Face to Face Updates, HIPAA HI-TECH Updates, and New RAC efforts for Medicare Advantage and Medicaid
The Face to Face Encounter Required for the Home Health Industry: More Updates
Be certain the face to face encounter information, for the physician, is in a short concise format.
-Let the physician know the face to face encounter visit is billable.
-Educate physician office personnel.
-Have a card with key websites that can provide information for the physician and his/her office personnel.
CMS identifies the reason for this encounter: “The face to face encounter requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition.” www.cms.gov/center/hha.asp.
CMS issued an update to the Medicare Benefit Policy Manual, Chapter 7, Pub 100-02 on February 16, 2011. It may be reviewed at:
www.cms.gov/transmittals/downloads/R139BP.pdf
General comments that answer some of the most frequently asked questions include:
Who may perform the face to face encounter?
-Only Medicare enrolled physicians may certify Medicare beneficiaries for Medicare certified home health services.
-The certifying physician must certify through documentation that (s)he authorized a “non-physician practitioner (NPP) to have a face to face encounter with the beneficiary.”
- A NPP is inclusive of a nurse practitioner, clinical nurse specialist, a certified nurse midwife, or a physician’s assistant.
-The physician or NPP may not be an employee or have a financial relationship with the home health agency as defined in 411.354 through 411.357.
-The certifying physician must document the encounter and sign the certification.
CMS FAQS stated: there have been questions as to whether residents may complete face to face encounters.
CMS FAQs reply: “Only the certifying physician or certain NPPs can perform the face to face encounter. Additionally, only Medicare enrolled physicians can certify home health eligibility, per the Affordable Care Act.”
Please note: There had been questions as to whether one physician could certify patient’s eligibility and document the face to face encounter based on information from another physician who recently saw the patient, such as the patient’s attending during an acute stay.
CMS FAQs state: “NO, The law mandates that either the certifying physician or certain non-physician practitioners (NPPs) who inform the certifying physician, can perform the face to face encounter. A patient’s encounter with an attending physician during an acute stay does not satisfy the requirement unless the attending physician is also who certifies eligibility. However, certain NPPs in the acute care setting may collaborate with the certifying physician. In such cases, an NPP’s encounter with the patient during an acute or post acute stay may satisfy the requirement.”
However, the new transmittal states that a hospitalist or an attending physician who cares for the patient in an acute care setting but does not follow the patient to the community MAY CERTIFY the need for home health care and transfer care to the designated community based physician who has assumed care for the patient.
When must the face to face encounter be completed?
-The face to face encounter must occur no earlier than 90 days prior to the Start of Care (SOC) or within 30 days after the Start of Care.
-If the face to face encounter meets the timeframe guidelines (within 90 days of the SOC), but the encounter does not relate to the primary reason for the home health admission, then a new encounter is needed to be completed within 30 days from the SOC.
Where can the face to face encounter be performed?
-There is no mandate as to location.
-Telehealth may meet criteria for face to face encounters but go to www.cms.gov/telehealth for the particulars.
What are the documentation requirements?
-The certifying physician must document the face to face encounter even if the approved NPP completed the actual encounter.
-If a NPP completed the encounter, they must document the clinical findings and give them to the certifying physician for review.
-If the face to face encounter is a part of the certification, it must have a separate section or be an addendum.
-The documentation MUST include the date of the encounter, a narrative describing the patient’s condition and its relationship to the primary reason for skilled home health services, and homebound status justification.
-The documentation must be dated and signed by the certifying physician.
-Agencies are NOT permitted to formulate drop down choices or provide written standard language on the forms for the physician.
-It is acceptable for the certifying physician to dictate his/her findings.
-It is Not acceptable for the physician to verbally dictate the encounter to the home health agency as part of the certification.
The face to face encounter is now a requirement. It will be fully enforced by April 1, 2011 so use this first quarter to work out the best processes for your agency. Use this time to educate the physicians and their personnel as well as educating hospital discharge planners. Also, be certain your clinicians are fully capable of explaining the face to face encounter as some agencies are reporting that physicians are asking questions when contacted by the home health nurse.
Remember, nothing has changed re home bound status rules or the “need for skilled services.” CMS reminds readers of their new powerpoint presentation re the face to face encounter, “to be eligible for the benefit, a patient must need skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy.”
Additional Sources: Home Health Prospective Payment System Rate Update for Calendar Year 2011, final rule, p.57-63: http://edocket.access.gpo.gov/2010/pdf/2010-27778.pdf
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Select Data’s new Seminar Series coming to your town soon. Click here for details.
HIPAA Rules and the HITECH Act – an Update
Compliance officers are awaiting the Office of Civil Rights (OCR) final rules on Breach Notification, Enforcement, and the modification to Privacy and Security Rules of HIPAA HITECH. The OCR states they expect to release all of the final rules at the same time in 2011 instead of staggering the dates. Know that the deadline for the final rule for HIPAA HITECH is March so expect a flurry of activity soon. We will be preparing a summary when the final rule is released.
Also, expect the proposed rule on accounting of disclosures of electronic health records (EHR) sometime during 2011. OCR is expected to expand the HIPAA accounting provisions to include treatment, payment, and disclosures when they occur via EHR.
The OCR will be releasing a detailed audit plan for 2011. Compliance officers can prepare for the audit plan by looking at who handles PHI and how that PHI is handled within the organization. Tracking the initiation of information from point of entry to the organization system and monitoring the intersection of technology and human touch may show weaknesses within the system. Look at personnel equipment and processes. An agency’s greatest risk is human so watch processes. Could any of those processes be moved from manual to technological processes to reduce risk?
Compliance officers need to keep compliance in front of personnel. Finding fun ways to do that can be challenging but well worth the effort. For most organizations, some of their greatest risks are those tied to PHI.
Build security into hardware and software to the greatest extent possible. Make security provisions operate automatically where possible. Can employees access the internet? Can they download programs from the net? Can they access your agency information system using their personal laptops? When replacing manual processes with technology, validate the process and the fact that it does not increase risk. Technology for the sake of technology needs to be monitored also.
Build a meaningful audit system foundation that has value for the organization. It is mandated by the OCR. As to when audits of organizations will begin has not been announced. But remember, not having an audit program can be costly as the OCR states the fine is up to $1.5 million.
Recently, our firm received a call from a home health agency that knew of an agency using smartphones to take photos of wounds to be sent to the home health office. We had a rigorous discussion re the agency’s policies and procedures for protection of PHI; security of the iPhone and photos of a patient’s wound, as well as retention of the photos on the phone, and what if the employee leaves the firm? Who owns the phone and the pictures? And, ask yourself what would the patient think of all of this?
It is expected that smartphones will be utilized in the future for transmission of PHI, but how and what is transmitted needs to be addressed first. These new models of sharing PHI can be exciting to some and downright scary to others. (others being compliance officers).
Read More »
Proper Coding, Homebound Status, and Awareness of Common Edits: Paid But Will You Retain Your Revenue?
No matter if your agency deals with an 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 agencies. 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 a certain number of episodes or number of visits.
The OIG has announced that, in 2009 Medicare-Medicaid paid over $54 billion in improper payments. There have been 2500 persons/entities involved 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 mission. Probe edits are one such process expected by CMS from the MACs to achieve that goal. Monitoring for homebound status is yet another area of focus review.
The Edits
Select Data has routinely made clients aware of edits and areas with insufficient documentation to substantiate proposed diagnosis. Edit 5023T with a second recertification proposed that continues to identify hypertension as a primary diagnosis and has 5-10 skilled nursing visits is a probe edit risk. This edit holds a 98% risk of denial.
A second recertification of Lymphoma will trigger a long used edit.
A second recertification of Cardiomyopathy NEC will also trigger an edit.
Recertifications with a primary diagnosis of diabetes and a secondary diagnosis of CHF will be monitored if the edit continues after each MAC quarterly review. Because the FIs have found merit, this edit has continued for years.
Other Edits include:
Recertifications with a primary diagnosis of Alzheimer’s Disease.
Recertifications with a primary diagnosis of Schizophrenic Disorders.
Recertifications with daily skilled nursing visits yet no therapy ordered.
Recertifications with a primary diagnosis of Long term Use of Anticoagulants and no therapy ordered.
Claim Denial Potential
The above 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.”
Common documentation deficiency areas include lack of progress:
¡ 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 nurse’s 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, or no willing and capable caregiver.
One of the most common home health reasons for denial is that the documentation does not support medical necessity.
Therapy is under scrutiny
Functional ability improvement is expected or why is therapy present?
Therapy may be covered if the patient or caregiver receives 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 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
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.
Agencies need to be aware the edits will increase over the next two years as CMS, the RACs, the MACs, and the Z-PICs ready for ICD-10 and the move from the present 17,000 codes to over 155, 000 codes or a 900% increase in codes. Will there be a 900% increase in edits also? Will there be a 900% increase in claim denials? Let us hope not.
Protecting justly due reimbursement starts with proper data gathering, coding to the highest level of specificity with sufficient documentation, and somebody looking out for the edits.
RACs are Gearing Up to Audit Medicare Advantage, Part D, and Medicaid
And yet another RAC audit…
Section 1902(a)(42)(B)(i) of the Social Security Act requires states to contract with Recovery Audit Contractors (RACs) to identify underpayments and to recoup overpayments as part of the state plan. The Patient Protection and Affordable Care Act required the states to have contracted with one or more RACs by December 31, 2010. Scheduled to begin April 1, 2011, the Medicaid RACs will be a bit different because of the different focus that could be seen by each state. There will be a large list of Medicaid auditors approved by each state.
In the September, 2010 Federal Register, CMS posted an “information collection request” about Medicaid RACs. They identified that contracts should be similar to those of the Medicare program. However, states may tailor the Medicaid RAC activities to the specific aspects of the Medicaid program in each state and collectively “propose targeted areas of susceptibility regarding improper payments.” Each state was required to amend their state plans reflecting the RAC program and attesting to a plan in place. This plan must also include Medicaid waiver contracts.
The RAC Medicaid requirements remain separate from the Medicaid Integrity Program (MIC) audits, which will continue. The RAC audits are additional Medicaid audits that the law requires to ensure plans under Parts C and D have claims examined for reinsurance payments to determine if the claims costs are in excess of allowable reinsurance costs. RACs are also to look at prescription drug plans for high cost beneficiaries.
New York State Medicaid Inspector General is leading the charge in attacking waste, fraud, and abuse, recently reminding home health agencies they “cannot bill for excluded providers or accept orders from excluded providers.” He has identified that many agencies were not appropriately verifying physicians approved for Medicaid payment.
In addition, the pressure is on to be certain that diagnosis codes, hospital admission and discharge codes, and procedure codes are all in order in all areas of health care. Coding, once again is at the forefront of audit review for all areas of healthcare.
Health care entities should review the annual OIG workplan, and besides the understood areas of risk; diagnoses coding, rehabilitation services, medical necessity, and adequate documentation, they might wish to add Medicaid Hospice services and being certain a process is in place to verify physician orders are not taken from Medicaid excluded physicians. How frequently is the exclusion list reviewed?
Risk areas identified by corporate compliance necessitate a policy and procedure to be in place with a method of verifying compliance to reduce corporate risk. Mandated corporate compliance programs are to become a reality in all areas of health care within the next few years. However, more and more organizations realize they need a corporate compliance program in place now. In case of a RAC, MAC, MIC, and especially in case of a Z-PIC or HEAT audit, establishing the view that you are compliance oriented with a compliance plan in place sends a far stronger positive message than you are waiting until a plan is actually mandated.
The OIG recently announced they will be reviewing “Medicaid Program Integrity Best Practices” in state Medicaid agencies especially in the areas of coding and payment risks. You may well have Best Practices in clinical areas but do you know that your billing practices follow Best Practices in Medicaid billing? You need to have this assurance.
For additional information:
www.cms.gov/RAC/01-Overview.asp
Reminder: RAC facts
RACs can review via automated review (no medical record from the agency required) or a complex review which entails a medical record request.
The four present CMS approved RACs include:
RAC A: Diversified Collection Services
RAC B: CGI Federal
http://racb.cgi.com racb@cgi.com
RAC C: Connolly, Inc
www.connollyhealthcare.com/RAC RACinfo@connollyhealthcare.com
RAC D: HealthDataInsights
http://racinfo.healthdatainsights.com racinfo@emailhdi.com