Archive for the ‘OASIS-C’ Category

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System Issues with Occurrence Code 55 and Referring Physician Information

Wednesday, October 31st, 2012

CGS has identified two issues affecting claims processing.  These issues are impacting all Medicare contractors.  The Centers for Medicare & Medicaid Services (CMS) is aware of these issues, and is working to resolve them as quickly as possible.

Issue #1:  Occurrence code 55, which was implemented with Change Request 7792, is required to be reported when the discharge status code reported on the claim is a 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown).  However, claims submitted with the occurrence code 55 via the 5010 format are being rejected before entering the Fiscal Intermediary Standard System (FISS).  This problem affects all provider types, and is being researched.  Until the issue is resolved, providers may choose to submit these claims to CGS via Direct Data Entry (DDE).

Issue #2:  Change Request 7755 requires hospice providers to report the certifying physician information (when different than the attending physician) on the claim in the referring physician 2310 F loop of the 5010 format.  However, claims reporting physician information in the 2310 F loop are being rejected before entering FISS. This problem is currently only affecting hospice providers, and is being researched.  Until the issue is resolved, providers may choose to submit these claims to CGS via Direct Data Entry (DDE).

Changes to M1024 Proposed in 2013

  • Significant loss of payment expected
  • 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 case-mix and dollars so documentation must be stellar and every other code must be accurate.

CMS asked for comments on the proposed 2013 changes and they received them! Providers and others in the home health industry voiced their concern re the proposed changes.

Restricting M1024 to only permitting fracture (V- code) diagnoses codes while according  to ICD-9 coding guidelines cannot be reported in a home health setting as a primary or secondary diagnosis. To further ensure compliance with coding guidelines, we propose to pair the fracture codes (V-code) with appropriate diagnosis codes and only when these pairings appear in the primary and payment diagnosis fields will the grouper award points, stated CMS in the proposed rule.

If providers cannot code medically identified conditions being treated in M1024, reimbursement will suffer. Agencies are providing the service but would not receive the payment for care delivered. The average lost per episode is estimated to be $200.00 per episode.  Keep in mind non-routine medical supply points also.

Providers and organizations like the Visiting Nurse Associations of America are also actively speaking out.

Many neuro and skin conditions are treated surgically. These diagnoses must be replaced with V codes in the primary and secondary fields. The VNAA believes the proposed change would “place all homecare agencies at an unfair advantage.”

In addition, the proposed rule, per NAHC seems to indicate that case-mix points will no longer be available for fractures when a fracture is not a primary diagnosis. This too, can negatively impact on payment.

In early November, CMS expects to issue the 2013 home health PPS Final Rule.

 

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Posted in CGS, CMS, Direct Data Entry (DDE), FISS, ICD9-CM Coding, Medicare, NAHC, OASIS-C, VNAA | No Comments »

A Validated falls Risk Assessment from the Missouri Alliance

Friday, October 12th, 2012

Finally, a validated falls risk tool that is multi- focal and that no longer requires an accompanying single focused tool such as a TUG or Tinetti,

NAHC stated recently that home health agencies have struggled with inadequate falls risk assessment tools since the beginning of OASIS-

The Missouri Alliance for Home Care (MACHO) has recently released the validated multi functional falls risk assessment tool (MACHO-10). Per the Alliance, home health agencies now have a single tool for the OASIS requirement.

Per the Missouri Alliance, related to OASIS item M-1910, the OASIS-C Guidance Manual specifically states: “The multi-factor falls risk assessment must include at least one standardized tool that 1) has been scientifically tested in a population with characteristics similar to that of the patient being assessed and shown to be effective in identifying people at risk for falls; and 2) includes a standard response scale. The standardized tool must be both appropriate for the patient based on their cognitive and physical status and appropriately administered as indicated in the instructions.” It further goes on to say: “An agency may use a single comprehensive multi-factor fall risk assessment tool that meets the criteria as described in the item intent.”

The MACHO Home Care Fall Reduction Initiative states their initiatives aim to:

Reduce falls

Improve patient outcomes

Establish a baseline of falls in home care

Each quarter,  MACHO compiles fall data submitted by participating agencies and returns to the agencies both individual agency data analysis as well as collected data analysis of participating agencies as a whole.

The data is “meant for clinicians to use to report and track outcomes, identify trends, and improve care.” 

Now agencies can use one comprehensive validated tool to complete their assessment. However, some agencies state, that since therapy will more than likely use a TUG or Tinetti, the skilled nursing SOC will utilize the tool to be used by therapy so an admission baseline is established.Some agencies prefer an active gait and balance evaluation. It can now be a choice. 

Please go to the site below to view the exact tool

http://www.homecaremissouri.org/projects/falls/documents/Oct2012FINALValidatedFallriskassessmenttool.pdfbb

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

Thursday, September 13th, 2012

Issue One: Looking at Statistical  Data

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

Predictive Analytics

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

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

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

Issue Two: Look at Clinical Data

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

Proposed provisions include:

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

Fines of $8500.00 per day for repeat deficiencies

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

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

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

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

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

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

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

ICD-10: An Overview Are You Prepared? Part 1

Thursday, August 16th, 2012

The implementation date for ICD-10-CM has been pushed back one year to October 1, 2014, but it doesn’t mean you have a lot of time. If you have not assessed, through a Gap Analysis, the impact of ICD-10 on your organization, you should be planning that event…soon. There is a lot to do.

 Consider organizing an ICD-10 Transition Team. That team should have a project leader.

One of the first tasks of the team is to conduct an overview of ICD-10, identify the differences between ICD-9 and ICD-10, as well as the changes soon to come.

 The ICD-10-CM Manual is available in both a print and an electronic version. It will provide the classification system that identifies diagnoses and injuries. Acute care procedures are not included in ICD-10-CM as they have been provided in a separate classification system called ICD-10 PC, so they are not a focus of home care.

 The Transition Team needs to understand that all entities covered by HIPAA, per the American Recovery and Reinvestment Act (ARRA) who conduct healthcare transactions must comply with ICD- 10 requirements.

 Per CMS, every day it pays 4.4 million claims totaling  $1.5 B. Each month, Medicare receives 19,000 provider enrollment applications. Each year, Medicare pays over $430 B for 45 million beneficiaries. Each year, Medicaid nationally pays 2.5 billion claims for 54 million beneficiaries in 56 states and territories. ICD-10 is expected to assist in cost savings as well impacting fraud and abuse. Because of the specificity of ICD-10, more sophisticated algorithms are designed to hone in on questionable combinations of codes coupled with OASIS answers to spot potential fraud.

 What is the rationale for ICD-10?

 - ICD- 9 is 30 years old and no longer has code space for new diagnoses or new conditions and treatments.

 - ICD-9 is not always precise or unambiguous.

 - US mortality data is being reported in ICD-10

thus making international comparison of mortality and morbidity difficult.

 We need more coding specificity!

- Accountable Care Organizations, Patient Centered Medical Models, Guided Coaches, etc will require more discreet data.

- Benchmarking and quality measurement require more detailed codes

- Reimbursement will require detailed documentation reflected by codes that portray accurate patient conditions

- Increased specificity in data means more robust design of algorithms to predict outcomes and care

- Increased coding detail offers the capability to find previously unrecognized relationships in  

  disease as well as variables

- Increased capability to measure healthcare quality, safety, and efficiency

- Space to accommodate future advances and expansion

- Improved capability to determine disease severity for audit risk and adjustment

 The primary physician or specialist must establish a patient’s diagnosis. A nurse or therapist will document all pertinent diagnoses on the OASIS-C and the Home Health Certification and Plan of Care (Form CMS-485). New or additional diagnoses that the clinician identifies at the assessment must be verified by the physician before the diagnoses may be added to the patient’s medical record. For ICD-10, nothing changes other than greater detail availability via codes.

 At first glance, trying to use the ICD-10-CM Manual may seem overwhelming. In ICD-9-CM, there were approximately 14,000 choices for codes. In ICD-10-CM, there are  approximately 68,000 choices. Codes exist for so many injuries, including W61.11XA biting by a macaw, initial encounter or W61.11XD biting, subsequent encounter or codes for bites by a parrot, a goose, a turkey, or a chicken. All in all nine codes for each animal and there are a total of 312 animals. There are even separate codes for a turtle as one may be “bit by a turtle” or “struck by a turtle.” Humor aside, there are now the precise combination codes to more clearly depict the true presenting picture of the patient and their needs.

 ICD-10 CM may now have 68,000 codes but acute care procedure codes, ICD-10 PC, have increased from 3,000 to 87,000 codes. That is a phenomenal increase, but necessary, given the medical advances these past 30 years. There are expected organizational benefits from ICD-10 including administrative efficiencies, cost containment, capability for more accurate trend and cost analysis, along with improved coding accuracy and productivity.

 CMS believes that the impact on reimbursement expected, includes increased accuracy, fairer reimbursement, improved justification for medical necessity, fewer errors and rejected claims (after the initial learning curve), and reduced opportunities for fraud.

 ICD-10-CM codes may have up to 7 digits and digits 2 and 3 are numeric, digits 4-7 are alpha or numerical. The greater the specificity, the greater the number of characters required.

 A Bit of Humor

 There are so many codes including injuries incurred while sewing, ironing, playing a brass instrument, even while crocheting. There is even a code, V91.07XA, for burns due to water skis on fire. Really, quite the vision and subsequent to…what, one might ask.

 Because of the precise specificity, ICD-10 requires expertise in anatomy and physiology, pathophysiology, and diagnostics. The specificity is far greater than ICD-9 and the need to better understand finite A&P as well as diagnostics is vital. Injuries are grouped by anatomical site rather than type of injury. Another change includes sequelae instead of after effects.

 CMS plans to have a draft grouper ready by April, 2013.

 New features in ICD-10 include combination codes for a large variety of conditions, commonly seen symptoms, and manifestations. An example of a combination code includes:

E13.331 Diabetic Retinopathy with Macular Edema- other specified diabetes Mellitus with moderate non-proliferative diabetic retinopathy with macular edema.

  There are a number of expanded codes for diseases and conditions, such as diabetes, substance abuse, and injuries. Codes for post operative complications have also been expanded with a distinction between intraoperative complications and post procedural disorders.

 There will be an impact on many home health departments. In our next article, let’s discuss what preparation will be needed and the specifics needed for the Gap Analysis.

 Next article: What do we do to prepare for ICD-10: Developing the Gap Analysis

 

 

 

 

 

 

 

 

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Posted in ACO, ARRA, CMS Guidelines, HIPAA, ICD-10-CM Coding, OASIS-C | No Comments »

Physicians and Care Plan Oversight (CPO) and Certification/Recertification

Tuesday, May 15th, 2012

Care Plan Oversight is physician supervision of patients under either the home health or hospice CMS benefit. CMS does not provide this reimbursement for these services if a patient resides in a nursing facility or skilled nursing facility.

Physicians should be made aware of this reimbursable service. They must review the Plan of Care and be made aware of the reimbursement for the process.

Understand the Difference between CPO and Certification/Recertification

G0180 – Certification of a home health patient.

G0179 – Recertification of a home health patient

G0181 – Home Health Care Plan Oversight

G0182 – Hospice Care Plan Oversight

Care Plan Oversight reimbursement allows physicians to bill CMS for the time physicians oversee the home health plan of care. The physician may bill for 30 minutes of time each month as long as they log the care delivered and it is allowable care for CPO. Remember: the face to face encounter must be included as part of the certification form itself, or as a signed addendum to it, and must include the certifying physician’s distillation of the patient’s clinical condition and needs for home care. It must also attest to homebound status and medical necessity.

Certification billing requirements include:

  • The physician signing the Plan of Care is the physician who may bill for CPO
  • Date of Service: Date the physician signs the POC
  • List home health agency provider number
  • List physician NPI number
  • List the care provided that meets the required services for payment

 

Recertification billing requirements:

  • Must be billed by the physician who recertified the patient
  • Used after a patient has received 60 days of covered skilled intermittent Medicare services
  • Date of service: Date the physician signed the POC
  • List agency provider number
  • List physician NPI number

 

What is CPO?

 

CPO is physician supervision and oversight of patients under either home health G0181 or the CMS hospice benefit G0182. The home health services may include:

    Developing an individualized plan of care

    Telephone calls with other health care physicians involved with the care

    Revising a plan of care

    Activities involving coordinating of care

    Documentation of planning

    Medical Decision Making

    Review of treatment plans, and analysis of labs, tests, and data analytics

    Team conferences

The beneficiary must require complex and/or interdisciplinary care. The physician may not have a significant financial or contractual interest in the home health agency. The physician may not be the medical director or employee of the hospice, and does not provide service under arrangement with the hospice.

Documentation must be completed by the physician and not the home health agency.

Non – Countable Services

 

  • Initial interpretation of a lab during a face to face encounter
  • Informal calls with office personnel
  • Telephone calls to patients, family, even if medication adjustment occurs
  • Travel time
  • Time preparing claims

 

Billing/Filing the Claim

Medical records for the dates must document the 30 or more allowable minutes for care planning activities for each patient. Dates of services must be the first and last date during which documented planning services were provided. No other services,  but from the CPO may be on the claim.

Agencies should spend the time to educate physicians to this reimbursement possibility. Have a simple fact sheet available with the steps to complete the process identified but do not complete the form for the physician. Offer a sample log to physicians so they may see what can be billed. Provide  the link to the CMS site so the physicians  may read the complete process outlined by CMS.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R999CP.pdf

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Posted in CMS, Compliance, G Codes, Home Health, Medicare, OASIS-C, Physician Orders | No Comments »

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