ICD-10-CM Coding whitepaper, new updates, and M&E article

Industry Changes are Driving Increased Coding and Financial Complexity

Every home health agency wants their deserved reimbursement for the care delivered to their patient and just as importantly, they want to retain that revenue. A good start toward achieving that goal is having coding team expertise.

According to one source, the average loss on a miscoded record is hovering around $1200+. The reasons for the errors vary; experience of the coding team, training level, maintaining competency and adherence to coding guidelines and conventions with the hundreds of changes that occur annually and not to mention the over 100,000 changes coming with ICD-10. A coding team needs to be dedicated to just that: coding, not other distracting duties. The team needs coders and clinicians so the full prospective of the patient portrait is accurately presented and the proper codes are compliantly assigned.

With tighter reimbursement, outcomes affecting future reimbursement, and coding driving certain audit alerts, coding is the area that requires emphasis.

Select Data has written a white paper on this subject. Looking at industry complexity and how coding importance came to the forefront to identifying the relationship of case-mix profile and case-mix adjustment models to coding. In addition, understanding the components of the HIPPS Codes as well as how supplies must link to diagnostic codes is included.

Success in this industry usually means the home health leaders have a good understanding of why the change in CMS focus as well as what is expected from that focus. Included in this white paper, you will also find the documentation requirements for coding in general as well as examples of the therapy risk areas. Documentation must be objective and specific. Just what does that mean? Clear examples are presented.

Being alert for “alerts.” Do you know what MAC alert 5023T means? You need this kind of information from your coding team.

The value of compliant coding is proper payment and peace of mind. This is not a trite statement. It is a desire of agency leaders who are working diligently to comply with quality parameters, best practices, and regulatory statutes and law.

To read the full white paper, please go to: Whitepaper link

As a reminder, you can find all of our new blog entries and industry information at http://www.selectdata.com/what-you-care-about

CY 2011: Physician Signatures on Lab Requisitions, Face-to-Face Encounters, and Therapy Updates

LABORATORY REQUISITIONS

Though CMS states there is delayed enforcement until April 1, 2011, home health agencies should be ready to hear from laboratories regarding the new CMS requirement to have physician signatures on requisitions. Agencies have been required to obtain orders for lab tests. CMS now requires signatures on requisitions in order for the laboratory to be paid.

Some agencies have expressed concern that laboratories may attempt to have home health agencies obtain the signatures for them, thus increasing the agency’s paperwork. The industry trends toward improving alliances with acute care centers and others may need to stretch to include laboratories. Your comments would be appreciated. We ask, could a dual purpose form be developed that would save everyone time

FACE to FACE ENCOUNTERS

Face to Face encounters also have a delayed enforcement component. Agencies are expected to be obtaining the encounter information. How is that progressing? What roadblocks or obstacles have you encountered? The enforcement delay is for the purpose of providing time for agencies to refine the process.

Remember, the physician must certify that the patient’s clinical condition supports the home health need for skilled services. The physician must document the clinical findings (no canned choices to circle) and they must also note the patient is homebound. Agencies have reported physician reticence with the new requirement, but CMS is increasing educational activities for the physicians. If you have suggestions, we would appreciate your comments.

THERAPY

While trying to refine processes for face to face encounters and lab requisition signatures, home health agencies should be planning the processes to track qualified therapist and therapy assistant visits, especially those visits required for the 13^th and 19^th visit that must be completed by the qualified therapist.

CMS clarified the language noting that assessments required APPLY TO EACH THERAPY DISCIPLINE individually, not in combination as most industry experts had believed from the text written.

Qualified therapists will also be required to reassess, measure, and clearly document patient progress at least one time every 30 days. How is your agency dealing with this process?

CODING 2011: ICD-10-CM and Other Deadlines Looming

Agency leaders know that now more than ever, coding is driving reimbursement. Agency leaders want appropriate payment and compliance. Besides coding itself, and CY 2011 changes, agency leaders need to be aware that other dates are looming in this area that can impact upon an agency’s success.

While Home Health Agencies were focusing on new CY 2011 regulations and plenty of changes, leaders need to remember that there was the change to Version 5010 for handling electronic claims. CMS will still accept Version 4010 claims until January 1, 2012. CMS expects that software vendors have been conducting internal testing so testing of the new version is now externally underway and full Level II compliance is completed by December 31, 2011.

To make this process as well as the transition to ICD-10 easier, the Coordination and Maintenance Committee has proposed ICD-9-CM coding changes be frozen, effective October 1, 2011.

“Recognizing the ICD-9-CM as a dynamic statistical tool that must be flexible to meet expanding classification needs, the ICD-9-CM Coordination and Maintenance Committee was created as a forum for proposals to update ICD-9-CM. A representative from the National Center for Health Statistics (NCHS) and one from the Centers for Medicare and Medicaid Services (CMS) co-chair the ICD-9-CM Coordination and Maintenance Committee meetings. Responsibility for maintenance of the ICD-9-CM is divided between the two agencies, with classification of diagnoses (volumes 1 and 2) by NCHS and of procedures (volume 3) by CMS”.(http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm).

The ICD-9-CM Coordination and Maintenance Committee’s role is advisory. All final decisions are made by the Director of NCHS and the Administrator of CMS. Final decisions are made after the December meeting and become effective October 1 of the following year. Official code revision packages, which are referred to as addenda, are available from this site.

The transition to ICD-10 is a major change for the industry. To better effect that transition as well as the Version 5010 to handle electronic claims, the ICD-9-CM Coordination and Maintenance Committee has proposed and accepted a partial freeze at a recent meeting. This freeze identifies:

The last regular annual updates to ICD-9-CM and ICD-10-CM would be made October 1, 2011
Limited updates to ICD-10 October 1, 2013 (ICD-10-CM is expected to be fully in use in Home Health by 2013)
Full regular updates to ICD-10 to be reinstituted October 1, 2014

Agencies need to be certain billing software vendors are in full testing for Version 5010 and are planning for ICD-10-CM. CMS reminds everyone that ICD-10-CM is far more comprehensive than ICD-9-CM and preparation should be underway now. (www.cms.gov/ICD10).

What are the Differences between ICD-9-CM and ICD-10-CM?

ICD-9-CM:

17 chapters and V and E code chapters

13,000 disease codes plus V and E codes

3,000 procedure codes in Volume 3

3-5 digits in disease codes

Essentially numeric system

Codes usually do not indicate timing encounter

No differentiation between left/right

ICD-10-CM:

21 chapters- V and E codes in disease chapters

68,000 disease codes, including V and E codes

87,000 procedures codes in ICD-10-PCS

3-7 digits in disease codes

Alphanumeric system

Codes specify initial and subsequent encounters

Differentiates between the right and left

Expertise in anatomy, physiology, and diagnostics will be a must

Third Party Coding experts should already be actively into their plan for additional education of their coding teams. Some, like Select Data, have been stepping up training sessions and will be offering ongoing Anatomy, Physiology, and Diagnostic seminars to refresh and maintain currency among their credentialed experts. It may look like ICD-10 is far away but, an additional 55,000 diagnostic codes, an additional 84,000 procedure codes, and increased coding specificity to the 7^th digit means increased risk for payment and more importantly, increased risk for payment retention. If your payment retention has been in question, can the MACs, RACs, or Z-PICs be far behind? Could you survive what is coming with what you have right now?

What is Management and Evaluation?

Since the new G-Codes have been implemented, G-162 has raised questions once again.

Management and evaluation is the Medicare covered qualifying skilled nursing service, introduced in 1989. Even though it has been around for over two decades, it remains a complex and confusing service, with a history of denials.

In the mid 1990s, during Operation Restore Trust (ORT), many agencies suffered costly denials when the ORT surveyors determined that the service was not properly documented with inadequate reflection of a beneficiary need that was reasonable and necessary. The Recovery Audit Contractors (RAC) are now honing in on medical necessity interventions provided by homecare agencies. Once again there is risk.

To read the coverage criteria, refer to the Medicare Benefit Policy Manual (MBPM)- Chapter 7, Home Health Services §40.1.2.2, to identify specific concepts and examples of management and evaluation, including the following:

Underlying conditions or potential exacerbation of complications.
Complexity of the necessary unskilled services (Places the patient at risk for hospitalization or health problem exacerbation).
Essential nonskilled care (The plan is complex but, unskilled).
Is part of a Medical Plan of Care.
Only an RN can assure that the care is followed (No LVN care is permitted).
Promote patient’s recovery and medical safety (There is an unstable caregiving situation).

Management and evaluation focuses on the implementation, by an RN, of a complex, unskilled care plan for a patient who is at risk because of underlying conditions or complications. that may be manifested in multiple medical diagnoses, limitations physically or mentally, or with other risk factors including safety and environmental.

Underlying complications, at risk of hospitalization

1. The patient must have underlying conditions or complications that place them at risk for hospitalization or exacerbation of a health problem if the plan is not implemented properly.

Documentation should include:

Multiple medical diagnoses, co-morbidities, or cultural, physical, or mental health problems
Limitations in activities of daily living, mental status, etc.
The examples identified by CMS includes “an aged patient with a history of DM and angina pectoris is recovering from an open reduction of the neck of the femur. He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in his condition or complications resulting from his restricted, but increasing mobility.”

No example in the manual shows a patient with a single primary diagnosis, thus, HTN or COPD alone does not seem to fit the requirements for this service.

The plan of care MUST be COMPLEX and UNSKILLED.

2. The plan must be complex, unskilled, requiring RN oversight.

Complex care means there are many facets involved in the patient’s care, which is unskilled. There may be many medications, treatments, or pieces of equipment that do not require the skills of a nurse to deliver if each is taught individually but, with another condition that adds risk, an RN is vital to coordinate and oversee a plan to minimize risk for hospitalization.

An example given in the MBPM includes a patient with mild dementia recovering from pneumonia, suffering from an increase in disorientation “has residual chest congestion, decreased appetite, and has remained in bed, immobile, throughout the episode with pneumonia.” In this situation, “skilled oversight of the nonskilled services would be reasonable and necessary pending the elimination of the chest congestion and resolution of the persistent disorientation to ensure the patient’s medical safety.”

The assessing RN must ask herself, what would happen if the RN was not involved in the careplan oversight?

There is an unstable caregiving situation

3. The caregiving situation is unstable.

An unstable caregiving situation can result from ongoing changes in the plan, the involvement of many services or caregivers, or an unsafe environment that does not provide adequate support. The RN will anticipate caregiver needs or identify potential factors in the environment that could complicate the patient’s safety or care. Because of complex situations, multiple diagnoses, and several caregivers, it is frequently the patient’s caregivers who cause or exacerbate the instability. In order to adequately provide the unskilled care, caregivers are needed. They are frequently not readily available or capable of managing a complex plan of care.

It takes the skills of the RN to manage the multiple complex diagnoses or factors and ensure that caregivers implement the complex, unskilled plan properly. Per the Medicare Benefits Policy Manual, “skilled nursing visits for management and evaluation of the patient’s care plan are also reasonable and necessary where underlying conditions or complications require that only a registered nurse can ensure that essential nonskilled care is achieving its purpose.”

Summary:

Management and evaluation is a qualifying skilled service provided by an RN only.
Management and evaluation focuses on safe and effective implementation of a complex, unskilled care plan for a patient who is at increased risk for problem exacerbation or hospitalization.
Management and evaluation services can be provided along with other skills such as assessment and teaching of patients (beneficiaries), education of caregivers, and direct procedures.

Remember, in the 1990s this skilled qualifying service was scrutinized heavily. There is reason to believe that this could occur again under MAC or RAC review.

Select Data Educational Video Series

Select Data is proud to share with the Home Health Community their educational video library hosted on their website and YouTube. The educational series is put together in playlists to make it easier to find information on the topic you are looking to find. Select Data will continue to update these sites with new topics weekly so come by often to see what’s new.

Topic Playlist Include:

You can also visit the Select Data YouTube channel page here http://www.youtube.com/selectdatainc