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

Friday, May 17th, 2013

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

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

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

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

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

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

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

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

For more information, call 714.524.2500

ICD-9-CM Official Guidelines for Coding and Reporting

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

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

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

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

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

The following are the CMS ICD-9 Site:

  1. CMS ICD-9 Site

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

  1. Attachment D

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

  1. Coding Clinic

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

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

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

Tuesday, April 30th, 2013

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

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

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

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

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

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

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

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

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

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

Wednesday, February 20th, 2013

PPS has always meant that “close enough” isn’t good enough. A digit off can be costly. Coding to the highest level of specificity can be complex and confusing. CMS has published Coding Guidelines and the Coding Clinic remains the source document for any coding questions. Agencies have hired coders. Yet still, many agency administrators pause when asked, “Are you leaving dollars on the table?” Most acknowledge they believe their coding may be costing them at least $200-$400 per episode.  Why continue to lose dollars?

Agencies have usually decided to complete their coding themselves. They have hired coders, certified or otherwise. Some coders are routinely reviewed and audited, most are not. Lessen the worry regarding dollar loss and the quality of your agency coding by instilling specific processes.

Consider a third party audit. Quality third party coding firms should have quarterly internal audits and annual external audits completed in their firms. So should you. Yes, the audits are costly, but so is $200-$400 per episode of care delivered

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

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

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

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

Susan Carmichael
MS, RN, CHCQM, COS-C
Executive Vice President
Chief Compliance Officer
Select Data
714.524.2500
949.584.6296

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Proper Coding, Homebound Status, and Awareness of Common Edits: Paid But Will You Retain Your Revenue? An Update.

Tuesday, January 22nd, 2013

No matter which MAC or RAC reviews your agency, high risk probes are on the rise. The intermediaries are mandated by CMS to monitor areas of greater risk. The RACs are paid by contingency on aberrant findings and their algorithms are making findings easier. When MACs or RACs find trends of concern they will launch probes. 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.

In late 2012, RAC auditors began sending out chart requests expansively. They were and continue to target specific issues such as medical necessity, seeking to have those specific issues approved by CMS. Once approved, other RACs can investigate those same issues in their areas. One issue all RACs are looking at involves specific numbers of therapy in specific episodes with specific diagnoses.

NAHC’s Mary St Pierre, VP, Regulatory Compliance, identified in the fall of 2012, that Comprehensive Error Rate testing (CERT) contractor inquiries are also on the rise. The CERTs are the QA component of MAC billing. In addition, they also oversee Z-PIC claim payments and the denials issued. They are looking at Face to Face documentation of medical necessity and homebound status documentation.

The OIG remains focused on both home health and hospice citing “Six Measures of Questionable Billing” especially in home health.

The OIG has announced that, in 2009 and again in 2010, Medicare-Medicaid paid over $54 billion in improper payments. There have been 2500 persons/entities indicted from Federal health care programs. There have been 625 criminal actions with over 400 civil actions including actions involving the False Claims Act. There have been another 2400 investigations that yielded expected results. 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. Monitoring for homebound status is yet another area of review.

The Edits

Specificity requirements to support codes have always been expected but are being actively scrutinized now. Expect specificity and complexity to rise even higher with ICD-10.

Coding Specialists must also keep clients or their agency aware of edits and trend areas with insufficient documentation to substantiate proposed diagnosis.

A second recertification of Lymphoma will trigger a long used edit.

Recertifications with a primary diagnosis of Diabetes and a secondary diagnosis of CHF will be monitored if the edit continues after a MAC quarterly review. Because the FIs have found merit, this edit has continued for years.

Other Edits include:

Recertifications with a primary diagnosis of Alzheimer’s disease, Schizophrenia disorders, or Long Term use of anticoagulants with no therapy ordered.

Claim Denial Potential

The above diagnoses run a great risk for denial because of probe edits and recertifications. Those records are reviewed also for homebound status. There must be “clear documentation that it is with considerable and taxing effort for the beneficiary to leave home, otherwise the episode or specific visits could be denied for lack of homebound status. (74% of ADRs reviewed for lack of homebound status were denied).”

Common documentation deficiency areas include lack of progress in:

* Repetitive clinical notes 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?

* Notes from different disciplines that reflect a lack of plan coordination

* Visit notes that 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 clinical 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, reteaching, and training needed

* The condition or disease symptomology has exacerbated or changed in another way

* 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.

Though we have heard this over and over, one of the most common home health reasons for denial is that the documentation does not support medical necessity.

Therapy is STILL under scrutiny

Functional ability improvement is expected or why is therapy present?

Therapy may be covered if the patient or caregiver received 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 2012-13 expectations are rigorous and denials are imminent if documentation is insufficient or inadequately substative.

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

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. Third party coding firms, like Select Data, monitor the FI sites, newsletters, and alerts to dig for present edits.

Agencies need to be aware the edits will increase over the next year as CMS, the RACs, the MACs, and the Z-PICs ready for ICD-10 and the move from the present 17,000 codes to over 68,000 codes or a 400% increase in codes. Will there be a 400% increase in edits also? Will there be a 400% increase in claim denials? Let us hope not.

Protecting justly due reimbursement starts with proper data gathering, coding to the highest level of specificity with sufficient documentation, and coding specialists looking out for the specific documentation needed. Do you have the coding specialists that you need in place to assist you in protecting your justifiably deserved reimbursement?

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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 »

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