Archive for the ‘MACs’ Category

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

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

  1. Attachment D

  1. Coding Clinic

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.

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?

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.

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, §, 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.


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.


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.

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

Thursday, September 13th, 2012

Issue One: Looking at Statistical  Data

Every time an OASIS is submitted to the state, portions of it may be parsed out to state, regional, and Federal groups such as the HEAT, MAC review groups, and Federal special projects in the DOJ and FBI. That means that when a review letter arrives, it may already be too late. Since we are aware that Predictive Analytics are employed, correct complete data must be submitted.

Predictive Analytics

In home health care, predictive models are being used to exploit patterns found in historical and transactional data to identify risks and opportunities. The present Models capture relationships among many factors to allow assessment of risk or potential risk associated with a particular set of conditions. The relationships should guide clinicians in their care plan decisions as well as care delivery. There are thousands upon thousands of potential OASIS and coding combinations. Because of the patient profiles and patterns retained over the years, comparisons can be made readily. Add HHRGs and service information to the OASIS and diagnostic data and CMS can gather very significant data regarding your agency’s care delivery and outcomes. MANY analytic filters are utilized to screen the data.  The initial round of filters are termed MUEs (Medically Unbelievable Edits). These edits are the first predictors of fraud and can alert the Z-PICs of agencies that should be monitored. Auditors may monitor an agency for years, gathering data, analyzing data and patterns, andreviewing payments. The agency profile is completed.

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

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

Issue Two: Look at Clinical Data

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

Proposed provisions include:

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

Fines of $8500.00 per day for repeat deficiencies

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

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

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

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

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

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