Part 3; RACs, MACs, Z-PICs
Part 3 of 3 on RACs, MACs, Z-PICs:
The Home Health Industry and Insufficient Documentation for Medical Necessity and ICD-9 Coding.
Therapy and Home Health ICD-9 Coding and Supportive Services…
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 goals to be achieved
- Specify the rehab potential
- Specify the discharge plan in clear, easy to understand goals and plan.
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.
NOTE: Do not use V57.1 Physical Therapy if SN is also involved with the care. (CMS OFFICIAL CODING GUIDELINES 2009).
- If 781.2 Abnormality of Gait is used to justify PT care, PT needs specific documentation and objective testing to support gait and balance and strength e.g. TUG or Tinetti Test Tools.
- Gait training should be specific with objective measurement progress.
- The gait should be described specifically and graphically; ataxic, spastic, staggers with increase in ambulation of ___feet this day. Lack of complete documentation means payment denial risks will increase.
- If 719.7- Difficulty in walking is coded, the therapist should be clear that this is due to e.g. degenerative and chronic joint disease.
- Use for e.g. gait deficiencies due to lower extremity joint stiffness or effusion.
- If muscle weakness 728.87 is coded, there should be manual muscle tests indicating weakness.
- The therapeutic plan should have specific exercises and goals related to the weakness.
NOTE: Absence of a specific exercise plan can jeopardize visit payments.
- The OT evaluation and documentation should reflect prior and present level with realistic goals.
- If PT is also involved with care the OT should clearly delineate a plan that justifies the OT intervention.
NOTE: Have objective tests with clearly defined short and long term goals that are measureable and can be achieved within a realistic time point with direct relationship to the specified diagnoses.
Medical necessity must be evidenced EVERY visit. Document progress towards goals every visit is vital and must be stressed to therapists.
NOTE: There is a high incidence of visit denials when both PT and OT are providing care.
Of the ADRs selected, 1 SN and 4 OT visits have a denial rate of 71% essentially, because OT is not an initial qualifying skilled service.
The Plan and Supportive Services:
- Medical Social Services can be added when skilled services are in place.
- Covered services include:
- Assessment of financial situation, community services available, personal/family social factors, and the potential for counseling
- Patient risk areas must be clearly identified. Remember that assisting a patient to apply for Medicaid services is not an MSS skilled service.
NOTE: If a patient has a LUPA, 5 visits or less, and 1 visit is a MSW, the denial rate, as of 2008 data, was 67%.
Medical Social Services have non covered services that, if required, may be performed along with a covered service.
Non-covered services include:
- Assistance with Living Wills and Advance Directives
- Assistance with Medicaid Applications and Meals on Wheels
- MSS is a service requiring a physician’s approval and the MSS may not be the only home health service being provided to a service. A qualifying service must also be providing care to the patient.
The Home Health Aide…
This service is provided by the least skilled individual and requires the most specific supervision as defined by CMS.
Home Health Aide Services are supportive and under the supervision of an RN, if multidiscipline case. If therapy only, the therapist may supervise the home health aide.
Supervision must be in the patient’s residence but the home health aide need not be present at the same time as the clinician performing the supervision.
Endpoint criteria to daily visits …
- When skilled nursing visits are ordered daily, there must be a , “finite and predictable endpoint to daily skilled nursing visits.” It can be listed in days, weeks, months, or have a specific date.
The visit documentation must substantiate the skill and substantiate the endpoint. The Medicare Home Health Benefit was not established to provide daily skilled visits but rather, to provide intermittent skilled nursing services. CMS states that, “The one and only exception to this rule is a patient who requires and qualifies for skilled nursing services to perform daily insulin injections.” Remember, that because of the abuse of daily insulin injections they have a high likelihood of ADR review.
The Plan of Care:
- The Plan of Care must be signed PRIOR to submission of the submission of the claim
- A date stamp in Box #25 should be present when the Plan of Care is received
- The POC must be supported by the clinician visits with a final claim.
There must be congruence between the OASIS 6 coding spaces: POC/485: 9 spaces+ E code on the UB-04 claim.
- From the 6 lines of M1020 and M1022, CMS makes a payment decision.
- Agencies should review progress notes and case management coordination to the POC.
- Documentation should support the codes which are sequenced on the OASIS and POC.
NOTE: Clinicians should learn to establish an audit trail on the way toward expected patient outcomes.
ICD 9 Coding has become very important in home health. References include:
- Official Coding Sources:
- -The annually published CMS ICD-9-CM Coding Guidelines
- -The Coding Clinic
- Allowable Coding Sources:
- -OASIS Chapter 3
- -Appendix D to Chapter 3
- -OASIS Q&As published quarterly by CMS
- Promoting accurate coding selection in M1020, M1022, and M1024 requires:
- Compliance with provisions of HIPAA, Title II.
- Compliance with refinements to the PPS Grouper effective January, 2008.
Compliance with Section 1862 (a)(1)(A) of the Social Security Act to ensure payment is reasonable and necessary can be monitored with internal audits. Deal with an expert coding firm that places high regard on compliance for your peace of mind.
- Diagnoses must comply with specific criteria to qualify as a primary or secondary diagnosis:
- -Code by adhering to ICD-9-CM coding Guidelines
- -Code only relevant medical diagnoses
- -Code only diagnoses supported by OASIS, POC, and clinician documentation
The 2011 changes in coding effective October 1, 2010 have become increasingly specific, preparing for the transition to ICD-10 Coding. It will be at that time when home health moves from 17,000 codes to more than 87,000 codes. It is only increasing in complexity and financial risk.
- List diagnoses in the order that best reflects the seriousness of each condition and supports the disciplines and services provided.
SOURCE: Official CMS I-CD-9-CM Coding Guidelines
- Assess the degree of symptom control in relation to identified signs and symptoms, medication profile review, frequency and duration, as well as care plan and treatments.
- Clarify which diagnoses and symptoms have been controlled in the past.
The primary diagnosis should be the key reason for the POC and the most intensive service. CMS has noticed an increase in incongruence between primary diagnosis and actual plan of care and resulting visits. Do your agency visits support the patient POC? Are diagnoses truly reflective of patient condition at assessments?
The secondary diagnoses should coexist at the time the POC was established.
Agencies must be careful to use approved co-morbid diagnoses that could affect the plan of care even if that diagnosis is not a focus of care. Agencies should strive to have the diagnoses and codes describe the care to be provided in a specific episode. Approved co-morbidity diagnoses should be listed if the patient has one of the diagnoses, as it is believed that these approved co-morbidities will impact care.
There are diagnoses that can cause specific alerts.
- These codes require VERY specific plans of care to substantiate need as they are case mix diagnoses. Once named case mix, these diagnoses were more frequently used by agencies and are now closely reviewed by CMS. They include:
- -Low Vision
- -HTN as a non SOC primary diagnosis
- -Alzheimer’s (primary non SOC).
The wisdom of the home health clinician and the ability to use critically reflective thinking is essential.
- Acute care coding is retrospective.
- Home Health coding is prospective.
- The diagnoses on the OASIS must match the POC/485 and the UB04
Clinicians must be certain the POC (primary/secondary diagnoses) and the discipline specific care plan are substantiated by each visit note and that each visit can withstand scrutiny on its own.
- Documentation to substantiate coding and care have become critical to agency providers.
- Documentation has become the key communication tool for care.
- Documentation has become the first and last line of defense with the scrutiny of the industry auditors.
- Documentation provides the demonstration of the skills of the clinician and justifies the retention of the agency payment received.
Truly, it is the critical thinking assessment and planning skills of the front line that will determine an agency’s bottom line. As we all know, it is easy to file a claim and be paid prospectively in home health. It is becoming more difficult to keep that payment, especially if fine skilled clinicians do not chart with the same fine skill.