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.
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?