Archive for the ‘Therapy’ Category

Summary of the CMS Released 2013 Final Rule

Tuesday, November 27th, 2012

Market Basket and Payment Rate Update

On November 2, 2012, CMS released the Medicare Home Health Final Rule for the Home Health Prospective Payment System 2013. The proposal includes the 2013 Market Basket Index (MBI) update of 2.3%, the required 1 point reduction under the Obama Affordable Care Act, and the reduction in rates of 1.32%, which is approximately a $10M decrease to payments for the home health 60 day episodes for 2013. The main change, per NAHC, from the July 5th proposed rule adjustment is an adjustment of the MBI from 2.5 to 2.3% occurring as a result of more current data. Proposed payment base episode rates are set at $2137.73 from a current $2138.52.

Though a small increase, the gain is that it is not the decrease CMS had proposed if  a full creep adjustment had been incorporated. The base rates are adjusted up by 3% for service to patients in rural areas.

 

LUPA RATES

For agencies submitting the required quality data, the LUPA rates are :

HH Aide $  51.79

MSS       $ 183.31

OT          $ 125.88

PT           $ 125.03

SLP        $  135.86

SN          $  114.35

 

For those agencies that have not submitted quality data, their rates will be reduced by 2 percentage points.

 

The outlier eligibility standards are changed from 2012. The Fixed Dollar Loss Ratio is lowered from 0.67 to 0.45. This will increase the number of episodes that will qualify for outlier payment.

 

Sequestration

Home Health agencies should expect payments subjected to a 2% sequestration, as part of the deficit reduction law. Though this is not a rate change, in and of itself, it will be a withhold of 2% from the claims payment. This is another  home health  reduction. Be prepared for expected significant changes for 2014 when CMS rebases the HHPPS rates as required under the Affordable Care Act.

 

Therapy

CMS finalized three revisions regarding qualified therapists completing a functional reassessment of the patient at the 14th and 20th visit and every 30 days.

 

First: CMS states that if a qualified therapist misses a reassessment visit, therapy coverage would resume with the visit during which the qualified therapist completed the late reassessment, NOT the visit after the qualified therapist completed the late reassessment.

 

Second: CMS states that in cases where there is multiple therapy disciplines involved, if the required reassessment by the qualified therapist was missed for any of the therapy disciplines, therapy coverage would cease for only the therapy discipline involved.

 

Third: CMS states that in cases where the patient is receiving more than one type of therapy, qualified therapist must complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and they must complete the 19th visit reassessment during the 17th, 18th, or 19th visit. CMS also states that in instances where the beneficiary receives more than one therapy type, if the frequency of a particular discipline does not make it feasible for the reassessment to occur during the specified times without providing an extra unnecessary visit or would delay a needed visit, then it is acceptable for the qualified therapist from each discipline to provide all of the therapy and functionally reassess the beneficiary during the visit associated with the discipline that is scheduled to occur closest to the 14th Medicare covered therapy visit, but no later than the 13th Medicare covered visit. Likewise for the 20th Medicare covered therapy visit but no later than the 19th covered therapy visit.

 

Thus, the revised rule states that if, in multiple therapy visit cases, the required reassessment was missed for any of the therapy disciplines, therapy coverage would cease only for that particular therapy. Therefore, as long as the required therapy assessments are completed timely for the remaining therapy disciplines, therapy services would continue to be covered for those therapy disciplines, unlike presently.

 

Face to Face

CMS finalized adjustments allowing non-physician practitioners in an inpatient setting to perform the encounter and inform the inpatient physician who can then become the certifying physician.

 

M1024

M1024, effective January 1, 2013, is to only be used for acute fracture codes for case mix points. Patient resolved conditions are not to be coded in home health. Citing Attachment D, CMS has clarified the only codes not allowed in homecare are acute fractures. These, then will be the only resolved codes allowed in M1024. Neoplasms, diabetes codes, neuro codes, and skin will no longer garner case mix points if placed in M1024, although CMS has stated an agency may continue to place resolved conditions in M1024 to present a more complete picture of the patient.

 

The final rule can be found at

http://www.ofr.gov/inspection.aspx

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Posted in Affordable Care Act (ACA), CMS, Face to Face Encounters, Home Health, LUPA Rates, M1024, Market Basket Index, Medicare, NAHC, Therapy | No Comments »

Some Important Sites for Providers of Home Health Services

Friday, September 21st, 2012

In this day when the only constant is change, here are a few important sites to add to your list.

MLN Matters Articles Index thru August 2012

An excellent site housing national articles designed to inform providers about the latest changes in the industry.

It includes links to MLN related information and over 50 products relating to DME, EHR, Education and Management, Medicare Payment Policy, Provider Compliance, and Provider Specific Information.

www.CMS.gov/outreachandeducation

Patient Centered Medical Home Model

CMS is still testing the patient centered medical home model in the multi-player Advanced Primary Care Practice Demonstration and the Federally Qualified Health Centers Advanced Primary Care Practice Demonstration.

CMS continues to test the PCMH model under the Innovation Center created by Section 3021 of the Affordable Care Act allowing CMS the opportunity to test a variety of models and expand implementation throughout the country.

http://innovations.cms.gov/

The Innovation Center

The Center was created by Section 3021 of the Affordable Care Act allowing the opportunity to test a variety of models and expand implementation throughout the country, the goal is to increase quality and reduce health care expenditures through innovation.

http://innovations.cms.gov/

Survey Guidelines

www.cms/surveycertificationinfo.gov/downloads

Preventing Billing Errors

To increase Understanding of billing requirements and to avoid common billing errors, visit

www.cms.gov/outreachandeducation

Claims Processing

To review expectations for proper claims processing, go to

www.cms/outreachandeducation

The Official Medicare Claims Processing Manual Chapter 22- Remittance Advice

http://www.cms.gov/manuals/downloadsclm104c22.pdf

Understanding the Remittance Advice:

A Guide for Medicare Providers, Physicians, Suppliers, and Billers

http://www.cms.gov/inproductsdownloads/RA_Guide_Full_2_22_06.pdf

Therapy Claims-Based Data Collection Strategy

Proposed rule CMS 1590-P was released as a proposal to collect more date on patient function as it relates to Speech/ language, occupational, and physical therapy services delivered. The Middle Class Tax Relief and Jobs creation Act (MCTRJCA) requires CMS to begin this data collection January 1, 2013.

Update on ACOs

We have written several blogs and ezines regarding the new Chronic Care Management Models, including Accountable Care Organizations. Health and Human Services Secretary announced that as of mid summer there are 89 new ACOs in 40 states serving 1.2 million people. As we have discussed in prior ezinesin both 2011 and 2012. ACOs may be formed by health care groups (not home health agencies) such as hospitals and physician groups. New applications continue to be accepted and there is expectation of the formation of many more of the alternative

care models. Go to:

http://www.hhs.gov/news

Remember, the CMS website has had new updates re Open Door Forum Discussions and MLN educational updates as well as content re ICD-10. Visit often as regulations are changing and being updated routinely.

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Posted in ACO, Affordable Care Act (ACA), Billing, CMS, ICD-10-CM Coding, Medicare, Surveys, Therapy | No Comments »

ICD – 10 CM: Completing the Gap Analysis and Transition Plan (Part 2 of a Coding Series)

Thursday, August 30th, 2012

ICD-10 CM is going to impact the entire home health industry and every department of your agency. Now that we know that the implementation date will be October 1, 2014, agencies need to establish a solid plan now. You need every day of the 24 months to educate, plan, educate, implement, reevaluate, test and retest, and educate.  Training for coding specialists is important, but training for those who will use the data will be equally important.

Creating a roadmap for ICD-10 integration within an organization may appear daunting. Let’s break down the process. CMS suggests presenting an overview of ICD-10 to the entire organization. This allows individuals to process the changes in ICD-10 and align those changes to processes they presently complete. This assists the organization to understand the depth and impact of ICD-10.

Completing the Gap Analysis

Define the agency’s present state. Review the list of processes for each department from intake of a potential patient to filing of the final claim of the patient and the resulting data analytics. Identify how the coding touches each area of work flow.

Identify the agency’s strong competencies and the additional training to maintain those competencies. Look at performance levels and consider the impact of ICD-10 on performance. Considering the increased specificity of ICD-10 coding, what will be the impact on clinical and operational processes? What new clinical tools will be needed? What form changes will be required? How will internal and external reports be impacted?

List, then communicate with vendors, payor sources, and clearinghouses. Where are they in their processes? What are their plans? Will they be ready?

Identify the timeline for the Gap analysis.

Organize an ICD-9/ICD-10 Transition Team

The goal of the team is to establish an overall organizational plan after the Transition Team either completes or receives from another committee, a Gap analysis; operational and technical impact analysis. The new Transitional Team should review that overall analysis, using those specific organization findings to provide the base of their project/transition plan.

The Transition Team should have representatives of each department: intake, clinical, IT, HIM, billing, QA, internal auditing, and administration so that they can adequately develop an expansive implementation strategy.

Choose a project leader of the transition team. This leader must organize the development of a budget, a timeline and action/project plan that will include a training plan for the organization. It must demonstrate how findings and planning will be communicated. The project/transition plan needs to be tied to endpoints that are reasonable and measureable. Compliance plays a huge role. The plan must be compliance oriented; attending to statute, convention, guideline and regulation.

Report from each Department Representative and Plan Creation

The representative from each department; IT/technology, Clinical, Coding, Revenue Cycle/billing/finance, QA/QI/Audit, Data Analytics, and Education/Training  must lead the indepth department evaluation as well as the department project plan.

What will be the impact to each department?

Coding specificity?

Impact on data capture at intake? At time of assessment? On data analytics and reports?

Impact on the plan of care (485)? Consistency of diagnosis/supportive documentation/careplan

What about the schedule and the depth of schedule notes?

Utilization and quality process and improvement

Need for increased clinical cues

Time/ amount to capture data at all time/patient points

Field sizes, alphanumeric composition, and decimal use

Code value alteration with Table structure alteration

Edit and logic changes

Overlapping time point of ICD-9 and ICD-10

Impact on the EMR

Impact on interfaces

Impact on HR and personnel needs

Education and training needed for each department

Budget creation for the project

Who will monitor the vendors and payors?

Do not trust the statement that the vendor will be ready. Your agency cash flow could be dependent upon their planning, testing, and implementation.

Ask to see the vendor plan and monitor progress to general goal completion. When will the upgrades or new software be available?

Evaluate health plan readiness. Evaluate the impact of ICD-10 on usual and customary reimbursement fee schedules as well as episodic reimbursement.

Training and Education

You want to prevent agency claim rejections as well as delays in processes. You want personnel comfortable with new processes. You want to be compliant.

Each department will have different training needs. Obviously, the biller does not need the same level of coding expertise as a credentialed coder, but they require an understanding of the impact of the new coding on their particular processes.

The leader of this department will need to work closely with each department head as to specific training needs as well as the best methods of training. Additional assessments needed include: Can the agency provide all, some, or none of the training needed? What training method will work best for the learners? Will classrooms and teleconferences work best? Should they be augmented by web-based learning? Are inservices and seminars by experts another route to pursue?

Consider length of time for education and training. Some departments will require more training over a longer period of time.

Coders will need an indepth review of Anatomy, Physiology, Pathophysiology, Diagnostics, and Pharmacology. Each of these areas should be relational to disease states so that a comprehensive understanding of the new code application exists.

Whether you code inhouse or you contract with outside experts, be certain that parallel coding will occur for several weeks before the new codes are applied to the claims. October 1, 2014 should mean all training and education has been completed, processes have been reviewed and tested. Be certain that data analytics and infomatics are meeting the new specificity requirements.

Clinicians will need a solid understanding of the specificity of the documentation now required. They will need orientation to the more indepth assessment tools. Clinical cues as to diagnosis documentation requirements will be needed.  

Hopefully, vendors will be able to assist clinicians so technology can be leveraged to make up for the detailed documentation needed.

October 1, 2014 will be the ICD-10 implementation date. You have only 2 years to complete the Gap analysis, establish the Transition Team, create the transition plans, lead and evaluate training/education needs of all departments, create new tools needed, modify and test processes as well as review data created and have all processes in place to submit compliant claims. You need to start NOW! You only have two years and the clock is ticking.

 

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Speech and Language Pathology, the “OTHER” Therapy

Friday, November 25th, 2011

While there is much focus on PT and OT, know that documentation will be scrutinized regarding Speech/Language Pathology also. Most clinicians have a good understanding of how PT and OT intervenes with the clients but many clinicians may admit, that other than help with dysphagia, they are uncertain what other care the S/LP can provide?

S/LPs are subject to the same documentation goals under the CoPs:

¡  Provide evidence that the care given meets clinical standards

¡  Justify reimbursement for the payor

¡  Provide protection from liability

¡  Means of communication among individuals providing services

Provide accurate data regarding care for specific patient and diagnostic populations.

S/LPs must meet the same legal requirement to communicate:

¡  Record must be accurate in all respects

¡  Content of the record should contain measurable and objective data

¡  Interventions must be specifically documented and be relational to the POC

¡  Document what was taught and to whom

¡  Document what was learned and by whom

¡  Legal signature includes: Full Name, Full credentials and be legible

S/LPs must have the patient meet the Home Health eligibility per the CoPs:

¡  Homebound Status

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

¡  Under the Care of MD, DO, DPM

“A medical treatment plan of care or the optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments”

See 42 CFR Part484, Conditions of Participation, Subpart A General Provisions and 484.18 Plan of Care.

¡  Medical Necessity and Skilled Need

CMS states that medical necessity is defined as a “reasonable and necessary need for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member.”

S/LPs must document specific care to justify Medical Necessity

¡  Is there a feeding and swallowing problem?

The S/LP will routinely perform an oral/motor examination. They will evaluate swallowing, coughing, and the size of bolus.

The S/LP can develop a plan to mitigate risk of aspiration such as bolus control.

The S/LP can assist with the plan to maintain adequate hydration and nutrition through body positioning and maneuvers to improve safety.

They will assist in evaluating the independence factors in compliance with the overall plan.

¡  Is there a problem with language  (verbal expression, comprehension, reading)

The S/LP can assist to minimize safety risks by finding tools and devices to aid in communication of safety needs to family and other caregivers.

¡  Is there a cognition issue?

The S/LP can assist with strategies to improve attention and attending cues, as well as memory cues.

The S/LP can identify strategies and tactics that can aid problem solving skills. This too can impact safety and independence.

¡  Does the patient require intervention with Voice?

The S/LP can identify strategies to impact on verbal expression, relieving vocal symptoms and, improving their functional voice. The S/LP will identify ways to increase voice loudness and decrease hypernasality.

The clinician should assess this need for S/LP under the Safety evaluation.

¡  Is the patient struggling with fluency and difficult sound production? Do they have an impairment of the tongue? Do they have a lower neuron disease or cerebellar lesion? Does the patient suffer from TBI or had a stroke, or MS?

The S/LP can provide assessment of and interventions for the patients suffering from receptive language deficits; the need to improve understanding of spoken language and can assist with expressive language needs also. It can be frustrating to a patient who cannot state needs or answer questions. Acting out behavior is frequently found to be due to fear, sadness, and frustration.

Depending upon the condition teaching and reteaching occurs.

¡  Three Types of Teaching:

¡  Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis

¡  Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching

¡  Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient has had prior instruction

The S/LP has expertise in learning principles and teaching techniques.

Using Descriptive Verbiage in Documentation

Expect to see documentation descriptors that create a visual image in the mind of the reader. They should demonstrate the skill of the therapist, the value of the care as well as progress of the patient toward their goals:

Accessed                    Assessed                          Assisted               Adaptive

Altered                     Accurate                   Automatic             Applied

Analyze                    Appraise

Cues/Cued                Compromise              Corrected             Customize

Calculate                  Compare                   Contrast               Construct

Compose                  Choose                      Categorize            Collect

Directed                   Develop                      Distinguish          Define

Demonstrate                      Dramatize                  Diagram

Evaluate                   Exercised                            Elevate                Express

Explain                     Examine

Facilitate

Illustrate                   Identify                     Interact                Instruct

Modify                 Measure

Progressed           Practiced                   Proposed

Revised

Stimulated            Scheduled

Updated

The S/LP should document prior functioning in comparison to current. They should clearly document care coordination.

Choosing the Assessment Instruments and Tools

The home health agency, in conjunction with the therapist, should determine what tests will be approved by the agency, so there is continuity among all therapists. Be certain each therapist is knowledgeable with the tools chosen so inter-rater reliability issues are minimized. Also, much like PT consistency; will a TUG or Tinetti be used, S/LP must consider test and re-test reliability.

Consider time for the administration of the assessment. Nurses have seen assessment tools come and go. I can recall a fabulously thorough clinical assessment tool to be used on an inpatient unit. It soon lost favor when its lack of practicality surfaced. Are you seeking comprehensive tools? Be certain they are standardized so that reliability and validity issues do not surface.

Look at the OASIS functional items and look to well thought of commercially acceptable outcome measurements such as the NOMS. The National Outcome Measurement System can be used as an objective measurement tool for the CMS 13th and 19th visit per the American Speech-Language-Hearing Association.

Eight of the fifteen Functional Communication Measures (FCM) from the Adult NOMs were submitted to the National Quality Forum (NQF) for review and were endorsed and became a part of the public domain.  The FCM is but one component of the overall NOMS, the national data base of treatment outcomes and customized data reports.

Other Common Tools Used by the S/LP

The Aphasia Language Performance Scale (ALPS)

The EFA-3, Examining for Aphasia

Boston Diagnostic Aphasia Exam

Cognitive Linguistic Quick Test (CLQT)

CADL, Communication of Activities of Daily Living

For a more complete list of Standardized Assessment Instruments, go to:

http://www.asha.org/assessments.aspx

¡  Documentation to substantiate coding and care have become critical to agency providers.

¡  Documentation has become the key communication tool for care.

¡  Documentation has become the first and last line of defense with the scrutiny of the industry auditors.

Documentation provides the demonstration of the skills of the clinician and justifies the retention of the agency payment received.

Quick tip: Recently, a colleague shared with me that on their psych team, besides the psych nurse and the occupational therapist, they have added a S/LP in certain circumstances, especially with patients with challenged cognition. With patients who are acting out and have recently suffered a stroke or have exacerbated MS, the S/LP has much to add to the Home Health Team in assisting to decrease frustration and anxiety. Speech and Language Pathologists (therapist) add depth to the total team.

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