Archive for the ‘Z-PICs’ Category

Good Coding: Helps Your Agency Keep Its Revenue Bad Coding: Can Mean You Lose Your Revenue

Friday, May 17th, 2013

PPS has always meant that “close enough” isn’t good enough. A digit off can be costly. Coding to the highest level of specificity can be complex and confusing. CMS has published Coding Guidelines and the Coding Clinic remains the source document for any coding questions.   Per CMS and as per the Federal Register, “The  Coding Clinic by AHA is the US Official Clearinghouse for Coding.”

Agencies have hired coders, some are credentialed, some not.  All usually do not have audits of their coding compliance.  As a result, when asked, “Are you leaving dollars on the table?” most administrators pause.  Most acknowledge they believe their coding may be costing them at least $200-$400 per episode.  Why continue to lose dollars?

Agencies have usually decided to complete their coding themselves, but that is changing.  In the past, agencies have hired coders, certified or otherwise. Some coders are routinely reviewed and audited, most are not.  Most agencies rely on their coders. They put a portion of their financial welfare in the hands of unreviewed coders.  Lessen the worry regarding dollar loss and the quality of your agency coding by instilling specific processes. At the very least, contract for routine third party coding and billing audits.

If you were to use a third party coding firm, be certain they have external audits performed on their coding.  Quality third party coding firms should have quarterly internal audits and annual external audits completed in their firms. Who has audited them? What are the firm’s names?  Yes, the audits are an increase cost, but ar $e you losing 200-$400 per episode of care delivered? Are you flagging your firm for a RAC, MAC, or Z-PIC audit?

You should take a close look at the coding completed in your agency. Look at the use of case-mix diagnoses and at comorbidities. Down coding can be as costly as upcoding, just in different regulatory ways, if it brings on an audit. Have your ADRs increased? Do you know the number of codes used routinely in your firm? Do you know the top 10 diagnoses assigned?  How many of the present 16,000 codes are your coders using? How much will preparing for ICD-10 cost you?  Is a plan in place now? How strong is your coder in anatomy, physiology, diagnostics, and pharmacology? How many of the 68,000 codes will they use?

Experts know that much training is required for ICD-10. If you do not properly prepare, how much more will it cost you? Perhaps it really is time to consider a third party coding specialty firm.

Consider a firm that has experienced, highly credentialed coding specialists. Ask if they employ a full time coding internal auditor. Ask if they have weekly training sessions paid for by the coding firm to keep their coding specialists current. Ask if they have a full time Compliance Officer, a compliance committee, and have current program policies and procedures. Ask if the firms’ employees are required to annually attend corporate compliance and HIPAA inservices. Ask if the coding specialists are reviewed quarterly. Ask about internal and external audits of the coding teams’ work. Ask about their % of documented accuracy as stated by an independent auditor.  If the coding agency is under 97% accuracy documented by independent external audit, look elsewhere. All of the above items are costly to the coding firm but a top coding firm should be investing in quality.

And lastly, identify the coding firm’s indepth ICD-10 curriculum for their coding specialists. Also, identify their overall plan for ICD-10 implementation including their plan for parallel coding of ICD-9 and ICD-10.  Do not continue to lose dollars. Make a move now.

For more information, call 714.524.2500

ICD-9-CM Official Guidelines for Coding and Reporting

Effective October 1, 2008

The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S.

Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO).

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are includedon the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself.

The following are the CMS ICD-9 Site:

  1. CMS ICD-9 Site

  1. Attachment D

  1. Coding Clinic

Operational coding advice and guidelines for ICD-9-CM are published quarterly by the American Hospital Association (AHA) in Coding Clinic for ICD-9-CM (Coding Clinic). The Editorial Advisory Board (EAB) for Coding Clinic consists of representatives of AHA, the American Health Information Management Association (AHIMA), NCHS, CMS, the American Medical Association (AMA), the American College of Surgeons, and other hospital coders and physicians. Four of those parties (AHA, AHIMA, NCHS, and CMS) are identified as Cooperating Parties for Coding Clinic. The Cooperating Parties must agree on the coding guidance before it can be published in the Coding Clinic. Anyone may send issues to AHA for EAB discussion.

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.

Psychiatric Nursing in Home Health: Caring for the Bipolar Patient

Thursday, June 7th, 2012

Developing a psychiatric (nursing) program has become a potential program considered for agency development. We have seen an increase in questions regarding psychiatric nursing services for the patient suffering from bi-polar disorder with depression. More agencies are considering new mental health programs. One agency has shared that Palmetto is no longer asking to see resumes of psychiatric nurses, but note that agencies must verify requirements with EVERY MAC before beginning a psych program.

 The CMS Publication 100-2, Chapter 7, §, simply says, “Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.”  MACs can establish the special training and experience required.  A home health agency should contact its MAC and look at the MAC website for any special qualifications needed.

Working with patients diagnosed with bipolar disorders can be challenging in the home care setting, but establishing trust and forming a meaningful alliance can add such quality to their life. Patients frequently need to better understand their condition, to learn the symptoms, to understand medications and other interventions, and to understand risk mitigation strategies.



CMS has recognized psychiatric home care as a reimbursable service since 1979, but nationwide, proportionately fewer home health agencies actually provide this service. The exact number of agencies that include psychiatric home care is unknown. There has been a reluctance of agencies to implement psych programs and there are many reasons for these decisions.

First of all, the skills of a psychiatric nurse are required and this specialist is usually more difficult to find. Second, the psychiatric patient is frequently more disorganized and needy than other patients causing the case management responsibilities to become time consuming and complex. Third, this patient is frequently homebound questionable.

CMS Publication 100-2, Chapter 7, §430.1.1, states that a patient with a psychiatric problem may be considered homebound if “the illness … is of such a nature that it would not be considered safe to leave home unattended, even if he or she does not have any physical limitations.”  The homebound status of patients with psychiatric needs require well written, clearly stated clinical visit notes, because there may not be physical impairments, and homebound status must be clearly delineated. Any patient in a certified home health program may leave their home for specific reasons, as identified in Chapter 7 of the Medicare Provider Benefits Manual. Homebound status for a patient suffering from a mental health issue may be just as painful and debilitating, but may not manifest itself with physical symptoms or behaviors.

Homebound status (for a patient suffering from a mental illness) may need to be evaluated as a clinician would evaluate a patient suffering from dementia or Alzheimer’s diseases That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended.

However, if the patient with a psychiatric condition leaves home regularly for reasons other than to visit the physician, he/she may not be considered homebound; the same as any other home health patient in the certified agency.  An example may be that of patient with a mental health issue attending partial hospitalization.


What is Psychiatric Home Health Nursing?

 What is unique about psychiatric home care? Although psychiatric home care is bound by the same CMS regulations that define other types of home care, these regulations are largely non-specific for the psychiatric patient. This means the clinician must be specific as to symptoms and needs while clearly documenting individualized plans and interventions based on sound evidenced based processes. Additionally, this specialty clinician tends to work closely with the physician.

On the surface, psychiatric care appears to be very eclectic, but there is much depth of choice for intervention strategies. Although psychiatric nurses may draw upon crisis intervention techniques as noted by Duffy, Miller, and Parlocha (1993) and Beck’s or Montgomery-Asburg Depression Inventories, Young Mania Scale, Sheehan Anxiety Scale along with Cognitive Restructuring therapy, there are a number of other psychiatric intervention models that can be very useful: psych-education, interpersonal reflective, supportive, individual, and/or brief therapy, as well as behavior therapy, relaxation strategies, contract binding, and reward provisions.

The psychiatric nursing home care plan must be intermittent. This short term program frequently focuses on improved problem-solving, stronger ego boundaries, and enhanced self-concept. This is important with patients of all ages, but the need is seen often with elder patients who are suffering significant losses in life; loss of friends, loss of status, loss of financial level, loss of relatives, loss of familiar surroundings, loss of physical strength, and loss of confidence in ability to maintain independence.

With patients suffering from depression, the psych nurse frequently seeks ways to displace internalized anger outwardly and safely. Activities designed by an occupational therapist can augment the skills of the psych nurse. An increasing number of home health agency psych programs are adding this discipline because of the physical activities that can be beneficial.


The Patient Suffering from Bipolar Disorder 

According to the Department of Health and Human Services, patients with Bipolar Disorder and Depression lose 25 years of life expectancy when compared to persons without a diagnosed mental illness (Federal Register: 6/22/2010, Vol 75, # 119). The common conditions causing an early death include heart and respiratory disease, stroke, and diabetes. The psychiatric nurse can provide preventive health information that may be needed in areas of self esteem so the patient may see value and purpose for adequate nutrition, weight, exercise, sleep, work, and relaxation.

The nurse will assist the patient to deal with depression using strategies involving physical and emotional symptomatology that can enhance their ability to adequately function. The patient may express anxiety, agitation, lack of concentration, and feelings of worthlessness and hopelessness. These feelings require a specialty RN to assist with evidenced based psychosocial treatments for the disorder that includes assisting the patient and family members to understand what the disorder is and how it can best be treated.

The psychiatric nurse will educate as to signs and symptoms as well as the risk signs of relapse. Developing strategies to cope with stressful life events will be a focus of home care. The nurse will assist the patient and their family to establish protective insulators to support successful treatment compliance. Once the patient is stable, understanding how to access the overall health care system to manage their illness is necessary.

Stress management and education of stress strategies are commonly taught. Many patients have weak or fragile coping mechanisms that require reinforcement or a new approach.

Forming linkages between the patient and needed community services is a vital component of the role of the psychiatric home care nurse. This type of nursing brings an existential/spiritual concern and dimension to patient care. The clinician frequently provides support to a patient with low self esteem and a belief that the community has prejudged them. The clinician can assist the patient to cope with behaviors and approaches patients with an attitude of respect, reinforcing or assisting to rebuild worth and dignity.

Demoralized individuals are frequently seen in this program. Assisting to redirect their focus, find purpose, and achieve goals is a frequent shared goal.  Patients may lack energy, frequently because of losses; losses of friends, of family, of job, of status, of money, of respect, and others. This patient frequently requires a nurse whose plan with the patient requires assessment of the patient, their role within the family, the family support system, teaching use of psychotherapeutic techniques to facilitate change, medication management, and supervising their care in a supportive fashion that sustains a physical, emotional, and a spiritual quality of life,


Cognitive Behavioral Therapy

This is but one therapeutic philosophy that may be employed to assist the patient to examine how their thinking can impact their feelings and behaviors. Encouraging participation in psychosocial therapies can augment other interventions and improve quality of life.


Relationship Building and Trust 

The clinician will build relationships established on trust, caring, compassion, empathy, education, and hopefulness. The RN will use verbal and non-verbal communication techniques to convey interest in the patient, to assess what the patient wants to accomplish, to assist with care planning and goal achievement, and to clarify the boundaries of the relationship, and lastly to affirm the patient has value and worth.


Medication Management

Medication management is frequently a need for patients and is one of the main reasons for hospitalization. CMS identifies a significant portion of hospitalizations are due to poor medication management. Some patients do not understand the reasons they has been prescribed certain medication. Sometimes, patients do not like the side effects and feel those effects are nearly as bad as the psychiatric condition. Some patients cannot afford their meds and still others do not wish to take their meds as they provide a constant reminder of a condition many wish could be forgotten. One patient once shared, “I look in the mirror, put the pill in my mouth, bring the glass to my lips, and know I am ill.” Unless this issue is addressed, the chance that this patient will become medication non compliant is great.

Medication management intervention must be individual. Certain patients may require a contract by which they contractually agree to take their medications as prescribed. It is this tangible “document” that assists with compliance reinforcement. Teaching about major effects of the medications can be an empowering experience. For those patients whose cognitive impairment is apparent, modified pictorial teaching tools may be necessary. Role-playing, coaching, and teaching can be a part of an empowering strategy.


Risks of Suicide and Substance Abuse 

Riser and Thompson in their study identified the high risk of both suicide and substance abuse for these patients. Because of the high risk, every home health clinician should screen for these areas of concern when visiting. Know that suicide risk is greater when there are mixed states of anxiety and agitation or when the patient mixes drugs and alcohol. Be prepared for transportation needs for further health care evaluation needs if suicidal behavior or ideations become apparent.  Be certain the family support system is taught all signs and symptoms and has the plan in place in case of needs. The psychiatric patient with a substance abuse problem intensifies their healthcare risk status. An empathetic alliance with the patient and family can assist them to see the negative link between substance abuse and they and their family’s quality of life.



Patients with stressors, depression, and cognitive impairments can frequently benefit by a psychiatric nurse. The program must be comprehensive aiding the patient through stabilization, caring, and reinforcement of strengths. A therapeutic relationship built upon trust can provide acceptance to teaching and compliance with medication. Leaving the patient more calm, organized, stronger, and knowledgeable can assist the individual to improve links with family, friends, and the community and be more compliant with their medication regime.

The psychiatric program can be a strong support to total quality care and improved outcomes.


The Surveillance and Utilization Review Subsystem (SURS)

Thursday, April 26th, 2012

Predictive Analytics or Provider Profiling? Call it what you want, is your agency being monitored by CMS and/or state Medicaid etal? And, have you directly triggered an alert? Or, are physicians that sign orders for your agency patients being investigated?

Should you be aware that your agency could trigger a PPS RAC, MAC, or Z-PIC audit and that a related party or a referral source under review could trigger an audit of your agency? Yes, that could be a reality.

CMS and related agencies are using predictive analytics to identify aberrant care delivery and utilization patterns for PPS. At the time the claim is dropped, an assessment of multiple patient factors is conducted. These factors may include diagnoses, frequency, and disciplines involved in care. Your agency practice patterns are now being compared to peer groups and may include a comparison to validated benchmarks. Physicians who refer to your agency may be having their practice patterns monitored also, especially if the payor source is Medicaid.

The Surveillance and Utilization Review Subsystem (SURS) is responsible for monitoring claims process for Medicaid, seeking indicators of fraud.  They look for duplicate, inconsistent, or excessive visits in relation to diagnoses and visits provided in State systems.

Section 456.25 of Title 42, Code of Federal Regulations writes that “States are required to have a post-payment review process that allows State personnel to develop and review: (1) recipient utilization profiles, (2) provider service profiles, (3) exception criteria; and (4) identifies exceptions so that the agency can correct misutilization practices of recipients and providers.”

No two state Medicaid systems are the same, thus, there are a variety of post- payment review SUR systems. Some state systems are routinely using tools that can statistically use random sampling with extrapolation for provider reviews. This allows the auditor to identify a current trend and apply the findings retrospectively for a specific past time point. Recoupment dollars can add up quickly using this methodology.

The SURS are also using tools that flag inconsistencies and over-utilization of visits in relation to care delivered at those visits. At times, they may be focusing on specific discipline practices.

States have different practices.  Personnel in the New Hampshire Surveillance and Utilization Review Subsystem (SURS) monitor financial claims for the NH Medicaid plan. SURS review provider claims for fraud, waste or abuse and may refer cases under suspicion to the Medicaid Fraud Unit of the State Attorney General.

The unit also recovers overpayments by using predictive analysis algorithms that search its data warehouse for aberrant claim information. “In addition, SURS in New Hampshire also conducts reviews to determine if recipients are inappropriately using certain types of medications.” This can trigger other areas of investigative need.

Some states are querying relational databases which provide flexible and easy access to years of paid claims and the ability to query real time data along with trending patterns and profiles.

The SURS also use exception profiling as a starting point for case development. Ranked reports can quickly identify outliers. A sample profile might include the following elements:

-Average patients per agency

-Average reimbursement per agency

-Average disciplines per patient

-Average diagnoses per patient

-Average number of patients with labs

-Average number of patients with injections

-Evidence of upcoding

-Evidence of downcoding

Medicaid is monitoring payment for care and now closely monitoring physician practices. Agencies need to be certain that they strictly adhere to the regulations for care provision. A physician who is being monitored now can bring review and audits to those for whom he or she may provide referrals.

Compliance risks have always existed. But now, agencies need to expand those risk mitigation practices to their referral sources as well as their marketing departments. Be certain you and your referral source philosophies are similar.

Quality oriented physicians are also seeking agencies with like philosophies. They too want to improve the patient transition of care.  The bad press regarding 78 Texas home health agencies and the linked Texas physician has raised some physicians concerns nationally re this industry.

Showcase your agency quality programs and excellent outcomes.

  • Work to improve bi-directional communication flow.
  • Establish points of accountability for sending and receiving patient information.
  • Increase the use of case management and professional care coordination.
  • Develop performance measures that encourage better transitions of care that are well documented.
  • Let it be known that your agency supports a strong regulatory culture that offers accountability and effort toward solid patient outcomes.

That well-stated philosophy and agency culture exhibited through employee conversation, patient care, and marketing materials tells all stakeholders involved that your agency strives to be a quality-oriented care delivery provider.

Proper ICD-9 CM Coding and an Effective Code of Conduct: Both are Essential in Home Health Care Today

Thursday, March 29th, 2012

Accurate coding with the highest level of specificity is required if an agency wishes to remain compliant and to retain revenues received.  Creating and maintaining a strong code of conduct sends a powerful statement to employees, customers, and business associates.

A strong code that is aligned to corporate values and ethics sends a message of comfort to those committed to those principles. Fraud in healthcare is being uncovered at a rising rate. RAC, MAC, and Z-PIC audits as well as HEAT raids have uncovered hundreds of millions of dollars of false claims filed. Because of an increasing mistrust of provider ethics, taking a strong stand is necessary.

The OIG had announced that in 2009 Medicare-Medicaid paid over $54 billion in improper payments. There have been 2500 persons/entities from Federal health care programs. There have been 625 criminal actions with 399 civil actions including actions involving the False Claims Act. There are another 2400 investigations pending. 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.

Agencies should design a code of ethics that is easy to understand and tailored toward the business sector served, such as home health or hospice, that clearly delineates expectations. Senior leadership should define the agency mission and the employee expectations.

Be certain that topics such as confidentiality, care of protected health information (PHI), fraud, areas of high risk such as coding and claims management, and conflicts of interest are covered.

When discussing the agency code of ethics, identify processes and data capture that will support the areas of high risk. Coding and claims management is supported by complete documentation. Documentation deficiencies that expose an agency include the following:

Common Documentation Deficiencies:

¡  Repetitive clinical notes are frequently seen stating the same things over and over with no progress 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 reflect lack of plan coordination

¡  Visit notes 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 nurses 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 and training needed

¡  The condition or disease symptomology has exacerbated or changed in another way

NOTE: the SN care must tie to the POC and the discipline specific care plan as well as the ultimate outcomes.

¡  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.

One of the most common home health reasons for MAC claim denial is that the documentation does not support medical necessity. A Code of Ethics supports the CMS Conditions of Participation.

No matter if your agency deals with a RHHI or a MAC, high risk probes are on the rise. The intermediaries are mandated by CMS to monitor areas of greater risk. When they see trends of concern they will launch probes usually of at least a 100 records of several firms. 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.

A strong Code of Ethics suggests not only the mission, expectations, and regulatory compliance, but it requires an audit process to verify adherence to expected principles.

Claim Denial Potential

Various diagnoses run a great risk for denial because of probe edits and recertification. If the file is pulled and  there is not “Clear documentation that it is with considerable and taxing effort for the beneficiary to leave home, the episode or specific visits could be denied for lack of homebound status.  (74% of ADRs reviewed for lack of homebound status were denied).”

NOTE: Documentation of “short of breath” does not justify homebound status. Acceptable documentation would include “short of breath after ambulating 10 feet and requires rest period.”

See: The Home Health Industry and Insufficient Documentation/Medical Necessity: Meeting the Challenges of Quality Care and the RACs, MACs, and ZPICs etc at the Select Data Website (Part 1).

Claims can be denied if skilled nursing care is not intermittent.

To meet the requirement for “intermittent” skilled nursing care, a beneficiary must have a medically predictable recurring need for skilled nursing services…at least one every 60 days.”

Your agency corporate compliance audits should be monitoring clinical documentation.

Therapy is under scrutiny

If your agency offers therapy, realize that employees and contractors alike must adhere to documentation requirements to support revenue expected to treat.

Functional ability improvement is expected or why is therapy present?

Therapy may be covered if the patient or caregiver receive 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 2011-2012 changes are rigorous and denials are imminent if documentation is insufficient.

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

Having a strong Corporate Compliance Program with a serious Code of Conduct can go far to mitigate risk. Audits of work products and processes can alert leaders to the plan’s effectiveness. Documentation must be reviewed routinely.

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. At Select Data, we monitor the FI sites, newsletters, and alerts to dig for present edits so our clients are aware before claim submission.

If You Are Not Auditing, Know that CMS Auditors Are

The goal is to achieve better outcomes, better care, and cost reduction. Each working day Medicare pays over 4.4 M claims to 1.5 M providers worth $1.1 B. Reducing fraud and abuse is a part of the goal to provide the better care, achieve the better outcomes, and reduce cost.

That will be accomplished in a number of ways. The old way of chart sampling to determine care and identify fraud is less used, being replaced by elaborate algorithms in predictive analytics.  Predictive analytics is a combination of data mining and sophisticated statistical techniques concerned with prediction of future probabilities and trends. Patterns are sought in both historical and transactional data that identify risks. The models look at relationships (given a variety of factors; i.e. discipline of care compared to diagnoses and the frequency of care delivered). The risks are assessed within the conditions described.

Fraud and Abuse

Under the Health Care Reform Law, Section 6402d, a health care provider receiving an overpayment now has 60 days to repay the overpayment to the appropriate Federal or State contractor. Exceeding the days allowed for dollar return can trigger liability under the False Claims Act ranging from $5,500 to $11,000 per claim. The Fraud Enforcement Act of 2009 (FERA) expanded FCA liability to include a person improperly avoiding timely repayment of an overpayment whether a false claim was made or not.

Home health agencies should be auditing clinical records carefully to be certain that the clinical assessment supports the plan of care and that each visit supports the medical necessity of the care being provided.

Protecting justly due reimbursement starts with a proper Code of Conduct, proper data gathering, coding to the highest level of specificity with sufficient documentation, and dropping claims according to regulation.

The Code of Conduct is your first line of defense. Proper Coding paints the picture of your agency care. Are you painting a masterpiece or a disjointed scribble?