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

Understand the Difference between CPO and Certification/Recertification

G0180 – Certification of a home health patient.

G0179 – Recertification of a home health patient

G0181 – Home Health Care Plan Oversight

G0182 – Hospice Care Plan Oversight

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

Certification billing requirements include:

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

Recertification billing requirements:

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

What is CPO?

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

    Developing an individualized plan of care

    Telephone calls with other health care physicians involved with the care

    Revising a plan of care

    Activities involving coordinating of care

    Documentation of planning

    Medical Decision Making

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

    Team conferences

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

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

Non – Countable Services

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

Billing/Filing the Claim

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

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

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

Administrators and owners have cited the CMS representatives presenting CMS badges.  Some have termed themselves as revalidation inspectors, site inspectors, and Medicare representatives while others termed themselves as Medicare Fraud Inspectors. Be certain to obtain a business card and look at the CMS badge closely. But, if you have recently sent a revalidation application, do not be surprised at the visit.

In order to be compliant with the Patient Protection and Affordable Care Act (PPACA) Section 6401, all new and existing providers must be reevaluated under the new screening guidelines delineated in the Act. These new procedures are expected to reduce fraud and abuse. For some providers, the new screening procedures will be more intense, involving the unannounced site visits, fingerprinting, and owner background investigation. For others, such as publicly traded providers, site visits are not designated.

Three Levels of Risk Assigned

In early March, 2011, CMS began basing the above interventions on a rated level of risk. There are three levels of risk per CMS; “limited,” “moderate,” and “high.”

Limited -risk providers, such a physician practices. Because there will be verification that the provider is in compliance with Federal and State guidelines, such as current licensure verification and periodic database checks prior to and following enrollment, the practices are rated limited-risk.. Also, included in the limited -risk category are ambulatory surgical centers, Indian Health Service Centers, mammography screening centers, and rural health clinics.

Moderate – risk providers, can anticipate unannounced visits. This level of provider includes community mental health centers, hospice organizations, and comprehensive outpatient rehabilitation facilities (CORFS). Home health agencies had been placed in this category however,  CMS has recommended this group to be moved to the high risk category.

High – risk providers will be expected to have unannounced site visits as well as fingerprinting and thorough background reviews. Providers in this category include new DME companies and new home health agencies.

Limited and moderate risk providers can be moved to high-risk under various conditions including: allowing one provider to use another provider’s identifier within the CMS program or if a provider has had their billing privileges denied within the last 10 years.
Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) CR 7350 provides the complete list of these three screening categories, and the provider types assigned to each category, as well as a description of the screening processes applicable to the three categories  and procedures to be used for each category. Have your state license posted. Make certain signage is clear.  Demonstrate your compliance with regulation.

We have all read about the stated recent fraudulent activities involving 78 Texas agencies and a physician who, allegedly bilked hundreds of millions from CMS. This new regulation is an additional attempt to minimize the risk of that type of fraud and abuse

To learn more about this new rule, visit: http://www.cms.gov/MLNMattersArticles/downloads/Se1126.pdf.

On April 17, 2012 the Department of Health and Human Services (HHS) published a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

Per the CMS website, “The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).”

HHS states that covered entities must be in compliance with ICD-10 on October 1, 2014. The statement was made that providers required the extra year to be adequately prepared for the transition.

Providers have outgrown the present ICD-9 CM system. That system is over 30 years old, implemented in 1979 and has no more room to handle needed codes for new medical conditions or technological advances. It is not always precise or unambiguous. Because the classification system is organized with specificity, each three-digit category can have only 10 subcategories and most of those numbers already have assigned diagnoses.

The ICD was developed in the late 1800s to collect data regarding mortality causes and rates. It is an international classification system endorsed by the World Health Organization (WHO) in 1994 and started to be used by WHO members in 1994. The WHO updates the classification usually every 10 years and is looking to beta test ICD- 11 next year.

ICD-10 is already being utilized in Asia, most of Europe and all of Canada and Australia enabling those 99 nations to share public health data. Implementing ICD-10 effective October 1, 2014 allows the USA to be aligned with those nations. ICD 10 is also available in 36 languages including English, Chinese, Arabic, Russian, and the Romance languages: French and Spanish. Improved clinically coded data is essential in this modern era.

Uses of the Clinically Coded Data

• Benchmarking and quality measurement: to improve quality and effectiveness of patient care

• Making clinical, financial, funding, expansion, and education decisions

• Healthcare policy

• Public health surveillance (increase ability to track and intervene if global health threats)

• Reimbursement

• Research- code analysis is crucial to research

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

• Increased coding detail offers capability to find previously unrecognized relationships of diseases and variables

Why ICD-10-CM

• Bring US in alignment with worldwide coding system

• Greater coding specificity and accuracy with “full code definitions”

• Increased capability to measure healthcare quality, safety, and efficiency.
• Lower Costs through increased efficiencies
• Decreased reduction in additional information sent to payors
• Synergistic effects with the Electronic Health Record (EHR)
• Clearer recognition of medical advances
• Clearer recognition of technological advances

ICD-10 and better data for QI

• Decrease in complications and improved patient safety

• Improved patient outcomes

• Improved ability to reassure outcome efficiency and costs

There is also improved capability to determine disease severity for audit risk adjustment.

Benefits of ICD-10 CM

Organizational Monitoring

• Administrative efficiencies
• Cost containment
• More accurate trend and cost analysis as well as analyze trend and cost data

Improved coding accuracy and productivity

Reimbursement

• Increased accuracy
• Fairer reimbursement
• Improved justification for medical necessity
• Fewer errors and rejected claims

Reduced opportunities for fraud

• To handle the complexities and shear size of the number of codes ICD-10

requires expertise in

anatomy,

physiology, and

diagnostics

• Besides moving from 13,000 codes to 68,000 available codes
• ICD-10 allows laterality and bilaterality

ICD-10 specificity improves coding accuracy and richness of data for analysis

The Coding specificity is far greater than ICD-9-CM and the need to better understand A&P and diagnostics is vital. Improved education for coding specialists is necessary.

A Sample Coding Preparation Plan: Phase 1

• 2012-2013…Assess for coder gaps

as to body system anatomy 15 hrs

as to body system physiology 15 hrs

as to diagnostics/pathophysiology 20 hrs

as to diagnostics/pharmacology 20 hrs

as to medical terminology 10 hrs

A Sample Coding Preparation Plan: Phase 2

• Organizational leaders need to assess their

– Organizational readiness: forms, clinical software, documentation readiness

- Billing/Support system needs

- EHR system

- Support systems

- Case management processes

- Disease management

- Compliance software

A Sample Coding Preparation Plan: Phase 3

There needs to be:

• Testing of Coding by parallel Coding  ICD-9 and ICD-10 CM

• Testing of Billing System for smooth transition

• Look for misinterpretation by auditors/payors

Be certain everyone has past training goals i.e. understands documentation of medical necessity to code

Sample Coding Preparation Plan: Phase 4

• Go Live

• Evaluate processes

• Evaluate Coding
• Evaluate Billing

In Phase 1 there is a need to fully review each body system.

• Choose 2-3 body systems for assessment of need such as:

• Cardiovascular System

Identify the Anatomy and Physiology of the heart. Prepare pre/post tests.

Identify the Anatomy of the circulatory system and the role of each vessel type

Review categories 100-109 in ICD-10-CM Chapter 9, “Diseases of the Circulatory System.”

• Explain ICD-10-CM terminology related to diseases of the circulatory system

• Create scenarios and have coding team gatherings where learning can be fun

These scenarios will allow you to assess gaps and needs

• Consider use of webinars

• AHIMA or like courses

• Online self study may fit certain lifestyles better

• Have videos/PowerPoints of body systems available

Look at workshops, seminars, lunch and learn sessions

Each body system should be reviewed, such as below:

• The Heart
  • Has three layers:  endocardium, myocardium, and epicardium
    • Endocardium – membrane lining interior wall
    • Myocardium – thick, middle, muscular layer
    • Epicardium – thin outer layer

• Pericardium – 3 layer sac that surrounds and protects the heart
• Route of Blood Flow Through the Heart
  • Blood enters the right atrium from the inferior and superior vena cavas (veins)
  • Blood leaves the right atrium to the right ventricle through the tricuspid valve
  • Blood leaves the right ventricle through the pulmonary semilunar valve to the pulmonary artery to the lungs

Unoxygenated blood

• Route of Blood Flow Through the Heart
  • Blood leaves the lungs via the pulmonary veins to the left atrium
    • Oxygenated blood
• Blood leaves the left atrium through the mitral valve to the left ventricle
• Blood leaves the left ventricle through the aortic semilunar valve out to the body
• A series of 20-30 slides could be developed to review the Cardiovascular System

These types of reviews could be excellent resources also for specific component answers such as Cardiac conduction

• Route of Blood Flow Through the Heart
  • Blood leaves the lungs via the pulmonary veins to the left atrium
    • Oxygenated blood
• Blood leaves the left atrium through the mitral valve to the left ventricle

Blood leaves the left ventricle through the aortic semilunar valve out to the body

• Cardiac Conduction
  • Sinoatrial node (SA node, called the pacemaker of the heart) à Atrioventricular node (AV node) à Bundle of His à right and left bundle branches à Purkinje fibers

SA node (pacemaker) is located in the upper part of the right atrium below opening of the superior vena cava

• Discuss disease processes such as:

CAD

CHF

Heart Failure

Use specific terms and processes in the discussions

• Discuss diagnostic and intervention procedures as well as pharmacology
• Have teams participate in establishing education plan after gaps have been identified
• Make certain some kind of training takes place each month, even if it is only a memo about a specific aspect of ICD-10

Keep ICD-10 in front of everyone. Remember, you only have until 2014. Let’s get started!

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.

Agencies need to identify, through policy or definitive tool, the questions to be asked. Some, but certainly not all questions, include:

What initiates or triggers the pain?

How and when did the injury occur or when was the disease been defined?

What treatments and interventions have been utilized?  Repositioning used?

Assess if Heat/Cold was used?  Homeopathic remedies used? Hypnosis or self relaxation exercises tried? Is Reflexology or Acupuncture used?

What medications have been prescribed? What frequency have medications been used?

What treatments have been effective?

Where is the pain located? Does it radiate?

Please describe the pain?

Is the pain present at this time?

How would you rate the pain?

How has the pain impacted your life? As to work? As to socialization? As to sports? As to family? As to finances? As to image?

Does the pain awaken you from sleep?

How frequently does this pain occur each day?

Do you still have pain despite having pain medication?

Let’s discuss your pain medications and other techniques you are using to manage this pain.

Rosdaqhl,  2010 describes a Description of Pain: COLDSPA:

Character

Onset

Location

Duration

Severity

Pattern

Associated factors

COLDSPA provides a cueing chart of terms to assess pain by clinicians. It is quick and easy to remember.

The Joint Commission and other accrediting bodies expect the clinician to adequately explain the rights of the patient to have an appropriate assessment, and to have clinicians who are educated in pain assessment and pain management.

Pain Measurement Tools

Though clinicians are usually aware of the Wong Baker Faces Scale which has facial expressions that correlate to an analog 0-10 rating scale, they may not be as accustomed to other scales such as the:

FLACC scale is an observational scale for preverbal children to assess specific body parts as pain indicators.

NPS is a neonatal pain observational scale to assess the child’s facial expressions, their cries, breathing, and state of arousal.

In addition, the McGill-Melzack Scale provides an assessment of word groupings from Group 1-Flickering, pulsing quivering, throbbing, pounding or Group 4- Sharp, gritting, lacerating, to Group 12- Sickening, suffocating to Group 20-Nauseating, agonizing, dreadful, and torturing.

Each scale offers pain assessment for  a specific population.

Pharmacological Therapy (in general)

Pharmacologic interventions are used to not only reduce pain but assist the patient’s mood, affect, and ability to increase socialization as well as providing a sense of hope. Controlled pain tremendously impacts the view of the world by the patient.

In general, the comfort and pain management medications can be divided into three analgesic classifications:

Nonsteroidal anti-inflammatory (NSAIDS) are used for mild to moderate pain. These drugs include Aspirin, ibuprofen (Motrin), and Naproxen (Aleve). Tylenol may also be used but with caution as Tylenol is frequently used in so many products including cough syrup. The NSAIDS require lab monitoring of the liver and stomach.

Opioid narcotic analgesics are used for moderate to severe visceral and somatic pain as well as Cancer and chronic pain. There are a variety of opioid types of analgesics which may be used together at staggered times to prevent breakthrough pain and manage intractable pain and to prevent tolerance to a specific single drug.

Examples of these drugs include:

Morphine: available in quick and slow release. Constipation is common as is initial nausea.

Dilaudid: considered to be 6-7 times more powerful than Morphine. Available in short acting doses.

Oxycodone: usually coupled with acetaminophen (Tylenol) or Ibuprofen. Short acting lasting usually only 6 hours or longer acting is also available.

Hydrocodone: usually coupled with Tylenol as Vicodin. Short acting for about 4 hours.

Fentanyl: provided in patch form providing various strengths of this systemic drug.

Adjuvant drugs are drugs that support NSAIDS and Opiods. These anti-epileptic drugs are usually used for neuopathic pain.

Neuotin: commonly used with patients demonstrating numbness, tingling, and burning pain. This may be seen with patients post chemotherapy use who exhibit peripheral neuropathy.

Antidepressants are utilized to combat depression and improving the quality of life of chronic pain sufferers. Some research supports the fact that over 60% of chronic pain suffers also have a psychiatric diagnosis.

Patient Controlled Analgesia: PCA

In the 1970s, PCA pumps became popular to allow patients to have a set dose of medication with almost immediate medication delivery. Patients were given autonomy with safe dosage, less sedation, and improved patient and physician satisfaction. PCAs are now routinely available post-op and available for cancer patients and select chronic pain patients.

Addiction Concerns

Patients are frequently concerned with potential addiction. They worry about the type of meds and the short and long term effects. If the patient does not have a terminal illness with less than six months expected lifespan, the clinician is overtly monitoring the patient for addiction.

Addiction is defined by the 4 Cs: Compulsive use, quantity Control, Craving the effects and feeling of the drugs, and Continued use even with significant drug adverse effects.

Non Pharmacologic Interventions

Nurses have been taught to utilize non pharmacologic interventions for pain management. These include:

• Skin and Ortho comfort from a clean comfortable bed
• Restful calm music or music of patient choice
• Warm comfortably lit room
• Tasty visually appealing food
• Reduction of strong odors
• Prevention of constipation and diarrhea
• Proper hydration
• Diversion activities
• Positional changes as necessary
• Warm baths (sponge or tub)
• Backrubs
• Therapeutic massage
• Reflexology
• Application of heat or cold
• Visual imagery
• Spiritual support
• TENS Units stimulation/Biofeedback
• Chiropractic Care
• Acupressure
• Acupuncture
• Hypnosis
• Homeopathy
• Aromatherapy
• Family support and contact
• Planning for future…having a plan….having hope.

Do you have other suggestions for pain management that have provided relief? Research continues in this area.  Know that clinicians must document pain management carefully. Know that the surveyors and auditors are focusing on pain and management of that pain.

Patients who transfer to home care frequently have long-term chronic pain that has been intermittently managed. But, are all of the clinicians comfortable in managing pain?  An increasing number of home health agencies are assessing the comfort level of their clinicians in this area. This gap analysis usually includes knowledge of adjuvant medications along with differentiating types of pain and recommending corresponding analgesics (Hansen and Gorski, 2004). After the clinical knowledge gap analysis has been completed a learning strategy and curriculum can be implemented.

Over the past 4-5 decades, pain management has improved, many say, because of awareness of how to use analgesics more effectively (Painter, J, 2006). Much of this knowledge has occurred because of the Hospice movement and the Agency for Healthcare Research and Quality. The latter organization has routinely published clinical practice guidelines.  The Joint Commission states, “Unfortunately, through the 1990s,  there continued to be reports of poor pain control for postoperative and trauma pain, cancer pain, and many chronic pain problems not related to cancer. Guidelines, professional curricula, and a multiplicity of professional education programs, per the Joint Commission (JC) were not improving the quality of pain management by themselves.” The Joint Commission also says its pain standards were its first evidenced-based standards. The pain standards directly identify recommendations of institutional responsibility provided in evidence-based guidelines developed by groups such as American Pain Society (APS) and the Agency for Healthcare Research and Quality (formerly the Agency for Healthcare Policy and Research).

The Basics: this article is a bare bones review of pain management

Your agency no doubt has researched or is researching the latest evidenced-based care policies and procedures adhering to your state QIO suggestions. In addition, excellent articles from the Center for Medication Safety and Clinical Improvement allow the clinician to have a broad perspective of well researched material to add to their clinical tool box.

How is Pain Defined?

McCaffey has stated that “Pain is whatever the experiencing person says it is, existing wherever they say it does” (McCaffey, M, 1968). It is the body’s signal of distress and remains one of the most common reasons people visit their physician or visit the hospital. Normal pain sensations involves transmission and interpretation termed nociception. The clinician must understand transduction, transmission, and perception as well as pain modulation in order to better care for the patient with pain. The types of pain are also evaluated when assigning ICD-9 CM codes to properly portray the patient condition.

Understanding Types of Pain is Essential

Acute pain: Defined as intermittent pain occurring for less than 90 days (Occupational Medicine Practice Guidelines, 2009) and resulting from trauma, impact, burns, or surgery. It is abrupt, intermittent, and nociceptive.

Chronic Pain: Defined as over occurring for at least 3 months by the AMA and over 6 months by the American Psychological Association. Both concur there is no active disease or unhealed tissue injury. This type of pain may be caused by faulty processing of sensory input by the nervous system.  Pain interventions may be ineffective resulting in frustration, anger, and depression (Rosdahl, Chap 55, 2010).

Somatic Pain: Defined as localized pain that becomes increasingly uncomfortable with movement and very tender when palpated. It is sometimes referred and described as, per the Occupational Medicine Practice Guidelines, sharp, throbbing, shooting, pinching, and deep aching that includes bone, post-op, and muscle pain.

Neuropathic Pain: Defined as difficult to cite the source of pain as it tends to follow dermatome pathways. Palpation tends to send pain to nerve endings distally. This pain is described as burning, radiating, and numbing at times with limb “heaviness.”  There may be swelling, redness, and mottling with skin temperature fluctuations (Occupational Medicine Practice Guidelines, 2008).

Visceral Pain: Defined as constant and localized but may be referred like diaphragmatic pain refers to the right shoulder and cardiac pain which can refer to the left arm and the jaw.

Cancer Pain: Defined as pain due to a malignancy which is described as very severe, chronic, and intractable causing resistance to many medications, thus long and short term analgesics are usually required to prevent “breakthrough pain) (Rosdahl, 2010). Hospice nurses are usually very skilled at pain management because of Cancer pain needs.

There are many factors that affect pain perception including pain threshold which is described as the lowest intensity of a stimulus that causes the subject to recognize pain. Another factor includes the release of endorphins by the patient which is specific to the individual. Finally, pain tolerance is considered one of the key perception factors and interventions are necessary to expand the medication tolerance times.

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?

Through collaboration amongst stakeholders, with coordination of expensive chronic care, and with partnership developments, strategic alliances are being encouraged. Is your home health agency ready? What specific programs do you have in operation? Are they evidenced-based? What have been the outcomes? Do you have reliable statistics?

As stated in the January, 2012 ezine:

“Home health agencies should be paying VERY close attention to the latest requirement for home health found in the Affordable Care Act. The Act encourages development of Accountable Care Organizations (ACOs) and provides for “incentives to enhance quality, improve beneficiary outcomes and increase value of care.” (CMS Q&As Section 1899 of Title XVIII)  The ACO becomes a type of managed care organization that may use fee-for- service or capitation payment, and is accountable to patients and the third party payor for the quality, appropriateness, and efficiency of the care provided. Because of the Affordable Care Act, CMS must have an ACO in place by January, 1, 2012.

Some home health agencies have begun aligning with physician offices, hospitals, rehabilitation facilities, and long term care providers to coordinate care across the health care continuum. Home health agencies are becoming members of hospital teams in both general and specialty areas. Agencies which cannot seem to form the alliances may find themselves with declining referrals in the near future. Home health needs to demonstrate their personalized approach to care so they may be appealing to the PCMH team.

Home health agencies should be encouraging discussions among provider leaders of all levels of the care continuum. Patient ultimate outcomes should be shared by all providers. Establishing those mutual patient outcomes is a primary step in a strategic alliance between ACOs and PCMHs.

Hospitals know that the bundled payment pilot begins January, 2013. It is expected that hospitals will be responsible for the patient three days prior to hospitalization, during hospitalization, and 30 days after hospitalization. They will more likely want to work with agencies with proven hospital reduction programs, quality care clinical programs, and positive patient outcomes. Agencies with those types of programs are already aligning to form care transition models to be ready to bill the new CMS ACO.” (Select Data ezine, 1/2012)

Hospitals are also expected to be working closely with primary care practices which have the PPC- Patient Centered Medical Home Recognition. Many practices approved using the 2008 Standards have now applied to meet the 2011 National Committee for Quality Assurance (NCQA) Standards.

The PCMH is defined by NCQA as an innovative program for improving primary care using clear and specific criteria centered around patients and their care needs, working in teams coordinating and tracking care over time. The PCMH program is for practices that “provide first contact, continuous, comprehensive, whole-person care for patients across the practice.” (NCQA, 2011)

Per the NCQA:

“The Patient Centered Medical Home is a health care setting that facilitates partnerships between

individual patients and their personal physicians, and when appropriate, the patient’s family. Care is

facilitated by registries, information technology, health information exchange and other means to assure

that patients get the indicated care when and where they need and want it in a culturally and linguistically

appropriate manner.”

The PCMH is being touted as an excellent way to improve healthcare in this country by “transforming how primary care is organized and delivered. The Agency for Healthcare Research and Quality (AHRQ) defines the PCMH as a model of the organization of primary care that delivers the core functions of primary health care.”

The Patient Centered Medical Home must encompass five core functions and attributes:

1. Comprehensive Care: The PCMH is accountable for meeting “the large majority of each patient’s physical and mental health needs, including prevention and wellness, acute care, and chronic care.” To meet required standards, comprehensive care must include a patient-centered team that may include physicians, nurses, PAs, pharmacists, social workers, and care coordinators. Large primary practices may have large teams while smaller practices may “link themselves and their patients to providers and services in the community” (NCQA, 2008).
2. Patient Centered: The PCMH must provide “primary care that is relationship-based with an orientation toward the whole person.”  The standards require a partnering with patients and families that demonstrates an understanding of their unique needs, values, and preferences. The PCMH primary physician and team are expected to assist patients to manage and organize their own care.
3. Coordinated Care: Care is required to be coordinated across “all elements of the health care system.” This care is considered critical during transition between levels of care with clear and open communication.
4. Accessible Services: The PCMH is expected to deliver care in shorter timelines with individualized hours of care and 24/7 phone or electronic access to a member of the PCMH team demonstrating responsiveness to patient needs.
5. Quality and Safety: The PCMH is committed to quality and quality improvement with ongoing evidence-based medicine and “clinical decision-support tools to guide shared decision making with patients and families.

CMS believes that for too long patients have been provided care by disparate systems; a hospital here, a home health agency there, and yet long term care over there. An ACO (created by health care reform law) is expected to include a broad network that will share responsibility for providing care. The ACO must be able to show they can provide care better than the singular services. Home health agencies should consider establishing patient populations of mutual interest and present evidence-based practice interventions that are likely to improve quality, diminish decline, and improve patient satisfaction not merely in one level of care but across that continuum.  NCQA released its ACO Accreditation Standards in 2011.The NCQA approach to ACOs emphasize patient-centered primary care; use of measurement techniques that improve health care, and high standards for care coordination.

The CMS ACO initiatives were launched January 1, 2012, but ACOs were already being explored not only for Medicare but for other payor sources as well.  ACOs, theoretically, would make the providers jointly responsible for care and offer incentives to achieve quality outcomes yet, make a profit. There would need to be a seamless way to share information.  They would encourage standardizing care to reduce variable clinical practices. It is expected that those who would achieve the quality and financial goals would retain a portion of the savings.  The amount or percentage is yet to be determined.

To work together with agencies with like values, goals, and evidenced-based processes could challenge present regulation. Would this mean the regulation regarding the hospitals discharge policy involving a referral list of local agencies would be changed? It would seem that would be needed since the hospital would be working with agencies that were a part of their ACO. Also, under a hospital led bundled payment, hospitals it would seem, would want to transition patients to agencies with specific programs in place to prevent readmissions. Agencies should be developing programs NOW that can significantly reduce emergent and inpatient care. Outcomes will play a larger role as to which agencies will be chosen as ACO members.

NCQA views primary care as the foundation of the health care system. The primary care physician/team is frequently the first point of contact. The NCQA new standards require a patient survey to help drive quality improvement. It also requires involvement of patients and family in quality improvement. In addition, tracking care over time is necessary. Reducing fragmentation, involving patients and families actively, while transitioning through levels of care is a primary goal of the PCMH and the ACOs.

Home health agencies should be prepared to statistically present outcomes and be ready to participate actively in devising a plan for sharing information. The need to dramatically alter home health care delivery is upon us. Agencies need to be prepared for this change. Be open and receptive to collaborative practices. Be prepared to assist in standardizing teaching and discharge planning instruction. And one other point: CMS is subtly suggesting that discharge planning will soon evolve into transitional planning as the patient moves from one level of the care continuum to another. Be prepared for that transition or face the potential consequences.

Before and after home health care could well be the PCMH. Home health agencies may need to blend into that model. No matter what, data, statistics, and analytical analysis will be vital and an integral part of any Chronic Care Management Model. Are you prepared…or preparing?

Below are some questions that you may already know, but of course, need to know about your agency and delivery of service:

What are your agency case mix averages by admission?  by clinician? by diagnosis?

Do you know your top five diagnostic patient profiles?

How do you set visit frequencies? Formula-based or just “what seems right” or a formula plus reflective clinical assessment?

Are you making visits that have no impact on patient outcomes?

Are you auditing for homebound status?

Are you auditing documentation for medical necessity?

What is your cost per visit by discipline?

What is your recertification percentage?

Do you know your supply utilization per patient?

Does supply usage have adequate supportive documentation?

Do you know what coding, operational, or billing edits you are routinely triggering?

How are you applying the data collected to your business processes?

The RACs, MACs, MICs, and Z-PICs are now in place. The auditors are expected to perform. They have been chosen based upon performance.

Algorithms and Matrices are in place using Predictive Analytics.

Per Wikipedia, predictive analytics “encompasses a variety of statistical techniques from modeling, data mining and game theory that analyze current and historical facts to make predictions about future events”.

CMS is using predictive models to identify patterns found in transactional data gathered to identify risks and potential future behaviors.  They are looking at diagnoses in relation to visit frequencies and recertifications. They are looking at HIPPS scores compared to visit frequencies and durations. They are looking at predictive models that capture relationships among many factors to allow assessment of risk or potential associated with a particular set of assessment/care frequency/payments expected. In other words, what are the guiding decision-making factors for agency transactions? This is one reason why there needs to be rhyme and reason for visit frequency and patient diagnoses and care needed.

Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future. That behavior is then compared to other agencies’ behavior in order to calculate risk, then encompasses models that seek out subtle data patterns that  answer questions about that agency’s overall  performance. These analytics quickly become fraud detection models.

The MACs are using predictive models to perform calculations during live transactions to evaluate the risk or opportunity of a given agency transaction, in order to guide a decision. Individual agency modeling systems can simulate likely human behavior or reaction to specific situations.  The new term for animating data specifically linked to an individual in a simulated environment is avatar analytics. Hopefully, CMS is not there yet but gaming experts ARE employed by CMS.

The government is serious about attacking fraudulent behavior. The danger that exists is that some agencies not intending to commit fraud, but who are not auditing their data submitted, may be triggering alerts. Home Health Agencies can no longer afford to provide care without auditing the assessment, the care predicted, and the care provided.

The RACs have also identified that insufficient documentation for medical necessity will be one of the first area of focus for their audits. But, no agency should believe that only therapy documentation will be scrutinized. Skilled nursing with observation and assessment O/A continues to be high on the list for visit and episode denials.

What happens if compliance measures are not employed? Targeted Medical Reviews (TMRs)/(ADRs) Additional Documentation Requests will rise. There will be claim denials and Medicare audits.

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.

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.

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.”

Can Audits be Prevented?

Maybe not, but exposure for paybacks can be limited by enacting solid compliance measures.

Prepare now. Be aware of what other providers have faced with auditors.

Be certain a clinical documentation chart audit is available for all disciplines for clinical records.

The following items should be included in every clinical note:

Homebound status: Identify what taxing effort was exerted if a patient left the house since the last clinical visit. Be certain all assistive devices are listed and/or the caregivers needed, the purpose for leaving the home, and if this was expected and/or a part of the careplan.

Identify what skilled the visit. If teaching was conducted, was it initial teaching, reinforcement teaching, or was it re-teaching? Identify in objective terminology measureable progress towards goals; ie for the psych nurse, what evidence toward cognitive structural behavior was identified? For physical therapy, how many feet were walked since the last visit and where does this relate to the plan? For the SN, did the patient identify at least two key side effects for their medications? Does the patient know what their medication is for and what it is expected to do for them? Do they know how to safely take their medications?

Compare the Visit Notes to the POC: Compare the visit note to the plan of care that is developed by the clinician based upon the assessment. Have physician orders or notification for changes in condition. Note all change of condition clearly.

SN should be reviewing the body systems noting VS and pain assessments.

When Teaching: Note if the teaching is New, Reinforced Teaching, or Reteaching of the same subject to, perhaps, another caregiver. Note the caregivers willingness and capacity to learn and carry out the learning skills. Note the patient and caregiver’s learning in percentage; ie 10% or 70% or 80%.

Interdisciplinary communication: Comments to the physical therapist or the home health aide or other disciplines should be clearly noted. The visits should show the progress of the care in relation to the plan of care.

Specificity of wounds, skin conditions, falls risk, depression, and the focus of care are necessary. Auditors look for detail; for reasons that support skill. No skill can mean denial of visit payment.

For Diabetics Receiving Insulin

Be certain homebound status is clearly and adequately documented.

Skilled Visits must have skill identified such as specific instructions.

Return demonstration responses by the patient or caregiver should be documented. Note the patient or caregiver’s ability to follow their diet. Give examples to support diet and meal planning learning.

Caregiver willingness and availability should be specifically noted on each visit.

More Strategies

Review all claims against known edits prior to submission.

Have a system that prevents claims from being submitted without a signed physician order.

Counsel and hold clinicians accountable for accurate, complete, and concise documentation that matches the planned care expectation.

Clinicians must now be aware that surveyors are looking at their assessments, discipline specific plan of care, the overall plan of care, the visit documentation outlining care provided and patient response, and the outcomes at the episode conclusion. The diagnoses listed in M1020/M1022 must be compliant with ICD-9 coding guidelines, be unresolved, must read as the table of contents for the clinical record, and must be supported by the clinical documentation.

RAC auditors use clinicians and coders on their team to provide more specific auditing. Ask your clinicians: could their visits withstand that kind of auditing review?

Consider peer review sessions at your agency. Proud clinicians want their peers to think highly of them. Peer Review audits can be an excellent defense against a RAC audit and can be enlightening to clinicians as to what is expected as well as a motivation for excellence.

The AMA lobbied hard for the delay of the ICD- 10 morbidity classification. On the other hand HIMSS (Health Information Management Systems Society) stated that ICD- 10 is “the very basic foundation of healthcare change”.

As we all are aware, ICD-10 will replace a 30 year old system that has not kept up with modern terminology and clinical practices. ICD- 10 offers detailed information on the patient’s condition through specific diagnoses. It is expected to allow upgrading of current data analysis of both diagnoses and procedures with improved care management for patients/clients as an outcome. It has increased capability allowing for far greater detail of the patient’s illness.

Because of increased specificity, the expectation is that interventions for chronic diseases will occur sooner. ICD-10 will allow tracking of disease severity and progress measurement as well as design educational programs for disease clusters identified. It is also expected to identify disease groupings that “may merit special attention” as well as the designing of new care management programs. It allows the US to work more closely with other countries.

The new system gives a much greater granularity to classifying disease and injury.  For instance, ICD- 9 still includes categories for injuries rarely seen, such as accidents in chicken coops and opera houses. It also has only 5 digit codes with no room for expansion.

HIMSS believes that there is “achievable value in the adoption of ICD-10″ by the original deadline, the group said in a 2/10/2012 press release.”The use of this more robust and upgraded data classification system, with the capacity to include current medical knowledge and 21st century patient procedures, will improve health care.”

Many healthcare experts believe that, at best, the ICD- 10 system is delayed for a short time only. The system has real merit, is needed for the specificity and accuracy required, and the US, in order to work with most other industrialized nations, must recognize that other countries are already using ICD 10.

As America considers when to implement ICD-10, ICD-11 is already in the works. The WHO, (World Health Organization) which already hosts an alpha-draft on its website, hopes to have a public beta this spring and a working version up in 2015.