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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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Posted in CMS, CMS Guidelines, Documentation, Home Health, Medicare | No Comments »

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.

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Posted in ACO, Affordable Care Act (ACA), CMS, Compliance, Corporate Compliance, HIPAA, Home Health, Hospital Readmission Reductions Program (HRRP), Hospitals, MLN, Patient Centered Medical Homes, Transitional Care Initiatives | No Comments »

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 »

Psychiatric Nursing in Home Health and Care of Patients with Depression

Wednesday, December 19th, 2012

Depression is a common, debilitating mood disorder. It is commonly seen among patients over 65 years of age with chronic medical disorders. To provide care for these individuals, home health agencies are developing psychiatric nursing programs with more frequency.  Depressive disorders afflict about 17.6 million Americans each year.  Depression is far more common in individuals with medical illnesses with about 25% of general medical inpatients meeting diagnostic criteria for Major Depressive Disorder (MDD).

The CMS Publication 100-2, Chapter 7, §40.1.2.14, simply says, “Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.”  MACs can establish the special training and experience required.  A home health agency should contact its MAC and look at the MAC Website for any special qualifications needed.

Introduction

There are several psychological conditions that can predispose an individual to depression. These factors include anxiety, impulsive and obsessional personalities, negative cognitive styles, neurosis, and chronic medical conditions. Certain neurological disorders such as Parkinson’s disease, stroke, and multiple sclerosis cause greater risk for depression.

25% of patients suffering from cancer, diabetes, and MI experience MDD. Research indicates that a major life event will precede the first episode of major depression in 50% of all patients.

CMS has recognized psychiatric home care as a reimbursable service since 1979, but nationwide proportionately fewer home health agencies actually provide this service. The exact number of agencies that include psychiatric home care is unknown. There has been a reluctance of agencies to implement a psych program and there are many reasons for this decision.

First of all, the skills of a psychiatric nurse are required and this specialist is usually more difficult to find. Second, the psychiatric patient is frequently more disorganized and needy than other patients causing the case management responsibilities to become time consuming and complex. Third, this patient is frequently homebound questionable.

CMS Publication 100-2, Chapter 7, §430.1.1, states that a patient with a psychiatric problem may be considered homebound if “the illness … is of such a nature that it would not be considered safe to leave home unattended, even if he or she does not have any physical limitations.”  Homebound status may need to be evaluated as a clinician would evaluate a patient suffering from dementia. That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended. The patient, in this example, could be considered homebound.  However, if the patient with a psychiatric condition leaves home regularly for reasons other than to visit the physician, he/she may not be considered homebound.  An example may be that of partial hospitalization.

Partial Hospitalization

In 1999, CMS, then known as HCFA, stated that a patient in a partial psychiatric hospitalization program does not qualify for psychiatric homecare services.  The partial hospitalization program should be able to provide necessary psychiatric services. The homecare services must be psych-related. If they are not focused on a psychiatric issue, the home health agency must evaluate the patient’s needs, just as it would normally do with any other patient, and evaluate whether home care services are in keeping with medical necessity and homebound status.

What is Psychiatric Home Health Nursing?

What is unique about psychiatric home care? Although psychiatric home care is bound by the same CMS regulations that define other types of home care, these regulations are largely non-specific for the psychiatric patient. This means the clinician must be specific as to symptoms and document specific plans and interventions.

Evidence supports the fact that major depression involves an alteration in the balance of neurotransmitters and/or their function. This alteration causes a decrease in levels of epinephrine causing dullness and lethargy, and decreased serotonin can cause irritability and potential suicidal ideation.

On the surface, psychiatric care appears to be very eclectic. Although psychiatric nurses may draw upon crisis intervention techniques as noted by Duffy, Miller, and Parlocha (1993), they may also utilize a variety of assessment tools such as Beck’s or Montgomery-Asburg Depression Inventories, or the Young Mania Rating Scale (YMRS), Sheehan Anxiety Scale, or Mood Disorder Questionaire (MDQ). These may indicate the use of  Cognitive Restructuring therapy or a number of other psychiatric intervention models that can be very useful: such as psycho-education, interpersonal reflective, supportive, individual, and/or brief therapy, as well as behavior modification, reward provisions, and antidepressant psychopharmacology.

The psychiatric nursing home care plan must be intermittent. This short term program frequently focuses on improved problem-solving, stronger ego boundaries, and enhanced self-concept.  With depression, the psych nurse frequently seeks ways to displace internalized anger outwardly. Activities designed by an occupational therapist can augment the skills of the psych nurse. An increasing number of home health agency psych programs are adding this discipline because of the physical activities that can be beneficial.

Stress management and education of stress strategies is commonly taught. Many patients have weak or fragile coping mechanisms that require reinforcement or a new approach.

Forming linkages between the patient and needed community services is a vital component of the role of the psychiatric home care nurse. This type of nursing brings a existential/spiritual concern and dimension to patient care. The clinician frequently provides a degree of support to a patient with low self esteem and a belief that the community has prejudged them. The clinician approaches patients with an attitude of respect, reinforcing  or assisting to rebuild worth and dignity.

Demoralized individuals are frequently seen in this program. Patients may lack energy, frequently because of losses; losses of friends, of family, of job, of status, of money, of respect, and others. This patient frequently requires a nurse whose plan with the patient requires assessment of the patient, their role within the family, the family support system, teaching use of psychotherapeutic techniques to facilitate change, medication management, and supervising their care in a supportive fashion that sustains physical, emotional, and spiritual life, promoting health.

Relationship Building and Trust

The clinician will build relationships established on trust, caring, compassion, empathy, and hopefulness. The RN will use verbal and non-verbal communication techniques to convey interest in the patient, to assess what the patient wants to accomplish, and to clarify the boundaries of the relationship, and lastly, to affirm the patient has value and worth.

Medication Management

Medication management is frequently a need for patients and is one of the main reasons for hospitalization. Some patients do not understand the reasons they have been prescribed certain medication. Sometimes, patients do not like the side effects and feel those effects are nearly as bad as the psychiatric condition. Some patients cannot afford their meds and still others do not wish to take their meds as they provide a constant reminder of a condition many wish could be forgotten.

Medication management intervention must be individual. Certain patients may require a contract by which they contractually agree to take their medications as prescribed. Teaching about major effects of the medications can be an empowering experience. For those patients whose cognitive impairment is apparent, modified pictorial teaching tools may be necessary. Role-playing, coaching, and teaching can be an empowering strategy.

Summary

Patients with stressors, depression, and cognitive impairments can frequently benefit by a psychiatric nurse. The program must be comprehensive aiding the patient through stabilization, caring, and reinforcement of strengths. A therapeutic relationship built on trust can provide acceptance to teaching and compliance with medication. Leaving the patient more calm, organized, stronger, and knowledgeable can assist them to improve links with family, friends, and the community and be more compliant with their medication regime.

The psychiatric program can be a strong support to total quality care and improved outcomes.


Posted in CMS, Depression, Home Health, Home Health Programs, Homebound Status, MACs, Major Depressive Disorder (MDD), MDD, Psych Nursing Home, Psychiatric Home Care | No Comments »

Summary of the CMS Released 2013 Final Rule

Tuesday, November 27th, 2012

Market Basket and Payment Rate Update

On November 2, 2012, CMS released the Medicare Home Health Final Rule for the Home Health Prospective Payment System 2013. The proposal includes the 2013 Market Basket Index (MBI) update of 2.3%, the required 1 point reduction under the Obama Affordable Care Act, and the reduction in rates of 1.32%, which is approximately a $10M decrease to payments for the home health 60 day episodes for 2013. The main change, per NAHC, from the July 5th proposed rule adjustment is an adjustment of the MBI from 2.5 to 2.3% occurring as a result of more current data. Proposed payment base episode rates are set at $2137.73 from a current $2138.52.

Though a small increase, the gain is that it is not the decrease CMS had proposed if  a full creep adjustment had been incorporated. The base rates are adjusted up by 3% for service to patients in rural areas.

 

LUPA RATES

For agencies submitting the required quality data, the LUPA rates are :

HH Aide $  51.79

MSS       $ 183.31

OT          $ 125.88

PT           $ 125.03

SLP        $  135.86

SN          $  114.35

 

For those agencies that have not submitted quality data, their rates will be reduced by 2 percentage points.

 

The outlier eligibility standards are changed from 2012. The Fixed Dollar Loss Ratio is lowered from 0.67 to 0.45. This will increase the number of episodes that will qualify for outlier payment.

 

Sequestration

Home Health agencies should expect payments subjected to a 2% sequestration, as part of the deficit reduction law. Though this is not a rate change, in and of itself, it will be a withhold of 2% from the claims payment. This is another  home health  reduction. Be prepared for expected significant changes for 2014 when CMS rebases the HHPPS rates as required under the Affordable Care Act.

 

Therapy

CMS finalized three revisions regarding qualified therapists completing a functional reassessment of the patient at the 14th and 20th visit and every 30 days.

 

First: CMS states that if a qualified therapist misses a reassessment visit, therapy coverage would resume with the visit during which the qualified therapist completed the late reassessment, NOT the visit after the qualified therapist completed the late reassessment.

 

Second: CMS states that in cases where there is multiple therapy disciplines involved, if the required reassessment by the qualified therapist was missed for any of the therapy disciplines, therapy coverage would cease for only the therapy discipline involved.

 

Third: CMS states that in cases where the patient is receiving more than one type of therapy, qualified therapist must complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and they must complete the 19th visit reassessment during the 17th, 18th, or 19th visit. CMS also states that in instances where the beneficiary receives more than one therapy type, if the frequency of a particular discipline does not make it feasible for the reassessment to occur during the specified times without providing an extra unnecessary visit or would delay a needed visit, then it is acceptable for the qualified therapist from each discipline to provide all of the therapy and functionally reassess the beneficiary during the visit associated with the discipline that is scheduled to occur closest to the 14th Medicare covered therapy visit, but no later than the 13th Medicare covered visit. Likewise for the 20th Medicare covered therapy visit but no later than the 19th covered therapy visit.

 

Thus, the revised rule states that if, in multiple therapy visit cases, the required reassessment was missed for any of the therapy disciplines, therapy coverage would cease only for that particular therapy. Therefore, as long as the required therapy assessments are completed timely for the remaining therapy disciplines, therapy services would continue to be covered for those therapy disciplines, unlike presently.

 

Face to Face

CMS finalized adjustments allowing non-physician practitioners in an inpatient setting to perform the encounter and inform the inpatient physician who can then become the certifying physician.

 

M1024

M1024, effective January 1, 2013, is to only be used for acute fracture codes for case mix points. Patient resolved conditions are not to be coded in home health. Citing Attachment D, CMS has clarified the only codes not allowed in homecare are acute fractures. These, then will be the only resolved codes allowed in M1024. Neoplasms, diabetes codes, neuro codes, and skin will no longer garner case mix points if placed in M1024, although CMS has stated an agency may continue to place resolved conditions in M1024 to present a more complete picture of the patient.

 

The final rule can be found at

http://www.ofr.gov/inspection.aspx

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Posted in Affordable Care Act (ACA), CMS, Face to Face Encounters, Home Health, LUPA Rates, M1024, Market Basket Index, Medicare, NAHC, Therapy | No Comments »

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