RACs, MACs, Z-PICs; and HHCAPs
Acronym overload!
This month we had a few articles touching on the fact that ADRs are on the rise and how additional audits in the future can affect the Home Health Industry. We are including our three part series titled, “RACs, MACs, Z-PICs: The Home Health Industry and Insufficient Documentation for Medical Necessity and ICD-9 Coding.”
Also in this E-Zine we will touch on the latest in HHCAHPs and the top ten frequently asked questions.
Part 1: RACs, MACs, Z-PICs: Insufficient Documentation for Medical Necessity and ICD-9 Coding.
CMS has now stated in the proposed PPS rule, “that after review of 2008 data that evidence continues to suggest that some Home Health Agencies may be providing unnecessary therapy.”
The RACs have also identified that insufficient documentation for medical necessity will be 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. Link
In 2008, claims chosen with 10-11 therapy visits and discharges 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 CY2011 proposed rule (dated July 23, 2010) requires objective evidence that the patient will improve. The rule also expects therapy patients to be assessed every thirty days and at the time of the 13th and 19th visit. It is expected that there will be more objective data inclusive of range of motion measurements, strength findings, and ADL dysfunctions with progress or regression noted. As previous; only the qualified therapist, not therapy assistant, will conduct the required assessment or reassessment.
Two new G-codes have been established to monitor therapy assistant visits. The current case-mix weight structure was designed based on data that home health patients received visits by qualified therapists 79% of the time with assistants visiting only 21% of the time. The new codes attached to both PTA and COTA will allow CMS to determine if that presumed fact is true.
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.
Part 2 RACs, MACs, Z-PICs:
Home Health Eligibility Criteria Includes:
Homebound Status
Must be Under the Care of an MD, DO, or DPM
Medical Necessity and Skilled Need
Homebound Status per CMS CMS expects that the patient’s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home. NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1
Homebound status is…
Dependent on the limitations of the patient
Dependent on the patient’s illnesses
Can be acceptable for patient to attend partial hospitalization
Can be acceptable for the patient to attend medical appointments
NOTE: For a patient to be eligible to receive home health services, the regulation requires a physician to certify that the patient is confined to his/her home. Homebound status requires…
Clear documentation that it is with considerable and taxing effort for the beneficiary to leave home. (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 requiring rest period.” Agency documentation frequently stresses a problem with little justification. Homebound status requires knowing the definition of a patient’s home. It is:
The patient’s residence is where the patient makes their home
Their personal dwelling
Residing with a family member or friend
In an assisted living facility
“The patient’s zip code is used for Home Health Compare to determine places where your agency provided service” Chapter 3, OASIS Guidance Manual, M0060. CMS requires the beneficiary (patient) to be under the care of an MD, DO, or DPM. Though there is active lobbying for orders to be signed by an NP or PA, that is presently not the law.
“A medical treatment plan of care or the optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments”
See 42 CFR Part484, Conditions of Participation, Subpart A General Provisions and 484.18 Plan of Care. Note the term, “attending physician”. CMS is frowning on a hospitalist signature with no patient follow through.
Part 3 RACs, MACs, Z-PICs:
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.
HHCAHPS Frequently Asked Questions:
Besides PECOS, RACs, MICs, MACs, and Z-PICs, the home health industry has been actively involved with CAHPs. Final rules were posted November 10, 2009.
The CAHPs survey was designed to essentially determine the performance and care quality delivered to a home health patient/client as identified by that patient/client. The industry is generally knowledgeable about CAHPS but, below are some of the most frequently asked questions to Select Data personnel.
Question 1: Which home health patients should have a HHCAHPs survey?
Answer 1: Patients whose care is paid by Medicare and Medicaid are eligible for inclusion in the HHCAHPS survey. Agencies must contract with a CMS approved vendor, who will conduct the surveys. Patients/clients have the right to state they do not wish to participate. The agency is not expected to ask the patient/client if they wish to participate. They are encouraged to leave that responsibility to the surveying vendor. For general information, visit the CAHPs website at www.homehealthcahps.org
Question 2: I know we are to include Medicare and Medicaid patients/clients but are there any guidelines?
Answer 2: Yes, for detailed guidance refer to the above website. In general be aware that the survey will consider current and discharged patients who have had at least one skilled visit during a sample month, who are at least 18 years of age, who have had at least two skilled visits from the agency during a 60 day look back period, who are not receiving hospice care, and who are not maternity clients.
Question 3: How many patient/clients should be surveyed?
Answer 3: Agencies are expected to survey 300 patients/clients annually with larger agencies using a sampling method and smaller agencies potentially surveying all clients. Agencies serving less than 60 HHCAHPs eligible patients/clients from 3rd quarter 2010 though 2nd quarter 2011 will be exempt from the HHCAHPs survey requirement. Going forward, the unduplicated patient count from 10/1 through 9/30 will be used to determine HHCAHPs.
Question 4: We are a relatively new agency and don’t have 60 patients. Do we just ignore HHCAHPs?
Answer 4: New agencies (with provider numbers) serving less than 60 patients had to notify CMS by June 16, 2010, with a patient count for the period from 4/1/2009-3/31/2010. The form used for such a count was/is available at www.homehealthcahps.org
Question 5: Can an agency decide not to participate in the HHCAHPs process and use their own survey instead?
Answer 5: HHCAHPs had been identified as a voluntary survey process, however, the final rule makes it clear that non participating agencies will be subject to a two percentage point reduction in the market basket update in 2012.
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