The new tiered system directs surveyors to focus on quality of care. A detailed list of surveyor probes are provided, outlining questions that may be asked throughout the survey process. Agencies should review the questions outlined for surveyors in order to prepare for the survey process. Preparation for this process will reinforce other patient focused processes. Are you ready? Visit www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_11.pdf to read more.

CMS stated surveyors would cite more deficiencies under the new process. After one year, it will be interesting to view the stats.

The Key Focus Areas

Patient Rights

Assessments

Plan of Care

Outcomes and Improvement

Infection Control

The survey process is guided by interpretive guidelines and survey protocols established to provide guidance for surveyors. The surveyor will review the assessment, the medication profile, and physician orders and then evaluate the established plan of care with review of that implementation of the plan of care. Patient and personnel interviews should support the findings of the clinical record.  Prepare personnel for survey interviews so they are familiar with terminology and types of questions they may be asked. Support the interviewees by having them understand that they are the experts in care delivery. They are merely verbalizing the assessment, the care, and the outcomes expected or achieved.

All surveyors are required, by CMS, to utilize these guidelines when evaluating an agency as to compliance with Federal regulation. Remember, the guidelines do not replace regulation and are not allowed to be the basis of any citation, but they provide guidance.  Violations are to be based upon clinical record reviews, interviews with patients, caregivers, and personnel, as well as the agency’s practices in relationship to regulation and agency policies.

“The survey and certification process provides a method for CMS to evaluate HHA compliance with the Conditions of Participation (CoPs), ensuring that patient services provided meet minimum health and safety standards and a basic level of quality. The HHA survey process incorporates an approach that is patient-focused, outcome-oriented and data-driven making it more efficient and effective in assessing, monitoring, and evaluating the quality of care delivered by an HHA…” (Appendix B, p.6).

The surveys are required to have at least one RN on the team.  Surveyors are required to attend the HHA Training Course prior to any survey. They are then required to be in an observational role as part of the training.

Preparing for the Survey

Appoint at least one person, in your agency, to become very familiar with the new survey process. You may want that person to be OASIS certified to readily discuss OASIS conventions. Develop a thorough process-oriented clinical orientation. Be certain all policies and procedures are current and personnel have had the appropriate inservices.

Have a third party or internal coding expert available to answer any questions regarding diagnoses coding conventions, manifestations, and sequencing. A coding audit by an external review agency may give you some peace of mind.

Be certain your clinical lead has reviewed and audited Starts of Care, Resumptions of Care, Recertifications, and Discharges. Be certain the assessments are well documented and the care plans adequately support that proposed Plan of Care.

Be certain the billing (revenue cycle management) audits include the compliance processes that prevent inappropriate billing without a physician order and evidence of all detailed and signed visit notes.

Types of Surveys

The survey process provides for a standard survey, a partial extended survey, and an extended survey. All HHAs must undergo a standard survey.

Initial Certification

The initial certification requires compliance with SS Act 1861(0) (4) as well as 2180 regarding licensing requirements. In addition, follow the guidelines of SS2008 “Early Surveys of New Providers and Suppliers”.

The State Agency (SA) surveyor or the National Accrediting Organization (AO) inclusive of Joint Commission, CHAP, or ACHC with deeming authority conducts the initial certification. At the time of that survey, the HHA must

• Be operational and have completed the Medicare Enrollment 855A verified by the assigned MAC.
• Provide nursing and one other therapeutic service (42 CFR 484.14(a).
• Meet the new capitalization requirements and have completed an OASIS test submission.
• Have provided care to a minimum of 10 patients requiring SKILLED care.

Standard Survey

This survey is to be a review of the quality of care and services furnished by the HHA as measured by the medical, nursing, and rehabilitative care indicators. The new changes require this survey to review compliance with regulations most related to high-quality patient care. These highest priority standards (regulations) are called Level 1 standards addressing 9 of the 15 CoPs. The thinking is that if the agency is in compliance with these standards, it is in compliance with all CoPs.

Therefore,  “the surveyor can make a determination  that the HHA is in compliance with all CoPs when, after a review of the Level 1 standards, and after completing the required clinical record reviews, home visits, and interviews with patients and HHA staff, he/she does not discover any findings which would support a deficiency citation.”

Partial Extended Survey

This survey occurs when a standard level survey identifies a non compliant Level 1 standard and/or a deficiency practice may exist at a standard or conditional level not examined at the standard survey.  During this survey, the surveyor reviews at a minimum, the Level 2 standards under the same condition which are related to the non compliant Level 1 standards. See Table 1 Level 1 and Level 2 Standards.

Extended Survey

This survey includes a review of all conditions. It may be conducted at any time at the discretion of CMS and is required to be conducted when any conditional level deficiency is identified. The surveyor is required to review all agency policies, procedures, and practices related to the substandard care (one or more condition –level deficiencies).

Recertification Survey

All HHAs are mandated (SS1891) to have a recertification performed no later than 36 months from a previous recertification survey. These surveys are standard unless a Level 1 citation is leveled.

Now, you know the types of surveys. The following chart lists the standard and partially extended surveys with their related priority standards and G-tags. The more you know about the new process, the better prepared you will be for your next survey.

Level 1 and Level 2 Standards Appendix B

Table 1

Conditions                            Standard Survey                Partial Extended Survey

Level 1                                   Level 2

484.10

Patient Rights                          G107, G109                             G101, G108, G111, G114

484.12

Compliance with                     G121                                        G118

Federal, State, Local

Laws

484.14 Organization,               G123, G133, G143,                 G124, G125, G127, G138,

Services and                             G144                                       G139, G150

Administration

484.18 Acceptance                 G157, G158, G159                      G160, G162, G163

Of Patients, Plan of Care,       G164, G165, G166

Medical Supervision

484.30 Skilled                          G170, G172, G173,                     G169, G179

Nursing Services                     G174, G175, G176,

G177

484.32 Therapy                        G186, G187, G188                      G190, G193

484.36 Home Health Aide      G224, G229                               G212, G215, G225, G226, G230

Services                                                                                     G232

484.48 Clinical Records          G236                                        G239

484.55 Comprehensive          G331, G332, G334,                  G339, G341

Assessment of Patients          G445, G336, G337,

G338, G340

Some agencies treat these plans as necessary evils while others embrace the strength of the process and its ability to reduce risk. Recently, we have been asked about initiating a workable, useable, beneficial program.

The Purpose

The purpose of a Performance Improvement Program, Plan, or Process (PIP) is to outline a process that needs improvement. The team that will review the improvement process needs to baseline the present processes seeking efficiencies or other outcomes. This Performance Improvement Plan should support the organization Mission and its Corporate Plan.

Quality Concepts

·            The PIP is established to benefit the organization. It should address an issue or issues that require improvement.

·            The entire organizational team chosen for this Program should be actively included in all phases.

·            Focus on patient or operational outcomes, but try not to take on too many projects at once.

Suggested Patient Care Functions

·            Rights and Responsibilities

·            Ethics and Compliance

·            Assessment and OASIS

·            Adequate Documentation of Care

·            Patient Education and Re-Teaching

·            Continuum and Care Transitions

Agency/Organizational Operations

·            Leadership

·            Ethics and Corporate Compliance

·            HIPAA Privacy and Security

·            Management of Resources

·            Appropriate and Current Policies and Procedures

·            Infection Control

·            Supportive Environment Conducive to Optimum Employee Performance

·            Safety

·            Fiscal Soundness

Responsibility

The Board of Directors approves the Agency Administrator position and the Performance Improvement Program supports with adequate resources and financial support. The Agency Administrator oversees the program or appoints a delegate and assures the Program is continuous, is providing meaningful process monitoring and improvement. Annually, at minimum, results are reported to the BOD.

The Process and the Design

Processes should approach an issue that requires improvement. Processes are designed to be in alignment with the agency mission and strategic plan. They should also be based on evidenced based processes or best practices. They may be benchmarked against other organizations.

Measurement

There needs to be a sound way to collect data. The data will be collected, measured, and analyzed. The goal is to decide the statistical control methods, agree upon how the data will be collected, and determine how it will be measured. Is the agency seeking to evaluate a present process? Design a new process? Assess Performance? Identify areas of Improvement?

Over what period of time will you collect data? Will you evaluate your methods of collection and tools of measurement? Will you evaluate unusual occurrences? Will you keep drilling down until you locate the root cause of the issue?

Assess

The agency should be assessing for improved efficient processes. Will you analyze and discuss new processes so the best process is chosen. Who will be involved? How will they be involved? Will you reevaluate the new processes? When?

Improvement

Buy- in comes with improvement. Be certain that the new processes are truly an improvement. For each issue resolved or impacted, be certain there are clear recommended actions with a responsible party named who will monitor the new processes. Have a timeframe delineated for evaluation as well as evaluation of the “improvement.” Be certain everyone knows the expected outcome. Survey results and identify satisfaction levels.

Buy- In

Buy- in can drive motivation and success. It is important that employees see results for the extra work of the PIP. This process can be applied after Organization Risk Assessments. It teaches problem resolution and hones skill sets. It encourages team building and drives results in an organized fashion. Organizational learning is essential for success. This is one simple way of achieving positive results while reinforcing respect and value for each employee.

Recently, I was speaking with an agency leader, whose firm is known for its Performance Improvement Projects. She has two teams. The key is fun as they attack real problems. Each team identifies projects that impact improved care, outcomes, impact employee morale, or directly impact costs. They present two projects each to the BOD or the Professional Advisory Committee. This allows many to be involved,

Each team defends their chosen project as to benefits derived. They defend the value of the project. Each year the BOD presents a cash bonus and dinner to the team with the best project over the past 12 months. The Leader stated employees via to be on the committees and the PIP are becoming more creative. They are “attacking real problems and finding real solutions we all can live with.” Employees see they are impacting positively on their agency; its care and reputation. They also see the value of group dynamics, peer pressure, and improved performance.

For 2012, the employees have proposed a third team. Leadership is thrilled at that proposal and the fact that she frequently hears, “That should be referred to the PIP, because we can do better.”

RACs, MACs, Z-PICs, Part II of IV

CERTS – (Comprehensive Error Rate Testing) To better calculate the performance of the FIs and MACs, as well as to look at the reasons for their errors, CMS decided to look at a number of additional rates. The additional rates include

—   provider compliance error (how well providers prepared claims for submission)

—   paid claims error rates (measures how accurately FIs and MACs make coverage, coding, and other claims payment decisions). CERTs randomly select a sample of about 100,000 claims each reporting period.

—  CERTs review the claims for proper Medicare coverage, coding, and billing rules, and if not in compliance, they assign an overall error rate.

CERTs also identify if providers received overpayment letters or notices of adjustments to be made for claims that were overpaid and underpaid. CERTs are considered the Quality Improvement specialists who track and trend the performance of fiscal intermediaries and Medicare Administrative Contractors.

Z-PICs – Zone Program Integrity Contractors will perform Medicare Program integrity functions for CMS. They will interact with each MAC to handle fraud and abuse issues within their jurisdictions. ZPICs are seen to consolidate the work of present CMS Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) and are divided into 7 zones.

The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time.  That power can cripple or financially devastate an agency.

HEAT –This auditing body is considered the more aggressive investigator of essentially DME and Home Health.  There has been expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay and as recently as September, 2011, they have struck, arresting 91.

The HEAT is the technologically oriented auditing body using state of the art analytics to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector.

CMS states that their mission includes, “providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and the private sectors.”

Clearly, with all of the auditing bodies, CMS is making a bold statement; fraud and abuse will not be tolerated.. Unfortunately, in this kind of environment, innocent casualties can occur. Agencies need to take action now.

RACs, MACs, Z-PICs, Part I of IV

CMS has Unleashed the Auditors

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.

CMS has unleashed the age of the auditor with the advent of the RACs, MACs, CERTs, MICs, Z-PICs, and now, the HEAT.

RACs- The contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, mostly due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, these auditors are expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only 22 cents for every $1.00 recovered. They are now in place and ready to go at measure. Certain RACs have been held back until all MACs were in place. That is now completed.

MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There are 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for over payment estimation of claims (current and prospective focus). MACs have power and Congress is encouraging them to use it.

The Federal Register published Nov. 4, 2011 provided the final rule that updates the home health prospective payment system (PPS) rates for 2012.

The notice identifies changes to the national standardized 60-day episode rates and per visit LUPA rates based on the market basket update and the case-mix creep adjustment. Additionally, this rule includes notable changes to the HH PPS case-mix system

As mandated by the Patient Protection and Affordable Care Act, the payment updates for 2012 include a 1.4 percent update factor to the episode rates, which reflects a 1 percent reduction applied to the 2.4 percent market basket update factor,

Average Episode Payment Rate Timeline

These episodes will then be reduced by 3.79 percent for case mix creep, resulting in an overall episode and per visit reduction of 2.39 percent. An additional 3 percent will be applied to payments for services to patients in rural areas based on the Congress-approved rural add-on. Be aware that agencies failing to submit required quality date will be subject to a reduction of 2 percent to their episodes and per visit payments.

The Centers for Medicare and Medicaid Services (CMS) will apply the CY 2012 HH PPS payment rates for episodes with claim statement “through” dates on or after Jan. 1, 2012, and on or before Dec. 31, 2012.

The 2012 national standardized episode payment will be $2,138.52, prior to case-mix and wage adjustments, as compared to 2011’s $2,192.07.

The table below gives a more detailed comparison:

Case-Mix System Changes

The case mix system 2012 changes identify removal of two hypertension codes – 401.1 benign essential hypertension, and 401.9 unspecified essential. Coders will need to be very careful that clinician written “renal failure” or “renal insufficiency” in a record for a hypertensive patient requires a query to the physician to be certain the insufficiency/failure is chronic as that is the only way they will garner their HTN points in 2012.

Policy changes in the CY 2012 HH PPS final rule related to the case-mix system will be effective beginning with episodes with OASIS M0090 dates of Jan. 1, 2012.

Therapy

Because of the presenting patterns of therapy utilization over the past few years, payments impacted by therapy have been revised by CMS. Lower therapy cases seem to be encouraged. Payment for higher-therapy episodes is reduced, while payment for lower-therapy episodes is increased.

The case-mix model has five steps:

• Step 1: First and second episodes, 0-13 therapy visits
• Step 2: First and second episodes, 14-19 therapy visits
• Step 3: Third episodes and beyond, 14-19 therapy visits
• Step 4: Third episodes and beyond, 0-13 therapy visits
• Step 5: All episodes with 20+ therapy visits

The revision seems to be indicating that the industry may have been providing more therapy than was expected by CMS. The changes also parallel payment with costs and redistribute dollars from high therapy payment groups to other case-mix groups.

Prepare Now

Change in regulation means a need for updated policies and procedures. Do not forget to alter your casemix list for coders. Be certain everyone understands the changes in therapy reimbursement. Therapy visit numbers should correlate to the OASIS integrated assessment identification for need.

Remember, CMS expects the changes to this rule to decrease payments to agencies by over $425 million dollars. It is essential that agencies are very efficient in assessment, care, and documentation.

.

ACOs were created by the Affordable Care Act (ACA) signed into law March 2010. The dual purpose, of this network provider model, is to reduce the increasing cost of healthcare and to include incentives to create this new way of providing care for individuals. Coupled with the ACO rules, CMS had unveiled the Shared Savings Program (SSP), a program created by Congress to allow the ACOs to share in the savings and potentially share the costs of care to Medicare beneficiaries.

The final regulations were released. The proposed rules did not stimulate the interest expected. CMS has since changed the final rule to focus on the themes of flexibility, accountability, and innovation. It also provides clear guidance aimed at encouraging the development of the ACO participation in the Shared Savings Program. The purpose of ACOs is to realize savings and quality care through the coordination of services among the various providers, including hospitals, individual physicians, group practices, hospitals, home health agencies, and community health centers, or any combination of the above. Applications for the implementation of ACOs are currently being accepted through January 1, 2012, and the first ACOs will begin April, 2012.

The three goals of the ACOs stressed under the Shared Savings program will be to promote: 1) effective, patient-centered care for individuals; 2) preventive oriented and education oriented care for specific populations; and 3) cost savings (and profit) for the ACOs and CMS in general as well as decreasing waste in the system.

To be eligible to participate in the Shared Savings Program, ACOs must be accountable for at least 5000 beneficiaries a year for each of the three years of the agreement. To be eligible to share the savings, ACOs will be required to report on four quality measure domains.

It is apparent that this new healthcare model will be very patient-centered, not only addressing the medical needs of its participants, but also the social, nutritional and community needs as well. The cost sharing for the ACOs is determined by not-yet established benchmarks for 33 quality measures (QMs) broken down into the four domains:

• Care Coordination/Patient Safety (6 measures)
• Preventive Health (8 measures)
• At-Risk Populations/frail elderly health (12 measures)
• Patient/Caregiver Quality Standards (7 measures).

The QMs include population focused areas that are approached in a patient-centered manner. These indicators include timeliness of physician appointments, effective communication, tobacco use, diabetes and other comorbidity control, as well as preventive screenings. Depending on the success of the outcome-driven education and approach to the care as well as patient ratings and surveys, specific provider scores could garner up to 60% of the savings realized by the organization. It is anticipated that the new system will save over $960 million over the next three years for the Medicare program, per CMS.

This new form of healthcare organization will utilize technology to link providers. “An ACO will be rewarded for providing better care and investing in the health and lives of patients,” said Donald M. Berwick, M.D., CMS Administrator. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”

Payment Rates and Market Basket Index Rate Effects On Home Health Care

Perhaps your firm would benefit from a third party quality clinical chart audit. Your Professional Advisory Committee, Board of Directors, and you may well see the merit of an independent view of clinical processes and care. Noting strengths and determining opportunities for improvement before a survey makes sense. Are you spending too much time and money internally for chart reviews? What does happen after those reviews? Do you educate personnel? How do you know if that education was successful?

Clinical chart audits can assist you to remedy issues, provide education and training, and improve efficiencies. Clinical audits can assist to streamline processes, determine areas of risk, and assist to improve the bottom line.  Clinical audits can assist to identify quality customer service and improve patient care.

“Identifying ways that an outcome-based corporate culture fully extends to both internal and external customers is the responsibility of leadership. Developing and using simple tools can aid in the process. Once systems are implemented, maintaining a true commitment to TQM becomes a powerful challenge. But, to the persevering leader, the rewards of quality customer service can go hand in hand with a positive bottom line” (Carmichael, 2005)*

The new survey protocols mandate an outcome–oriented survey process, therefore, know that the surveyor will continue evaluating, per CMS, “the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care.” In addition, the new process will emphasize the clinical record of assessment and care, agency personnel interviews, and home visits. The new regulations provide clear guidance for expanding the survey, if needed.

Besides Process and Chart reviews, agencies should routinely use the Surveyor Worksheets to review agency data filed with the state, look at diagnoses and expected outcomes, monitor potentially avoidable event outcomes, and be certain there is adequate documentation for case mix indicators.

An evaluation of Level 1 indicators (see Select Data University April, 2011 article on New Survey Protocols, Survey Protocol Worksheets) includes standards under skilled nursing and therapies. If the agency is in compliance with Level 1 standards and no additional issues or concerns are identified, the survey is completed. If the expected outcomes are not met for one or more Level 1 standards, then the survey expands to become a partially extended survey.

At the very minimum, compliance with Level 2 standards is evaluated if deficiencies were identified with Level 1 standards. This is the partially extended survey. Be aware that surveyors may review additional non Level 1 or 2 standards under the same conditions during the partially extended survey at their discretion. (State Operations Manual, SOM, Appendix B). In an extended survey, all conditions will be reviewed. Appendix B and Survey Protocols provide specific recommendations for: citing condition-level deficiencies, extending the survey, and related conditions for further survey.

Now, more than ever, a thorough assessment must drive discipline specific care plans that drive the overall POC with every visit skilled and enhancing the process toward expected outcomes. Clinical record reviews, clinical interviews, and home visits drive the survey process. Documentation is essential. Good documentation starts with a thorough assessment. That assessment should be specific. Does your assessment tool set the stage for success? Is it detailed enough to gather data to allow the highest level of coding specificity? Does it cue the clinician with requests for detail to support a case mix diagnosis that may be assigned?

It is simple in the guidelines; a good POC starts with a solid clinically integrated OASIS assessment. That assessment drives the discipline specific care plan and those plans contribute to the overall POC. That POC has diagnoses present that require substantiation in the clinical record and the expertise of master coders. That very record supports the diagnoses sequences chosen. The visits can stand alone as to skill but reflect that they are a part of an individualized skilled plan of care.

Documentation takes time and thought. Clinicians are busy and require assistance and support. Consider a third party coding entity. Also consider an OASIS data collection service that was created by clinicians.  The system should be reflective of what you expect and of what your clinicians need.

The new survey protocols are data driven. Agency leaders need real data daily, weekly, monthly to monitor clinical performance and patient care outcomes.

The Surveyors have the data when they arrive. Do you?

*Carmichael, S (2005). Total quality management and outcomes based quality improvement: revisiting the basics. In Home Health Care Management and Practice (17)(2),119-124

The patient Plan of Care must identify the skilled services needed that will be provided by MSS. Under the Medicare Home Health Benefit 42 CFR 409.45(c), Medicare Benefit Policy Manual Chapter 7, Section 50.3, and Medicare Conditions of Participation 42 CFR 484.34 Publication 100-07, Appendix B, Medical Social Services is described as a dependent service that is only covered in a certified home health agency when the patient is already ordered and receiving skilled nursing, physical therapy, occupational services, or speech/language therapy. Think of Medical Social Worker as providing services that will provide intervention or resolution of emotional or social issues that might impact unfavorably on the patient’s recovery. Agencies are citing increasing patient challenges in a struggling economy especially with the housing challenges that are so prevalent. If you believe those issues could impede progress in care outcomes, then MSS should be considered.

The frequency and duration of the services are necessary to be quantified just as with other skilled services and the delineated services must be provided by a Masters or Bachelors prepared social worker. The MSW is also required to have one year of social work experience in a health care setting prior to working in home health care. The Social Work Assistant must have a bachelor degree in social work, psychology, or sociology. The bachelor prepared assistant works under supervision of the MSW in accordance with the patient Plan of Care.

The Assessment and MSS

The MSS assessment of the patient is completed by the Masters prepared social worker (MSW). Medical Social Services works with the patient and family to use community resources, provides short-term intervention skills, assists to design a plan of care to deal with chronic conditions such as Alzheimer’s disease. Additionally, as with other skilled services, medical social services are supported by OASIS answers:

• M1018 identifies medical condition change

Are the patient and caregiver coping with the change of condition?

• M1022-24 sequences diagnoses
• M1032 states risk for hospitalization

Is there emotional, social, or financial risks that necessitate MSS intervention?

• M1034  cites overall status
• Look at reduced functional status
• Identify any medication issues
• M1100 looks at patient living situation

Is the living situation impeding patient progress?

• Look at the safety evaluation

Is the patient at risk for abuse? Is there risk for emotional issue exacerbation?

• M2100 sources and types of assistance

Medical Social Services and the Challenges in Home Health

Involving MSS can assist to reduce the hospital readmission and assist the patient with a positive adjustment to the home health experience. Medical Social Services can provide family and caregiver support services. The MSS can facilitate access to needed medications, supplies, and DME, as well as aiding in removing barriers to transportation access.

The MSS can assist with case coordination with all disciplines addressing social and environmental factors while skilled nursing addresses the medical and nursing factors. The MSS can document patient and family challenges so the physician has a better “view” of how the patient interacts with their home environment.

The social worker can assist the family with referral services and act as a liaison for that care. The MSS can provide patient counseling. Brief Counseling or Cognitive Restructuring Therapy may be needed for the depressed patient. The MSS can liaison at both the macro and micro patient care level; addressing patient specific needs.  Medical Social Services can add value and positive customer satisfaction. Think patient satisfaction calls. A strong social work program can aid in reducing the number of clinical visits needed, improve customer relations, support team members, and increase referrals to your agency. This is usually an under-utilized valuable service benefiting patients, employees, and the agency.

This week’s article:
Documentation, Edits, and Auditors, Are You at Risk?

Let’s Talk Documentation and Edits

Medicare has been called the “largest wasteful program in the Federal government.” With the expanded overpayment recovery mechanisms and stiffer penalties for those who commit fraud, the Affordable Care Act is committed to increased audits, deterring waste, and stopping those individuals who perpetrate fraud.

CMS will now disallow payment for illegible signatures and lack of documentation to support need or skill. There are widespread edits to AUTOMATICALLY reroute claims at risk for payment errors, for review prior to payment consideration, and to verify that care was appropriate to the plan of care submitted.

The Auditors

We have all heard the acronym auditing groups. They are real and because of the Affordable Care Act they now have more momentum.

¡  RACs- contingency motivated recovery audit contractors (retrospective focus). They are now in place and working closely with the MACs and ZPICs.

¡  MACs (Your Fiscal Intermediary) – can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for overpayment estimation of claims (current and prospective focus).

¡  CERTs- described as the “QI for MACs“ looking at claims payment accuracy.

MICs- described as the RACs of Medicaid

¡  Z-PICs- primary goal is to identify cases of fraud, develop the investigation, and refer to the OIG. If you receive a Z-PIC letter, one can presume they believe they have grounds for pursuit.

¡  HEAT- The more aggressive investigator of essentially DME and Home Health. Using state of the art technology to expand the CMS Medicaid provider audit program. Their raids result in convictions.

¡  Expansion of DOJ/CMS/HHS Inspector General Medical Strike Forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay. Raids in these cities are as recent as September, 2011.

NOTE: Fiscal Intermediaries reviewing denials May 28, 2008- October 31, 2009 identified lack of medical necessity and homebound status unsupported in the medical record. In addition, ADRs were not received in a timely manner.

¡  CMS expects that the patient’s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home.

NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1

The Edits

There are a growing number of widespread edits including diagnosis in combination with related factors or by itself, changes relating to utilization and skill, number of episodes and number of visits.

Are you monitoring the following:

• Parkinsons Disease 332.X > 60 days or more with 10 or no therapy visits.
• Trauma wounds 870-879.
• COPD Long-term 496 with two episodes or more.
• Long-term use of Anticoagulants V58.61 with no therapy ordered.
• 5 Visits in an episode comprised of 1 SN and 4 of any therapy.
• 5 Visits including 1 MSW.
• Hypertension 401.X with 3 episodes or more.
• Daily SN visits with no therapy exceeding 1 episode.
• Chronic diseases as primary diagnosis two episodes or more.

Claims are Denied When

• A matrix shows suspected reasonableness substantiated by lack of documentation
• Orders and plan of care cause alerts
• Homebound criteria not met every visit
• SN visit care is not intermittent
• HIPPS code billed is not validated by documentation
• CAHABA denied more claims in 2009 and 2010 for lack of proper documentation than any other reason.
• Long term claims show lack of documentation for reasonableness. The longer term the care, the more redundant the documentation.

Longer Term Care Edits Triggered

• Parkinsons Disease 2 plus episodes with no therapy.
• Primary Diagnosis COPD 2 episodes or more.
• Hypertension 3 plus episodes.

Skilled Nursing

Skilled nursing coverage is clearly identified in the Medicare Benefit Manual Chapter 7.40.3. If the G Code indicates observation and assessment, then documentation of the patient’s change of condition is necessary and nursing is required until the condition is stabilized. There is a need to note the abnormal symptoms of change such as VS, weight changes, pulse ox and respiratory changes, and/or mental status. There is also a need to document the plan modification and the skilled intervention on each visit. Just observing and assessing without clear intervention will not allow for ongoing payment.

Physical Therapy is a Target

Physical therapy remains a target because therapy documentation frequently remains inadequate and the therapy visits seem to adjust to payment regulation changes. This has triggered the new regulations for 13^th and 19^th visits requirements and 30 day reassessments. Scrutiny of therapy is acute.

In homecare, observable functional ability improvement is expected. Documentation should be clear and concise with objective measurements. To justify therapy for non direct hands-on treatment, therapists must be clear what was taught to a caregiver to qualify it as a necessary treatment. Services provided must be consistent with the severity of the illness originally assessed.

CMS states, “therapy services are provided with the expectation of the beneficiary’s rehabilitation potential that the condition will improve materially in a reasonable and predictable period of time. The term “materially” means having real importance to consequences, to an important degree or perceivable in material form (objectively).”

Diagnosis must illustrate the focus of care. Diagnoses codes must be updated for each episode. The documentation must support the diagnoses, the plan of care, and the treatments.

Diagnoses Edits

Diabetes primary with CHF secondary is downcoded when DM is incorrectly listed as the primary dx. It can only be listed in M1020 when it truly is the focus of care. The documentation must clearly and consistently reflect this focus.

Hypertension as a primary diagnosis for two or more episodes is a clear flag. A clinician must ask, “if the hypertension is unstable for over 180 days, could there be another problem?”

Schizophrenia is questioned when that diagnosis and the corresponding care are not consistent. An injectable med must be supported by adequate need. Why is it required vs the like oral medication?

Daily visits will be at high risk for audit review. They must have documented support with a finite, predictable, and reasonable endpoint. If BID insulin is being administered, an agency would be wise to have clear documentation, each episode, by a Medical Social Worker who investigates and find no willing, able, reliable caregiver to administer the insulin.

Watch out for LUPAs. Your agency should be monitoring the reasons for LUPAs. Trends such as specific physicians or diagnoses should be monitored. Your LUPA level is being monitored by CMS.

One SN visit with 4 therapy visits is an alert. The MACs look for the medical necessity of nursing. If one nursing visit was ordered then there was no plan for intermittent care thus SN will be denied. It will appear to an auditor that the RN opened the case for a therapy only case.

Minimizing  the Risk of Denials

Educate personnel as to how auditors are reviewing claims. Also, make the clinicians aware that auditors are now looking at the clinician as well as the agency.  If the documentation does not support medical necessity, the question becomes, why is the clinician stating the care is needed when the documentation does not support that fact.

Agency internal review should show why the QA/QI clinician concurred with the plan of care and visit documentation provided. Conduct routine audits and find issues before CMS summons you.

Be certain that ADRs are answered promptly. RACs auditors find that one reason they have had such success is because requested items were not provided timely.

In 2011 and 2012, CMS has required that the MACs not only consolidate fiscal intermediary edits but have them uniform throughout their jurisdiction. Agencies should stay current with MAC Alerts and Newsletters. Consider attending MAC workshops and ask that the edits be made available to providers.

References:

CMS Medicare Benefit Policy Manual, (CMS) Pub 100-02) Chapter 9.

www.cms.hhs.gov/Manuals/IOMlist.asp

OASIS Implementation Manual Chapter 3