications.

Documentation

Clearly, the home health clinical documentation must be meticulous, show support of diagnoses chosen as the focus of care as well as co-morbidities and other related diagnoses.  In addition, the documentation must confirm collaboration with the physician as well as reflect his/her defining specifics of many diagnoses, such as COPD or COPD exacerbated, and must show POC review and agreement.

A segment of the POC (485) includes patient diagnoses that will necessitate a well defined plan of care.  Diagnoses coding is a key component of that plan of care and should reflect sequencing based upon the symptom control of the diagnoses.  The codes should provide the table of contents of the patient record that includes the Comprehensive Assessment, other discipline assessments, careplan, and visit notes. A clinician, an auditor, or a surveyor should be able to review the listing of the assigned codes in the sequence noted and have a solid understanding of what must have been in the assessments and what should be in the careplan and documented in subsequent visits.

Homebound status and Medical necessity

The initial areas that must be reviewed by the coding specialist are the clinical documentation supporting homebound status and medical necessity. The number one citation for surveyors last year was inadequate supportive documentation to support medical necessity for home health care. One may ask, just how is that possible?  Essentially, the clinical documentation did not substantiate need and the assessment did not meet skilled need requirements.

  •  “Skilled services are those services that are medically reasonable and necessary to the treatment of a patient’s illness or injury” CMS

It must be clearly documented that the services provided required the skills of the professional clinician AND that the patient     condition/illness/injury warranted those services. Cite specific examples of patient care and condition needs.

 

Approved Sources

The Coding Specialist relies on specific sources that include the Coding Clinic, enacted by Congress as the Official Coding Source. Other approved sources include CMS Coding Guidelines and the ICD-9-CM Coding Conventions, as well as the OASIS C Guidance Manual, both Chapter 3 data items and Appendix D diagnoses, as well as the Medicare Benefit and Claims processing Manual.

Per CMS, only the assessing clinician can determine the primary and secondary diagnoses, and assign symptom control settings based upon the assessment of the patient. Clinicians can collaborate with Coding Specialists because of the complexities of ICD-9CM coding conventions and guidelines.

The Coding Specialists can assist the clinician in determining sequence based upon documentation after the chief or primary focus of care has been determined. The primary diagnosis is to be the most serious condition that is “skilling” the care under the CMS Conditions of Participation.

Other diagnoses or comorbidities listed should delineate how they may impact the healing process or the length of recovery. The clinician should list how they will actively treat these diagnoses.

  • Remember that the records:
  • MUST have a specific order for EVERYTHING the clinician does
  • The clinician:

-MUST do EVERYTHING that has a physician order and

-MUST document EVERYTHING done…thoroughly.

The clinical deficiency items frequently cited:

  • Repetitive clinical notes are frequently seen stating the same things over and over with no patient progress identified. How is it that the clinician is unable to teach a new med successfully within a visit or two ask the MACs.
  • Notes from different disciplines reflect lack of plan coordination
  • Visit notes do not substantiate orders and goals on Plan of Care/485

Clinical interventions are without orders. These are areas that continue to generate survey deficiencies.

Three Types of Teaching

Clinicians should keep in mind the Three Types of Teaching:

  • Initial Teaching of a patient requires instruction on a new order, new medication, or a 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 that the patient and/or caregiver has had prior instruction.
  • 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.
  • Be certain the skilled nursing visit supports the diagnosis and the reasons for the SN visit. If the primary diagnosis is DM but the majority of the visits are directed toward CAD, the SN should be alerted as it appears there is an incorrect primary diagnosis.

 

The Coding Specialist should look at the OASIS questions and clinician answers as they relate to coding.

 

In the next three parts of this series, we will focus on the OASIS questions more specifically. In home health, you cannot code without an OASIS review.  Next time, let’s code, and create the HIPPS/HHRG and the episodic reimbursement. Here is where you see the impact of an experienced Coding Specialist.

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.

The Role of Compliance : Home Health and Hospital Readmissions

Tuesday, January 8th, 2013

This is THE topic one sees everywhere; trade journals, conferences, CMS, MLN, State Alerts, Home Health Associations. This topic is no longer just an operational and financial issue. Boards of Directors are looking to the Corporate Compliance Department and stating hospital readmissions should be part of the Corporate Compliance Plan.

More and more, leaders are demanding that the Corporate Compliance Officer be involved in evaluating the underlying causes for readmission and discerning the readmission issues.

Hospitals have put in place operational and financial impact reviews of readmissions into their facility within 30 days of discharge. The Affordable Care Act has required a number of measures be instituted to reduce hospital readmissions. Among these measures is the Hospital Readmission Reductions Program (HRRP) that regulates adjustment for payment to facilities with excess readmissions within 30 days of discharge.

Hospitals recognize that evaluation of the issue requires review of three phases of operation; admission/inpatient care, discharge/transition planning, and post-discharge care. The hospital compliance officer is beginning to look at each phase of care. They are beginning to have active involvement on the “Safety and Quality of Post Acute Care” Committees. These committees are looking at which agencies have the most readmissions and which physicians are involved. What diagnoses are seen most frequently and which medications are seen most frequently? Which agencies have overall compliance issues?

Smart Home Health Providers are viewing this as an opportunity. Not only can the agencies market their hospital readmission prevention programs; i.e. falls risk, heart failure, and medication reconciliation, but now is the time to market the home health agency corporate compliance program and theirleaders involvement in this program.

Hospitals usually do not envision compliance programs in home health agencies, even though they are strongly encouraged, they are not mandated by the OIG as

they are in the acute care setting. Positioning the home health agency as compliant, meeting the OIG required elements and also focusing on HIPAA, strongly states the agency parallels the hospital’s focus on compliance. It also non -verbally speaks to the agency’s root cause analysis approach to seeking solutions to problems. Since audit and prevention are required elements of a compliance program, the home health compliance officer can relay the home health agency’s approach to reduce hospital readmissions and discuss data infomatics leading to present programs and review of hospital readmission.

It is this type of collaboration that positions a home health agency as a future partner in new programs; i.e. ACOs, Patient Centered Medical Homes, and other Transitional Care Initiatives.

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.