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The RACs are Coming… The RACs are Coming… And Coding is a Target

Tuesday, January 31st, 2012

RACs have recovered over 96% of all audited claims resulting in take-backs of over 2 billion dollars. Is it any wonder that the home health industry is concerned about their new focus in our industry? The RACs have been identified. The MACs, who will work with the RACs are all now in place.

RACs are contingency based, so, they are motivated to seek out variances.  They can audit 1% of the average monthly Medicare episodes of care (maximum 200) every 45 days per NPI.

Home Health agencies should anticipate to see audits of outlier payments for insulin injections. They should expect, based on coding algorithms to see records reviewed. Are you monitoring your coding and documentation closely? Expect audits.  Fiscal Intermediaries have identified reasons for claim denials and identified high risk areas for non-compliance. Those targeted areas include areas involving coding, homebound status, the documentation of the skilled services delivered, and the overall medical necessity of care administered.

Agencies should be cautious that the codes affixed are well supported by the documentation of the clinician. Too frequently, there has been partial denial of therapy resulting in medical review down-code. Too often and easily, FIs have found clinical documentation incongruent with OASIS M items. Too many times, the reviewers have found that the documentation does not support the focus of care, the sequence for coding, or the medical necessity of the skilled services billed.

In the RAC demonstration project, 35% of the findings pertained to coding. Expect Home Health coding to become one of the chief areas of focus. Remember, the RACs will be looking at variance which will allow them to view consistency of a client’s OASIS, coding, clinical documentation, and the plan of care.

The RAC attack: how to prepare and manage the audits

The Centers for Medicare and Medicaid  (CMS) has implemented, in home health, the  audit process that has proven successful in other areas of the health care industry.  The RAC auditors have been authorized to recover “improper payments “of preapproved areas of risk.  In the demonstration project, high areas of risk included incorrectly coded records, therapy appropriateness, and medically unnecessary services. The RACS use public information from the Office of Inspector General (OIG) and the General Accounting Office (GAO) to focus improper payment audits.

RACs have recovered over 96% of all audited claims resulting in high take-back dollars. Is it any wonder that the home health industry is concerned about their new focus?

RACs are contingency based, so, they are motivated to seek out variances.  They can audit 1% of the average monthly Medicare episodes of care (maximum 200) every 45 days per NPI.  The question is: what action should the home health agency consider now?

Choose a RAC Leader and RAC Response Team

First of all, agencies should appoint a RAC Team Leader who will identify the single point of contact and establish a RAC Response Team. This dynamic team should represent the components of the clinically driven revenue cycle management (RCM) process. Specifically, 1) physicians and clinicians;, nurses, therapists, social workers, 2) quality improvement and documentation specialists, 3) casemanagers, 4) coders, 5) HIM, 6) chargemaster/billing/RCM specialists, 7)  data analysts, 8) Education/Training Specialists, 9) corporate compliance, 10) legal, 11) department heads, 12) mitigation sub-committee that will actually analyze and track each RAC record , and others will be called as needed.  This team will need to address both past and present tactical and oversight issues while prioritizing areas of risk. Additionally, they will review the agency’s ability to complete processes, including audits, and tracking the appeal response.

RAC audits represent significant risk to revenues, profit margins, and workflow stability.  The education of the RAC Response Team is vital in developing the most thorough, yet, efficient approach to establishing RAC risk review and protocol preparedness. Have the team ready.

Identify Vulnerabilities

RAC Response Team education should include lessons learned from the home health industry past: Operation Restore Trust (ORT), May 1995, a two year project in five states resulting in $187.5 million in fines, recoveries, and civil money penalties.  After four years, ORT was credited with a 45% decrease in improper payments, recovery of over $524 million in judgments and settlements and prevention of nearly $11 billion paid in inappropriate claims.

In general, ORT found issues with medical necessity, lack of homebound status, and lack of documentation to support care provided.  Sound familiar? ORT targeted agencies by volume of claims, frequency of medical review issues, LUPA episodes, outliers, therapy thresholds, as well as medical necessity determinations and coding errors.

The recent RAC demonstration results reflected similar focus areas. Agencies should heed those trends identified.

The RAC Response Team should become familiar with regulatory requirements and timeliness. Inservices as well as FAQ sheets with key regulatory highlights and a list of appropriate links to review could be provided. The leader should become familiar with the RAC website as well as monitor the CMS website, alerts, and transmittals.

The RAC Demonstration project showed a 7% payment recovery because of inadequate response to medical record requests so, a process will be needed, to mitigate information flow and manage RAC audit activities thus, create the RAC mitigation sub-committee. This committee or team should function as a subsection of the RAC Response Team, aiding the RAC Team Leader in tracking claims under review.

Identify the patient and document flow, identifying tasks and tools. Diagram patient care flow from intake > admission> medication profile review> discipline specific careplan development > coding >  plan of care development > RAP drop> discipline visits > outcome achievement> QA process review >to final claim submission and A/R management.

Retrospective chart audits as well as present processes and concurrent chart audits should be completed to identify risk. The RAC Response team may decide to contract with third party specialists for comprehensive consulting services to assist the team. The services can include:

  • ICD-9-CM Coding Review (Soon to be ICD-10 CM)
  • Documentation adequacy to substantiate the Plan of Care and the Codes
  • Billing and Revenue Cycle Management (RCM) Review
  • Process and Workflow Analysis
  • Clinical and RCM Resource
  • Presenting OASIS C and Evidenced-Based Practice correlations
  • Conducting RAC training sessions to prepare identified personnel for audits

Comprehensive third party clinical/RCM review of care delivered can assign potential organization susceptibility.  The chart audits can distinguish:

  • If the admission was medically necessary and the plan appropriate and covered all disciplines.
  • If the clinical visits support the plan and the notes
  • If the coding met convention and had adequate documented support
    • Focus on case mix diagnoses
    • Review diagnoses sequencing
  • If therapy, treatment and procedures were appropriate
  • If the reason qualifying homebound status was documented each visit and used objective measureable language
  • Other criteria mutually identified by the RAC Response Team and the outside specialists

The RAC Team should consider reviewing the agency overall compliance process, keeping basic CMS regulations in mind.

There have been no limits placed upon the number of sixty day episodes per beneficiary as long as they remain eligible for the home health benefit.  Payment is adjusted to the patient’s need. It becomes the home health agency’s responsibility to assess the patient accurately. Based upon answers to OASIS items describing the patient’s condition and projected therapy needs, a case-mix adjustment is determined. It is the agency’s responsibility to be certain the assessment is accurate, the care is appropriate, and expected outcomes are achieved. Congruency is a key.

Though no limits have been placed on the number of episodes, the Medicare home health benefit is intended to address short term medical needs designed to be met within 60 days. Ongoing recertification is meant to be the exception, not the norm. That recertification must be signed and dated and have backup support of clinical visit and progress notes, copies of summary reports sent to the physicians, and discharge planning. 42 C.F.R. 484.48.  Sometimes, agencies forget that recertification episodes must be clearly justified and are being reviewed carefully. The RAC Team may wish to call for an audit of patients with two episodes and higher.

Expect recertification assessments to become a focus of review.

Because, the RAC audits have focused on medical necessity, it is vital that the intake process and admission policies be reviewed to ensure compliance.  Involve case managers to discuss how they determine projected visit numbers as well as reconcile their careplan focused visits to the Plan of Care. That Plan of Care is the physician ordered medical certification substantiating the need for home health services. 42 C.F.R. 409.43(c) (3).

The coding processes have historically been one of the highest targeted areas of concern because of inaccurate coding in relation to the assessment and documentation submitted. Improper sequencing of codes with incongruence between assessment and plan of care create chart concerns. Chargemaster functions are to be reviewed to determine how identified problems are corrected. Consider third party coders or third party billing sources who know the rules and assist you to remain compliant.

Billing processes are diverse and should be order centric. A record and process review is necessary to map out areas of high risk, such as physician orders and signatures reconciled prior to final claims dropped. Timeliness requirements should be noted when the process is diagrammed.  Billing can become complex when changes and corrections must be made, so a clear tracking process must be maintained. Personnel must be kept current in billing code changes and CMS requirements.

Anytime adjustments or corrections must be made to the billing, there is a risk for duplicate billing. A strong, consistently reviewed process is needed to track beneficiary eligibility, routine billing requirements, billing adjustments, timeliness, and order centricity.  This review process will go a long way toward preventing automated audits. Remember, the automated audits are intended to locate the simple errors.

The Complex reviews are seeking errors that require more intense review; through medical record reviews.  If a RAC demand letter should arrive, the agency may wish to use that informal discussion period, to discuss the RAC’s reason for the repayment. The agency

You should discuss with the RAC auditor how they can submit supportive documentation. If the RAC agrees to see additional information, they can stop the recoupment process If they do not agree the agency can continue with the appeal process.

Providers/agencies have 120 days (from the date on the demand letter) to file an appeal.  This appeal can halt recoupment but, without a valid appeal, recoupment starts on day 41 per CMS.  Appeal prevention oriented agencies need strong process review and implementation. They need to start their own review now.

Coding and Documentation. Coding and Documentation. Coding and Documentation. They just keep becoming more and more important!

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Posted in CMS, Compliance, Home Health, ICD-10-CM Coding, ICD9-CM Coding, MACs, Medicare, OIG, RACs, Surveys | No Comments »

Caring Across the Transitions: The Federal Health Information Technology Strategic Plan 2011-2015

Thursday, December 8th, 2011

The Patient Protection and Affordable Care Act (PPACA) and the American Recovery and Reinvestment Act (ARRA) have and will continue to have some of the most significant impact on how this nation will care for patients as well as store and access data on those  patients. As just a part of the latter Act, HIPAA HITECH addresses security and privacy of data while the PPACA expands public and private health care initiatives.

Some of the new initiatives include the Transitions of Care movement, the Accountable Care Organization, as well as the Patient-Centered Medical Home Model. In future issues, we will deal more with these alterations and potential impacts to the health delivery system. Know that PPACA and ARRA are designed to fundamentally expand access to health care for all US residents. They are meant to look at new ways to deliver safe, quality, and economically affordable care.

In doing so Congress has stated the new delivery models will require rapid engineering of the health care delivery system to consistently provide high quality care at an overall lower cost.

The new delivery systems essentially require ready access of information across the care continuum to empower individuals to use and manage their own care. PPACA identifies one way of “improving health and health care for all Americans is through the use of information and technology.” But, in order to expand use of the information from one care provider to the other requires ready access, and ready access requires the ability to protect individual rights.

At a time when rapid sharing of data is essential for improved quality health care, the government learned the confidence in the protection of health data was low. The Federal Health Information Technology Strategic Plan 2011-2015 was established to “Inspire consumer confidence and trust in health IT.”

The Federal Health IT Vision and Mission

Vision: “A health system that uses information to empower individuals and to improve the health of the population.”

Mission: “To improve health and health care for all Americans through the use of information and technology.”

To do so, the Office of the National Coordinator for Health Information Technology (ONC) published the plan, opened it for public comment, and finalized the Plan in October, 2011 after incorporating over 200 public comments.

Privacy and Security were key concerns. Though individuals rely on HIPAA to assist in guarding how data is transmitted, maintained, and received, the HITECH regulations provide more control of that data by Covered Entities as well as Business Associates. There are stronger provisions for sanctions and significantly higher fines. In addition, the Office of Health and Human Services has commissioned a “principal-level, inter-division workgroup to develop an updated approach to privacy and security policies.” That workgroup will make recommendations to the HIT policy Committee as well as to the HIT Standards Committee.

The Federal Health IT Principles support the government in its desire to “put individuals and their interests first” (Overview Federal Health IT Strategic Plan 2011, p2).

Goal 1: Achieve Adoption and Information Exchange through Meaningful Use of Health IT

The new Federal Health Information Technology Strategic Plan (FHITSP) will be a living document that will be responsive not only to those committees, but also to the public, and other organizations, including Congress. The ONC, responsible for the Plan, already has proposed an extension of Meaningful Use, Stage 1, by a year (to 2014), to allow time to incentivize more providers in the use of Electronic Health Records (EHRs). Giving another year would allow providers and vendors more time to develop functionality for the EHR. CMS has requested more improvement of data portability.

One goal of improved data accessibility is to, per Congress, “engage patients and families in their health care.” To accomplish this goal, patients are to have an electronic copy of their health information; test results, medications, problem lists, procedures, and instructions, upon request. Providers are to be able to easily exchange data, including information that may have been patient-authored. When the patient is transferred from one setting to another, a patient transfer summary of care should be available for each transition of care or referral. You will see the use of the word discharge begin to fade away. The belief is the patient is not discharged, merely transitioned to the more appropriate level of care; thus a transition summary, not a discharge summary will be written.

Meaningful Use- Stage 1 Objectives include protection of health information created and /or maintained by the Electronic Health Record technology through the “implementation of appropriate technical capabilities.”

Meaningful Use- Stage 1 Measures include conducting a security risk analysis and implementation of updates as necessary with identified security deficiencies identified as part of the risk management process. (45 CFR 164.308 (a)(1).

The belief is that to ensure mass acceptance, privacy and security must be the solid foundation. Patients, families, and providers must feel confident that laws, regulations, and procedures are in place to keep health information safe and they must be able to access care from one level to the next.

Goal II: Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT

Exploring the use of new health care delivery models is being encouraged. From Care Transition programs to Accountable Care Organizations, CMS is seeking new ways to treat populations. The year 2012 brings in the CMS regulations regarding ACOs:

On October 20, 2011 the US Department of Health and Human Services released the final rule implementing the ACO Shared Savings Program and the complementary regulations and guidance from CMS/OIG as well as the DOJ/FTC. It should be noted that the final rules are materially different from the proposed rules of March, 2010.

ACOs were created by the Affordable Care Act (ACA) signed into law March 2010. The dual purpose of this network provider model is to reduce the increasing cost of healthcare and to include incentives to create this new way of providing care for individuals. Coupled with the ACO rules, CMS had unveiled the Shared Savings Program (SSP), a program created by Congress to allow the ACOs to share in the savings and potentially share the costs of care to Medicare beneficiaries.

The final regulations were released. The proposed rules did not stimulate the interest expected. CMS has since changed the final rule to focus on the themes of flexibility, accountability, and innovation. It also provides clear guidance aimed at encouraging the development of the ACO participation in the Shared Savings Program. The purpose of ACOs is to realize savings and quality care through the coordination of services among the various providers, including hospitals, individual physicians, group practices, hospitals, home health agencies, and community health centers, or any combination of the above. Applications for the implementation of ACOs are currently being accepted through January 1, 2012, and the first ACOs will begin April, 2012.

The three goals of the ACOs stressed under the Shared Savings program will be to promote: 1) effective, patient-centered care for individuals; 2) preventive oriented and education oriented care for specific populations; and 3) cost savings (and profit) for the ACOs and CMS in general as well as decreasing waste in the system.

To be eligible to participate in the Shared Savings Program, ACOs must be accountable for at least 5000 beneficiaries a year for each of the three years of the agreement. To be eligible to share the savings, ACOs will be required to report on four quality measure domains.

It is apparent that this new healthcare model will be very patient-centered, not only addressing the medical needs of its participants, but also the social, nutritional and community needs as well. The cost sharing for the ACOs is determined by not-yet established benchmarks for 33 quality measures (QMs) broken down into the four domains:

  • Care Coordination/Patient Safety (6 measures)
  • Preventive Health (8 measures)
  • At-Risk Populations/Frail Elderly Health (12 measures)
  • Patient/Caregiver Quality Standards (7 measures).

The QMs include population focused areas that are approached in a patient-centered manner. These indicators include timeliness of physician appointments, effective communication, tobacco use, diabetes and other comorbidity control, as well as preventive screenings. Depending on the success of the outcome-driven education and approach to the care as well as patient ratings and surveys, specific provider scores could garner up to 60% of the savings realized by the organization. It is anticipated that the new system will save over $960 million over the next three years for the Medicare program, per CMS.

This new form of healthcare organization will utilize technology to link providers. “An ACO will be rewarded for providing better care and investing in the health and lives of patients,” said Donald M. Berwick, M.D., CMS Administrator. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”

Goal III: Inspire Confidence and Trust in Health IT and

Goal IV: Empower Individuals with Health IT to Improve their Health and the Health Care System

Regulations are Stronger because Risks are Higher. Recent breach statistics show the cause of consumer concern. On 5/19/11, 1 million people were impacted by the theft of 517 unencrypted hard drives from servers at BCBS Tennessee Call Center.   (www.healthcareinformationsecurity.com)

On 9/9/11 Microsoft Cloud Evaporates Leaving 365 Million Users without access for hours.     (http://techcrunch.com)

The Federal list of major health information breaches since September 2009 includes 345 incidents affecting 18.5 million people as of 10/24/11. Breaches affecting 500 or more individuals 9/09- 8/11 included 328 breach incidents affecting 11, 819, 283 individual records.

Security

In a 2010 survey, the Office of Health Information Management saw that 74% of providers surveyed offer patient access to the website or portal through the use of a unique log-in identifier. Believe it or not, 17% of those surveyed had no controls in place and were in violation of several regulations.

In the HIPAA final Security Rule (2006) personnel must be responsible for security, sharing of data safely must be provided in an electronic format, and there must be a patient identity validation.

Per the Federal HIT committees, the only secured data is data that has been destroyed or encrypted. Your IT provider should have Patient Privacy and Security Safeguards in place. Those will include an Assessment of Risk, IT Policies and Procedures with ongoing evaluations, Data Integrity Lifecycle Management, Audits, Storage and Data Retention Safeguards, with Disaster Recovery and data replication capability.

Goal V: Achieve Rapid Learning and Technological Advancement

Usability of EHR:

The ONC is looking at ways to improve the ability of providers to be more responsive to user need and improve data portability. CMS is monitoring the Medicare and Medicaid EHR incentive programs. Expect to see another collective ONC, Office of Civil Rights (responsible for HIPAA), and CMS national campaign to increase consumer awareness in the areas of:

  • A National Transition to Electronic Health IT
  • The Benefits of Managing Health IT Tools to Improve Health Care Management
  • The Fact that this Move to EHIT Helps Keep the Consumer Empowered
  • Health Information Privacy and Security

The campaign slogan chosen is to be “Putting the I in Health IT” which will encourage patients, families, and providers to share how IT can and has improved health care.

For more information and to read the Federal Health IT Strategic Plan visit http://healthit.hhs.gov/StrategicPlan

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Posted in ACO, Affordable Care Act (ACA), CMS, Compliance, HIPPA HITECH, Home Health, Medicare | No Comments »

Speech and Language Pathology, the “OTHER” Therapy

Friday, November 25th, 2011

While there is much focus on PT and OT, know that documentation will be scrutinized regarding Speech/Language Pathology also. Most clinicians have a good understanding of how PT and OT intervenes with the clients but many clinicians may admit, that other than help with dysphagia, they are uncertain what other care the S/LP can provide?

S/LPs are subject to the same documentation goals under the CoPs:

¡  Provide evidence that the care given meets clinical standards

¡  Justify reimbursement for the payor

¡  Provide protection from liability

¡  Means of communication among individuals providing services

Provide accurate data regarding care for specific patient and diagnostic populations.

S/LPs must meet the same legal requirement to communicate:

¡  Record must be accurate in all respects

¡  Content of the record should contain measurable and objective data

¡  Interventions must be specifically documented and be relational to the POC

¡  Document what was taught and to whom

¡  Document what was learned and by whom

¡  Legal signature includes: Full Name, Full credentials and be legible

S/LPs must have the patient meet the Home Health eligibility per the CoPs:

¡  Homebound Status

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

¡  Under the Care of MD, DO, DPM

“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.

¡  Medical Necessity and Skilled Need

CMS states that medical necessity is defined as a “reasonable and necessary need for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member.”

S/LPs must document specific care to justify Medical Necessity

¡  Is there a feeding and swallowing problem?

The S/LP will routinely perform an oral/motor examination. They will evaluate swallowing, coughing, and the size of bolus.

The S/LP can develop a plan to mitigate risk of aspiration such as bolus control.

The S/LP can assist with the plan to maintain adequate hydration and nutrition through body positioning and maneuvers to improve safety.

They will assist in evaluating the independence factors in compliance with the overall plan.

¡  Is there a problem with language  (verbal expression, comprehension, reading)

The S/LP can assist to minimize safety risks by finding tools and devices to aid in communication of safety needs to family and other caregivers.

¡  Is there a cognition issue?

The S/LP can assist with strategies to improve attention and attending cues, as well as memory cues.

The S/LP can identify strategies and tactics that can aid problem solving skills. This too can impact safety and independence.

¡  Does the patient require intervention with Voice?

The S/LP can identify strategies to impact on verbal expression, relieving vocal symptoms and, improving their functional voice. The S/LP will identify ways to increase voice loudness and decrease hypernasality.

The clinician should assess this need for S/LP under the Safety evaluation.

¡  Is the patient struggling with fluency and difficult sound production? Do they have an impairment of the tongue? Do they have a lower neuron disease or cerebellar lesion? Does the patient suffer from TBI or had a stroke, or MS?

The S/LP can provide assessment of and interventions for the patients suffering from receptive language deficits; the need to improve understanding of spoken language and can assist with expressive language needs also. It can be frustrating to a patient who cannot state needs or answer questions. Acting out behavior is frequently found to be due to fear, sadness, and frustration.

Depending upon the condition teaching and reteaching occurs.

¡  Three Types of Teaching:

¡  Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis

¡  Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching

¡  Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient has had prior instruction

The S/LP has expertise in learning principles and teaching techniques.

Using Descriptive Verbiage in Documentation

Expect to see documentation descriptors that create a visual image in the mind of the reader. They should demonstrate the skill of the therapist, the value of the care as well as progress of the patient toward their goals:

Accessed                    Assessed                          Assisted               Adaptive

Altered                     Accurate                   Automatic             Applied

Analyze                    Appraise

Cues/Cued                Compromise              Corrected             Customize

Calculate                  Compare                   Contrast               Construct

Compose                  Choose                      Categorize            Collect

Directed                   Develop                      Distinguish          Define

Demonstrate                      Dramatize                  Diagram

Evaluate                   Exercised                            Elevate                Express

Explain                     Examine

Facilitate

Illustrate                   Identify                     Interact                Instruct

Modify                 Measure

Progressed           Practiced                   Proposed

Revised

Stimulated            Scheduled

Updated

The S/LP should document prior functioning in comparison to current. They should clearly document care coordination.

Choosing the Assessment Instruments and Tools

The home health agency, in conjunction with the therapist, should determine what tests will be approved by the agency, so there is continuity among all therapists. Be certain each therapist is knowledgeable with the tools chosen so inter-rater reliability issues are minimized. Also, much like PT consistency; will a TUG or Tinetti be used, S/LP must consider test and re-test reliability.

Consider time for the administration of the assessment. Nurses have seen assessment tools come and go. I can recall a fabulously thorough clinical assessment tool to be used on an inpatient unit. It soon lost favor when its lack of practicality surfaced. Are you seeking comprehensive tools? Be certain they are standardized so that reliability and validity issues do not surface.

Look at the OASIS functional items and look to well thought of commercially acceptable outcome measurements such as the NOMS. The National Outcome Measurement System can be used as an objective measurement tool for the CMS 13th and 19th visit per the American Speech-Language-Hearing Association.

Eight of the fifteen Functional Communication Measures (FCM) from the Adult NOMs were submitted to the National Quality Forum (NQF) for review and were endorsed and became a part of the public domain.  The FCM is but one component of the overall NOMS, the national data base of treatment outcomes and customized data reports.

Other Common Tools Used by the S/LP

The Aphasia Language Performance Scale (ALPS)

The EFA-3, Examining for Aphasia

Boston Diagnostic Aphasia Exam

Cognitive Linguistic Quick Test (CLQT)

CADL, Communication of Activities of Daily Living

For a more complete list of Standardized Assessment Instruments, go to:

http://www.asha.org/assessments.aspx

¡  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.

Quick tip: Recently, a colleague shared with me that on their psych team, besides the psych nurse and the occupational therapist, they have added a S/LP in certain circumstances, especially with patients with challenged cognition. With patients who are acting out and have recently suffered a stroke or have exacerbated MS, the S/LP has much to add to the Home Health Team in assisting to decrease frustration and anxiety. Speech and Language Pathologists (therapist) add depth to the total team.

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Posted in CMS, CoPs, Compliance, Home Health, Therapy | No Comments »

Compliance Q&A: Survey protocols, CoPs, HIPAA, ACOs, and Transitions of Care

Saturday, November 19th, 2011

Questions regarding 2011 Survey protocols

Q. We have several questions re the new survey protocols. What are some of the key differences? What does the pre-survey preparation include?

A. The new survey protocols focus on specific standards within identified conditions that are related to quality care. To identify the care delivered and its relationship to the assessment and plan of care designed, besides reviewing the clinical record, the surveyor will also rely on personnel interviews as well as home visits. The survey is data-driven, patient-focused, and outcome-oriented.

The surveyor is expected to collect data and review State file data, prior survey results, OASIS reports, and agency specific characteristics. (S)he will review outcomes, potentially avoidable events of both active and discharged patients, and make visits for higher risk patents. The new protocols provide specific guidance on citing standard and condition-level deficiencies.

Q. Can you explain the survey levels? How is a standard survey extended?

A. A Standard Survey focuses on Level 1 standards (9 of 15 CoPs) which focus on the delivery of high quality patient care using not only clinical records but inclusive of interviews. If the home health agency is in compliance with all Level 1 standards and there are no identified concerns requiring investigation, the survey will be concluded and form CMS 2567 is issued.

Partial Extended Survey begins/expands when expected outcomes are not met for one or more Level 1 Standards. It requires a review of Level 2 standards. It should be expected that related information would be sought for areas of concern such as agency policies and procedures, personnel competency evaluations, and inservice training

Condition-Level Deficiencies can occur with serious findings related to or not related to Level 1 and 2 standards. Immediate patient jeopardy is always cited at the condition level. All conditions are reviewed.  Refer to the State Operations Manual, Appendix B Guidelines.

Questions re CoPs

Q. What are the required leadership positions stated in the CoPs?

A. The Conditions of Participation cite three administrative positions:  a governing body, an administrator, and a supervising physician or RN.  You may title these three positions whatever  your agency prefers, however the positions must exist and the individuals appointed must perform the duties identified in the CoPs. Be certain job descriptions, policies and procedures, and other necessary documentation clearly define that the positions perform all required designated responsibilities.

Do not forget the delegates required. Be certain that agency policy identifies who will function as the administrative delegate. The agency must also be in compliance with state requirements, which frequently are more stringent. Compare both State and Federal requirements so the agency is in compliance.

Q. Is it true that we must have a realistic end point for intermittent services for a patient who has a chronic diagnosis, such as Alzheimer’s disease?
A.The CMS Publication 100-2, Chapter 7, § 40.1.1,  states  services can be provided “without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time.”

According to the publication, if the patient with a chronic disease is homebound and needs skilled, reasonable, and necessary services that meet the part-time or intermittent requirements, then the agency can provide care.  That documentation must carefully be documented, The agency must be certain there exists an intensive assessment of the patient and their support services with interventions and goals clearly stated.  Carefully delineate the SKILLED need for each visit made. If the patient with Alzheimer’s disease qualifies for Medicare coverage through a need for monthly catheter changes and receives home health aide services 1x per mon, be certain each visit shows progress and document pt/cg response to care.

Up to a maximum of 28 hours per week of skilled nursing care and home health aide services combined completed in less than 8 hours per day or up to 35 hours per week of skilled nursing and home health aide services and subject to review by the fiscal intermediary. Medicare requires supporting evidence of the continued skilled care need. The agency must reflect the need for compliant skilled care through clear documentation.

Questions about ACOs and New Payment Methods

Q. I am hearing about bundled services. Should I be concerned?

A. Home Health Agencies should be aware of potential ACO formation in their respective markets.  Does your agency have a specialty you should be marketing to local hospitals? Some hospitals are looking at the bundled payment options as well as ACOs. Read more at the CMS website but know that the proposed pilot gives participants the opportunities to make choices regarding patients to include, length of episodes of care, whether acute inpatient care should be included, and the target payment to be established. There are a variety of proposed models. Go to www.CMS.hhs.gov to learn more.

Q. I have heard there will be new payment methods. What are they?

A. Select Data will be providing ezine articles in late November and December regarding some of the proposed payment and treatment methods being considered and presently being evaluated. Those may include:

Accountable Care Organizations (ACOs) with Bundled Payments or Shared Savings Programs where the ACO shares risk. There will be various types of risk sharing programs. There may be Value- based Payment plans. Expect to see ACOs lead by hospitals or physician groups. Home Health Agencies will need to show value to become a part of such collaborative formalized groups.  Expect CMS to utilize comparative-effectiveness techniques of evidenced-based practices. Become familiar with the following terms:

ACOs: Integration of providers to assume responsibility for the quality, costs, and outcomes of care.

Total Costs of Care: A reimbursable methodology that is being designed to reduce cost by person by episode.

Predictive Modeling: A methodology to estimate how clients may use services and the related costs based upon variables, prior behavior, and attributes assigned.

Transition of Care: The movement of patients from one health care practitioner or setting to another as the condition and care needs change. Under this model, there will be NO discharge summary. Instead expect a “Transition Summary”. See the next Select Data article: CMS and Transitions of Care.

Questions re Face to Face

Q. Is anyone working to get some help for home health agencies regarding the face-to-face rule?

A. Yes, several state associations as well as NAHC are working to obtain some legislative relief. NAHC has called for 1) exemptions in specific hardship circumstances, 2) a reduction in documentation required, 3) expanded use of telehealth to meet the face to face requirement, 4) protection of home health agencies from denials without fault, 4) allow one physician/NPP to complete the Face to Face and another to certify (CMS has proposed this but is limiting it only to an inpatient physician).

Q. Could you give a summary of key points of the proposed 2012 Home Health PPS Rate Rule?

A. Agencies will need to be efficient as there is a proposed 2.5% inflation update, a 5.06% case mix creep adjustment, and a 3.56% rate reduction for 2012. In addition there is a recalculation of case mix weights proposed that includes elimination of two hypertension codes (401.1 Benign essential hypertension and 401.9 Unspecific essential hypertension). Also, there would be lower therapy episode coding weights. This would include a deceleration of a higher number of visits with a removal of the therapy visit step indicators. There will also be a recalculation of points to clinical and functional scores. Additionally, if an agency failed to complete a successful dry run  in Q3 of 2010 for HHCAHPs, they risk a 2% reduction in payment. (See October, 2011 Select Data ezine for more regarding HHCAHPs).

A few questions regarding HIPAA

Q. Could you give a brief summary of HIPAA HITECH? Can you discuss breach? Can you discuss best practices needed?

A. The American Recovery and Reinvestment Act (ARRA) of 2009 brought changes to HIPAA regulations in three broad areas: breach notifications, business associations, and penalties. It increases enforcement of HIPAA and allocates billions of dollars to invest in the implementation and exchange of health information technology such as the EMR.

Under HITECH, if a breach compromises the privacy and security of the patient’s information and poses a significant risk of financial, reputational, or other harm, patient notification is required.

Five new definitions have been added:

  • Breach Electronic
  • Health Record (HER)
  • National Coordinator
  • Personal Health Record (PHR)
  • Vendor Of PHI

HITECH strengthens the specifics of privacy, significantly increasing penalties, establishing a heightened enforcement scheme and giving state attorney general enforcement authority. Individuals may now be held accountable for wrongful disclosure (HITECH Act section 13409).

If a breach involves 500 or more individuals, the department of HHS should be immediately notified. DHHS began posting names on March 1, 2010. Breaches below 500 must be logged and annually sent to DHHS.

For Business Associates, the Covered Entity must ensure that BAs have implemented the administrative, physical, and technical safeguards of HIPAA security. The CE must also specify that the BA must comply with use and disclosure rules in the HIPPA Privacy Rule. The BA should demonstrate how they will negotiate security/data breach coordination. There should also be an agreement on reporting and dispute resolution.

If the health care organization suspects or knows that a BA has committed a material breach or violation of the agreement, “the health care organization is in violation of the business associate rules unless it takes reasonable steps to cure the breach or end the violation {45CFR 164.504 (e)(1)(ii)” (Decision Health, HIPAA, 2010).

Penalties include a Tiered System for assessing both the level and penalty for each violation. There is a cap of $50,000 per violation and 1.5 million for the calendar year for the same type of violation.

Health care organizations should have in place policies that address various levels of violation, such as failing to sign off a computer terminal when not attended, sharing passwords, assessing a patient record without legitimate reason, releasing data for personal gain, and intentionally destroying or altering data.

Use Best Practices for:

Authentication: pre-boot and intricate passwords

Access: Need to know basis on approved devices

Retention: Destroy if not needed

Encryption: Laptops, notebooks, desktops, email, and social networks

For some peace of mind, have a written information security program, an active HIPAA privacy program, and a living Corporate Compliance Program.

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Posted in ACO, Best Practice Intervention Practice, CMS, CMS Guidelines, Compliance, Face to Face Encounters, HIPAA, HIPPA HITECH, Home Health, Medicare, Patient Survey, Surveys | No Comments »

CMS released the final regulation which implement a new form of healthcare organization, the Accountable Care Organization (ACO)

Saturday, November 5th, 2011

On October 20, 2011the US Department of Health and Human Services released the final rule implementing the ACO Shared Savings Program and the complementary regulations and guidance from CMS/OIG as well as the DOJ/FTC. It should be noted that the final rules are materially different from the proposed rules of March, 2010.

ACOs were created by the Affordable Care Act (ACA) signed into law March 2010. The dual purpose, of this network provider model, is to reduce the increasing cost of healthcare and to include incentives to create this new way of providing care for individuals. Coupled with the ACO rules, CMS had unveiled the Shared Savings Program (SSP), a program created by Congress to allow the ACOs to share in the savings and potentially share the costs of care to Medicare beneficiaries.

The final regulations were released. The proposed rules did not stimulate the interest expected. CMS has since changed the final rule to focus on the themes of flexibility, accountability, and innovation. It also provides clear guidance aimed at encouraging the development of the ACO participation in the Shared Savings Program. The purpose of ACOs is to realize savings and quality care through the coordination of services among the various providers, including hospitals, individual physicians, group practices, hospitals, home health agencies, and community health centers, or any combination of the above. Applications for the implementation of ACOs are currently being accepted through January 1, 2012, and the first ACOs will begin April, 2012.

The three goals of the ACOs stressed under the Shared Savings program will be to promote: 1) effective, patient-centered care for individuals; 2) preventive oriented and education oriented care for specific populations; and 3) cost savings (and profit) for the ACOs and CMS in general as well as decreasing waste in the system.

To be eligible to participate in the Shared Savings Program, ACOs must be accountable for at least 5000 beneficiaries a year for each of the three years of the agreement. To be eligible to share the savings, ACOs will be required to report on four quality measure domains.

It is apparent that this new healthcare model will be very patient-centered, not only addressing the medical needs of its participants, but also the social, nutritional and community needs as well. The cost sharing for the ACOs is determined by not-yet established benchmarks for 33 quality measures (QMs) broken down into the four domains:

  • Care Coordination/Patient Safety (6 measures)
  • Preventive Health (8 measures)
  • At-Risk Populations/frail elderly health (12 measures)
  • Patient/Caregiver Quality Standards (7 measures).

The QMs include population focused areas that are approached in a patient-centered manner. These indicators include timeliness of physician appointments, effective communication, tobacco use, diabetes and other comorbidity control, as well as preventive screenings. Depending on the success of the outcome-driven education and approach to the care as well as patient ratings and surveys, specific provider scores could garner up to 60% of the savings realized by the organization. It is anticipated that the new system will save over $960 million over the next three years for the Medicare program, per CMS.

This new form of healthcare organization will utilize technology to link providers. “An ACO will be rewarded for providing better care and investing in the health and lives of patients,” said Donald M. Berwick, M.D., CMS Administrator. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”

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Posted in ACO, Affordable Care Act (ACA), CMS, CMS Guidelines, Compliance, Home Health, Legislation, Medicare, OASIS-C, OIG | No Comments »

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