Posts Tagged ‘CMS Guidelines’

Good Coding: Helps Your Agency Keep Its Revenue Bad Coding: Can Mean You Lose Your Revenue

Wednesday, February 20th, 2013

PPS has always meant that “close enough” isn’t good enough. A digit off can be costly. Coding to the highest level of specificity can be complex and confusing. CMS has published Coding Guidelines and the Coding Clinic remains the source document for any coding questions. Agencies have hired coders. Yet still, many agency administrators pause when asked, “Are you leaving dollars on the table?” Most acknowledge they believe their coding may be costing them at least $200-$400 per episode.  Why continue to lose dollars?

Agencies have usually decided to complete their coding themselves. They have hired coders, certified or otherwise. Some coders are routinely reviewed and audited, most are not. Lessen the worry regarding dollar loss and the quality of your agency coding by instilling specific processes.

Consider a third party audit. Quality third party coding firms should have quarterly internal audits and annual external audits completed in their firms. So should you. Yes, the audits are costly, but so is $200-$400 per episode of care delivered

You should take a close look at the coding completed in your agency. Look at the use of case-mix diagnoses and at comorbidities. Down coding can be as costly as upcoding, just in different regulatory ways, if it brings on an audit. Have your ADRs increased? Do you know the number of codes used routinely in your firm? Do you know the top 10 diagnoses assigned?  How many of the present 16,000 codes are your coders using? How much will preparing for ICD-10 cost you?  Is a plan in place now? How strong is your coder in anatomy, physiology, diagnostics, and pharmacology? How many of the 68,000 codes will they use?

Experts know that much training is required for ICD-10. If you do not properly prepare, how much more will it cost you? Perhaps it is time to consider a third party coding specialty firm.

Consider a firm that has experienced, highly credentialed coding specialists. Ask if they employ a full time coding auditor. Ask if they have weekly training sessions paid for by the coding firm to keep their coding specialists current. Ask if they have a full time Compliance Officer, a compliance committee, and have current program policies and procedures. Ask if the firms’ employees are required to annually attend corporate compliance and HIPAA inservices. Ask if the coding specialists are reviewed quarterly. Ask about internal and external audits of the coding teams’ work. Ask about their % of documented accuracy.  If the coding agency is under 97% accuracy documented by independent external audit, look elsewhere. All of the above items are costly to the coding firm but a top coding firm should be investing in quality.

And lastly, identify the coding firm’s indepth ICD-10 curriculum for their coding specialists. Also, identify their overall plan for ICD-10 implementation including their plan for parallel coding of ICD-9 and ICD-10.  Do not continue to lose dollars. Make a move now.

Susan Carmichael
MS, RN, CHCQM, COS-C
Executive Vice President
Chief Compliance Officer
Select Data
714.524.2500
949.584.6296

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Posted in ICD-10-CM Coding, ICD9-CM Coding | No Comments »

ICD – 10 CM: Completing the Gap Analysis and Transition Plan (Part 2 of a Coding Series)

Thursday, August 30th, 2012

ICD-10 CM is going to impact the entire home health industry and every department of your agency. Now that we know that the implementation date will be October 1, 2014, agencies need to establish a solid plan now. You need every day of the 24 months to educate, plan, educate, implement, reevaluate, test and retest, and educate.  Training for coding specialists is important, but training for those who will use the data will be equally important.

Creating a roadmap for ICD-10 integration within an organization may appear daunting. Let’s break down the process. CMS suggests presenting an overview of ICD-10 to the entire organization. This allows individuals to process the changes in ICD-10 and align those changes to processes they presently complete. This assists the organization to understand the depth and impact of ICD-10.

Completing the Gap Analysis

Define the agency’s present state. Review the list of processes for each department from intake of a potential patient to filing of the final claim of the patient and the resulting data analytics. Identify how the coding touches each area of work flow.

Identify the agency’s strong competencies and the additional training to maintain those competencies. Look at performance levels and consider the impact of ICD-10 on performance. Considering the increased specificity of ICD-10 coding, what will be the impact on clinical and operational processes? What new clinical tools will be needed? What form changes will be required? How will internal and external reports be impacted?

List, then communicate with vendors, payor sources, and clearinghouses. Where are they in their processes? What are their plans? Will they be ready?

Identify the timeline for the Gap analysis.

Organize an ICD-9/ICD-10 Transition Team

The goal of the team is to establish an overall organizational plan after the Transition Team either completes or receives from another committee, a Gap analysis; operational and technical impact analysis. The new Transitional Team should review that overall analysis, using those specific organization findings to provide the base of their project/transition plan.

The Transition Team should have representatives of each department: intake, clinical, IT, HIM, billing, QA, internal auditing, and administration so that they can adequately develop an expansive implementation strategy.

Choose a project leader of the transition team. This leader must organize the development of a budget, a timeline and action/project plan that will include a training plan for the organization. It must demonstrate how findings and planning will be communicated. The project/transition plan needs to be tied to endpoints that are reasonable and measureable. Compliance plays a huge role. The plan must be compliance oriented; attending to statute, convention, guideline and regulation.

Report from each Department Representative and Plan Creation

The representative from each department; IT/technology, Clinical, Coding, Revenue Cycle/billing/finance, QA/QI/Audit, Data Analytics, and Education/Training  must lead the indepth department evaluation as well as the department project plan.

What will be the impact to each department?

Coding specificity?

Impact on data capture at intake? At time of assessment? On data analytics and reports?

Impact on the plan of care (485)? Consistency of diagnosis/supportive documentation/careplan

What about the schedule and the depth of schedule notes?

Utilization and quality process and improvement

Need for increased clinical cues

Time/ amount to capture data at all time/patient points

Field sizes, alphanumeric composition, and decimal use

Code value alteration with Table structure alteration

Edit and logic changes

Overlapping time point of ICD-9 and ICD-10

Impact on the EMR

Impact on interfaces

Impact on HR and personnel needs

Education and training needed for each department

Budget creation for the project

Who will monitor the vendors and payors?

Do not trust the statement that the vendor will be ready. Your agency cash flow could be dependent upon their planning, testing, and implementation.

Ask to see the vendor plan and monitor progress to general goal completion. When will the upgrades or new software be available?

Evaluate health plan readiness. Evaluate the impact of ICD-10 on usual and customary reimbursement fee schedules as well as episodic reimbursement.

Training and Education

You want to prevent agency claim rejections as well as delays in processes. You want personnel comfortable with new processes. You want to be compliant.

Each department will have different training needs. Obviously, the biller does not need the same level of coding expertise as a credentialed coder, but they require an understanding of the impact of the new coding on their particular processes.

The leader of this department will need to work closely with each department head as to specific training needs as well as the best methods of training. Additional assessments needed include: Can the agency provide all, some, or none of the training needed? What training method will work best for the learners? Will classrooms and teleconferences work best? Should they be augmented by web-based learning? Are inservices and seminars by experts another route to pursue?

Consider length of time for education and training. Some departments will require more training over a longer period of time.

Coders will need an indepth review of Anatomy, Physiology, Pathophysiology, Diagnostics, and Pharmacology. Each of these areas should be relational to disease states so that a comprehensive understanding of the new code application exists.

Whether you code inhouse or you contract with outside experts, be certain that parallel coding will occur for several weeks before the new codes are applied to the claims. October 1, 2014 should mean all training and education has been completed, processes have been reviewed and tested. Be certain that data analytics and infomatics are meeting the new specificity requirements.

Clinicians will need a solid understanding of the specificity of the documentation now required. They will need orientation to the more indepth assessment tools. Clinical cues as to diagnosis documentation requirements will be needed.  

Hopefully, vendors will be able to assist clinicians so technology can be leveraged to make up for the detailed documentation needed.

October 1, 2014 will be the ICD-10 implementation date. You have only 2 years to complete the Gap analysis, establish the Transition Team, create the transition plans, lead and evaluate training/education needs of all departments, create new tools needed, modify and test processes as well as review data created and have all processes in place to submit compliant claims. You need to start NOW! You only have two years and the clock is ticking.

 

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Posted in Billing, CMS, Compliance, ICD-10-CM Coding, ICD9-CM Coding, Therapy, Uncategorized | No Comments »

Missed and PRN Visits

Tuesday, June 28th, 2011

With the advent of the new Surveyor guidelines that went into effect May 1, 2011, the focus is data collection and outcome achievement moving away from the prior focus on process. Outcome achievement starts with a great assessment, careplan, and visit strategy that means adherence to physician frequency orders. What happens if the clinician misses a visit?

Missed Visit
In home health care under the CMS guidelines, a missed visit occurs when a scheduled RN, LVN/LPN, HHA, PT, PTA, OT, OTA, S/LP, or MSS does not keep an appointment with a patient.  Examples:  1) Because of an ice storm, a PT does not visit the patient as planned.  2) The RN wound care specialist does not visit the patient as she is detained with another patient.

If calls to the agency to apprize them of the situation and a call to the patient results in the rescheduling of the visit to maintain the physician-ordered frequency, then there is no missed visit.  The agency must communicate with the patient to ensure that his or her needs are met and there is no jeopardy.

Though the physician must be notified, there is no need to get an order.  The agency can notify the physician by phone, fax, e-mail, or mail. 

If no rescheduling within the physician prescribed frequency can be accomplished, then a call to the physician to apprize him/her of the missed visit is necessary and, in this case, a new order may be necessary.

Make certain documentation reflects the missed visit and is a part of the clinical record.

The Interpretive Guidelines for the Conditions of Participation, §484.18, discuss notification of the physician when a visit is missed.

PRN visit
A PRN visit is an additional visit or visits, ordered by the physician, that can be made when the  specifics of the identified care are warranted.

It must include a specified number of visits during a designated time (usually a certification period) and a specific reason or a delineated description of signs and symptoms necessitating the visit.  The reason for the visit must be anticipated and the frequency predicted based upon the assessment of the situation.  Reasons for a PRN visit might include the need to change a catheter, manage an IV, or reassess vitals if a B/P exceeds specific parameters.  Other situations might include a description of signs and symptoms that are linked to the patient’s specific medical condition, such as specific fluctuations in blood glucose readings. PRN orders can apply to any discipline if they are written specifically. Examples of complete, valid orders include:

2 wk 6 + 2 PRNs when blood sugar is over 280 then 1 w3 + 2 PRN visits when BS over 280 .

PRN visits can be denied if the order was found invalid/ lacking in specificity. Both the services and the number of PRN visits to be permitted for each type of service must be clearly identified as well as predictable.  CMS state that “Open-ended, unqualified PRN visits do not constitute physician orders since neither their nature nor their frequency is specified”.

CAHABA states,

PRN Orders

Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.2.2)

  • PRN orders are acceptable only when the orders are qualified for a specific potential need of the beneficiary and quantified to a specific number of visits to meet this need.
  • When a PRN visit is made, the date and reason for the visit should be explained in the medical record.
  • When an extra visit is billed and the plan of care contains open ended and/or unqualified PRN orders, an additional physician order must be obtained for the visit. If the agency does not have a signed interim order for the visit, the visit will be denied as in excess of orders.

Example 1: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders “Two (2) PRN visits per month for problems with the Foley catheter including blockage and/or leakage around the catheter.”  Visits are allowed because the physician specifically quantified the number of visits and qualified the visits to a specific need.

Example 2: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders include “PRN visits.” In this instance, since the orders are not quantified as to the number of visits or qualified as to a specific potential need of the beneficiary, no PRN visits are allowed.

Summary

Well written PRN orders and clear concise documentation supports patient need  The orders are acceptable (per CAHABA), if audited, when they are qualified for a specific potential need of the patient with a quantified  number of visits to meet this need. Make certain the physician is made aware of  PRN visit use, where appropriate. Also, be certain to inform the physician of trends in use of PRN visits which begin to identify a clear need for order frequency  modification.

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Posted in CMS, CMS Guidelines, Medicare, OASIS-C, PRN Visit, Surveys | 1 Comment »