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Billing Compliance, Q Codes, Edits and Audits: Compliance in the Home Health Industry an Update

Tuesday, May 7th, 2013

CMS revised the requirements on “April 19, 2013 to delete “and indicating whether services were added to the HH plan of care by a physician who did not certify the plan of care” from the Provider Action Needed” section of MLN Matters numberMM8136 Revised.

Implementation date remains: July 1, 2013

Please see the following updated article.

Statistical Data

Every time an OASIS is submitted to the state, portions of it may be parsed out to state, regional, and Federal groups such as the HEAT, MAC review groups, and Federal special projects in the DOJ and FBI. That means that when a review letter arrives, it may already be too late.

Each time a claim is submitted, it is being reviewed using sophisticated predictive analytics that review a number of indicators including: frequencies, certain HIPPS codes and now Q codes. Is your billing company or department aggressively assisting to protect you?

Each time a diagnosis code is assigned to a clinical record and attached to that patient claim, an audit can be triggered. Is your coding department aggressively assisting to protect you?

Alerts in billing, Q Codes, and with ICD-10 looming, are you prepared?

The Q codes

Recently, CMS issued Change Request 8136 that requests new data reporting requirements for Home Health Prospective Payment System (HH PPS) claims. It is to go effect July 1, 2013, Home Health Agencies (HHAs) must start reporting new codes indicating:

The location where services were provided

The location where services were provided should be reported along with the first billable visit in a home health PPS episode with one of three Q codes: • Small clarification in the wording, but it can mean a BIG difference. Q Codes will be required to identify where the services were PROVIDED not necessarily the place of residence. Note the difference in wording.

1.  Q5001  – Hospice oe Home Health Provided in a patient’s home/residence

2.  Q5002 – Hospice or Home Health Provided in an Assisted Living Facility

3.  Q5009 – Hospice or Home Health Provided in a place not otherwise specified (NO)

Further, changes in the location during an episode must be reported on the corresponding line to the first visit in the new location.

CMS’ requirement to report new Q codes and modifiers could cause claims denials and rejections for your agency. Industry leaders predict CMS auditors will use these new codes to target duplicate services for patients in an ALF.

The patient’s residence is where he or she makes their home. “This may be his or her own dwelling, an apartment, a relative’s home, a home for the aged, or some other type of institution. Refer to www.cms.gov/Outreach-and-Education/Merdicare-Learning-Network-MLN/MLNMatters/Articles/Downloads/MM8136.pdf.com for the entire update from CMS MLN.

These codes also can interrupt productivity if your agency does not have a process in place by July 1 for documenting these services and supplying your billing specialists with the necessary information. Select Data has been providing billing services to the home health and hospice industry for over 22 years. If we can assist, call us.

On another matter…EDITS

Per CMS, in a report released a while ago, the NHIC Corp Medical Review Department reviewed claims selected by three service- specific home health edits between July1 and December 31, 2012. The alert was entitled Home Health Prepay Results. These reviews have found continuing high error rates. The three edits are:

·         5ACO1- billing of the HHRGs 3AFK

·         5ACO2- billing the HHRG 1AFK

·         5ACO3- billing 5-7 visits for full episode

52% of the claims were denied. The top denial reason was 55H3A-skilled observation was not reasonable and necessary. This was the denial reason for 56% of the denials. They cite “CMS Publication 100-02, Medicare Benefit Policy Manual Chapter 7, Section 40.1.2.1 explains that nursing services for observation are covered when the patient’s condition is changeable. Once the condition stabilizes, the nursing services are no longer medically necessary.”

The next highest denial reason stated CMS. was no physician certification (about 15% of denied claims). “The face to face encounter must be documented by the certifying physician.” They referred to Publication 100-02, MBPM, Chapter 7, Section 30.5.1.

“Documentation not supporting the homebound status was the reason for denial in 14% of the denied claims. Reason code 55H2B is appended to the claim when the documentation does not support the patient is homebound.” This was the third most common denial. Homebound status should be one of the first things reviewed by the clinician and the first item reviewed by any coding specialist. If there is insufficient documentation to support homebound status or medical necessity, a coding specialist should not be coding this record as it does not meet Home Health regulations right from the start. Is this a requirement of your coding specialists? It is a standard at Select Data.

The fourth most frequent denial was “physician orders not signed timely.” Another reason found as a denial reason was that” therapy services were determined to not require a therapist.”

Agencies should be auditing records routinely for these errors as well as the completeness of the record. Consider developing or using a chart audit tool. A sample of such a tool can be found on the Select Data website. That tool may be modified for completeness to meet your agency specific needs.

The NHIC Corp Medical Review Department review of specific claims are not the only claims being reviewed. Palmetto GBA recently announced new medical prepay audits based on certain HIPPS codes that have the highest denial rates. While PGBA internally identified the top 20 HIPPS groupings that have the highest denial rate. Here are the two under specific review:

  • 2CGK*
  • 1BGP*

As an agency provider, you should be prepared for possible ADRs on claims with these HIPPS. When an End of Episode claim is submitted using one of the two above HIPPS groupings, Palmetto GBA may place the claims into ADR status and you will be required to submit additional documentation from the chart in order for a determination to be made on the claim either being paid or denied. If you have limited QA resources, these are the charts you may want to focus on.

PECOS is placed on Delay per CMS

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed.   These edits would have checked certain claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If this information were missing or incorrect, the following types of claims would deny:
• Claims from laboratories for ordered tests;
• Claims from imaging centers for ordered imaging procedures; and
• Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS.
• Claims from Part A Home Health Agencies (HHA)

CMS will advise you of the new implementation date in the near future. In the interim, informational edits will continue to be sent for those claims that would have been denied had the edits been in place.

Predictive Analytics for operations and clinical data

In home health care, predictive models are being used to exploit patterns found in historical and transactional data to identify risks and opportunities. The present models capture relationships among many factors to allow assessment of risk or potential risk associated with a particular set of conditions. The relationships should guide clinicians in their care plan decisions as well as care delivery. There are thousands of potential OASIS and coding combinations. Because of the patient profiles and patterns retained over the years, comparisons can be made readily. Add HHRGs and service information to the OASIS and diagnostic data and CMS can gather very significant data regarding your agency care delivery and outcomes. MANY analytic filters are utilized to screen the data.

The initial round of filters are termed MUEs (Medically Unbelievable Edits). These edits are the first predictors of fraud and can alert the Z-PICs of agencies that should be monitored. Auditors may monitor an agency for years, gathering data, analyzing data and patterns, and reviewing payments. The agency profile is completed.

This data and these pre-probe edits allow Z-PICs to have plenty of time to analyze data and monitor agency behaviors so that when they send a letter, they have already completed their initial audit and arrived at a solid conclusion.

Since experts state that 75-85% of all agencies are acutely unaware of business operations data and do not have necessary compliance rules built into or a part of their billing practices to protect them from wrongful claim submission. Agencies are at risk so questions must be asked. Who is auditing your clinical records and care, the ICD-9 coding, and the claim submission? Who is monitoring your data? Do you have clinical and operational benchmarks? In 2009, billing errors were found to have doubled. Be proactive now, because if your compliance rules and program are weak, you could be hearing from the Z-PICs soon.

If you are considering third party ICD-9 (soon to be ICD-10) coding or billing specialty services, consider Select Data, the Gold Standard in these services for over 20 years.  Call us at1.800.332.0555.

 

 

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Proper Coding, Homebound Status, and Awareness of Common Edits: Paid But Will You Retain Your Revenue? An Update.

Tuesday, January 22nd, 2013

No matter which MAC or RAC reviews your agency, high risk probes are on the rise. The intermediaries are mandated by CMS to monitor areas of greater risk. The RACs are paid by contingency on aberrant findings and their algorithms are making findings easier. When MACs or RACs find trends of concern they will launch probes. 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 certain numbers of episodes or number of visits.

In late 2012, RAC auditors began sending out chart requests expansively. They were and continue to target specific issues such as medical necessity, seeking to have those specific issues approved by CMS. Once approved, other RACs can investigate those same issues in their areas. One issue all RACs are looking at involves specific numbers of therapy in specific episodes with specific diagnoses.

NAHC’s Mary St Pierre, VP, Regulatory Compliance, identified in the fall of 2012, that Comprehensive Error Rate testing (CERT) contractor inquiries are also on the rise. The CERTs are the QA component of MAC billing. In addition, they also oversee Z-PIC claim payments and the denials issued. They are looking at Face to Face documentation of medical necessity and homebound status documentation.

The OIG remains focused on both home health and hospice citing “Six Measures of Questionable Billing” especially in home health.

The OIG has announced that, in 2009 and again in 2010, Medicare-Medicaid paid over $54 billion in improper payments. There have been 2500 persons/entities indicted from Federal health care programs. There have been 625 criminal actions with over 400 civil actions including actions involving the False Claims Act. There have been another 2400 investigations that yielded expected results. 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 missive. 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 review.

The Edits

Specificity requirements to support codes have always been expected but are being actively scrutinized now. Expect specificity and complexity to rise even higher with ICD-10.

Coding Specialists must also keep clients or their agency aware of edits and trend areas with insufficient documentation to substantiate proposed diagnosis.

A second recertification of Lymphoma will trigger a long used edit.

Recertifications with a primary diagnosis of Diabetes and a secondary diagnosis of CHF will be monitored if the edit continues after a 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, Schizophrenia disorders, or Long Term use of anticoagulants with no therapy ordered.

Claim Denial Potential

The above diagnoses run a great risk for denial because of probe edits and recertifications. Those records are reviewed also for homebound status. There must be “clear documentation that it is with considerable and taxing effort for the beneficiary to leave home, otherwise the episode or specific visits could be denied for lack of homebound status. (74% of ADRs reviewed for lack of homebound status were denied).”

Common documentation deficiency areas include lack of progress in:

* Repetitive clinical notes frequently seen stating the same things over and over with no 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 that reflect a lack of plan coordination

* Visit notes that 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 clinical 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, reteaching, and training needed

* The condition or disease symptomology has exacerbated or changed in another way

* 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, and no willing and capable caregiver.

Though we have heard this over and over, one of the most common home health reasons for denial is that the documentation does not support medical necessity.

Therapy is STILL under scrutiny

Functional ability improvement is expected or why is therapy present?

Therapy may be covered if the patient or caregiver received 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 2012-13 expectations are rigorous and denials are imminent if documentation is insufficient or inadequately substative.

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. Third party coding firms, like Select Data, monitor the FI sites, newsletters, and alerts to dig for present edits.

Agencies need to be aware the edits will increase over the next year 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 68,000 codes or a 400% increase in codes. Will there be a 400% increase in edits also? Will there be a 400% 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 coding specialists looking out for the specific documentation needed. Do you have the coding specialists that you need in place to assist you in protecting your justifiably deserved reimbursement?

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Posted in CMS, Compliance, ICD-10-CM Coding, MACs, NAHC, OIG, RACs | No Comments »

The Role of Compliance : Home Health and Hospital Readmissions

Tuesday, January 8th, 2013

This is THE topic one sees everywhere; trade journals, conferences, CMS, MLN, State Alerts, Home Health Associations. This topic is no longer just an operational and financial issue. Boards of Directors are looking to the Corporate Compliance Department and stating hospital readmissions should be part of the Corporate Compliance Plan.

More and more, leaders are demanding that the Corporate Compliance Officer be involved in evaluating the underlying causes for readmission and discerning the readmission issues.

Hospitals have put in place operational and financial impact reviews of readmissions into their facility within 30 days of discharge. The Affordable Care Act has required a number of measures be instituted to reduce hospital readmissions. Among these measures is the Hospital Readmission Reductions Program (HRRP) that regulates adjustment for payment to facilities with excess readmissions within 30 days of discharge.

Hospitals recognize that evaluation of the issue requires review of three phases of operation; admission/inpatient care, discharge/transition planning, and post-discharge care. The hospital compliance officer is beginning to look at each phase of care. They are beginning to have active involvement on the “Safety and Quality of Post Acute Care” Committees. These committees are looking at which agencies have the most readmissions and which physicians are involved. What diagnoses are seen most frequently and which medications are seen most frequently? Which agencies have overall compliance issues?

Smart Home Health Providers are viewing this as an opportunity. Not only can the agencies market their hospital readmission prevention programs; i.e. falls risk, heart failure, and medication reconciliation, but now is the time to market the home health agency corporate compliance program and theirleaders involvement in this program.

Hospitals usually do not envision compliance programs in home health agencies, even though they are strongly encouraged, they are not mandated by the OIG as

they are in the acute care setting. Positioning the home health agency as compliant, meeting the OIG required elements and also focusing on HIPAA, strongly states the agency parallels the hospital’s focus on compliance. It also non -verbally speaks to the agency’s root cause analysis approach to seeking solutions to problems. Since audit and prevention are required elements of a compliance program, the home health compliance officer can relay the home health agency’s approach to reduce hospital readmissions and discuss data infomatics leading to present programs and review of hospital readmission.

It is this type of collaboration that positions a home health agency as a future partner in new programs; i.e. ACOs, Patient Centered Medical Homes, and other Transitional Care Initiatives.

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Posted in ACO, Affordable Care Act (ACA), CMS, Compliance, Corporate Compliance, HIPAA, Home Health, Hospital Readmission Reductions Program (HRRP), Hospitals, MLN, Patient Centered Medical Homes, Transitional Care Initiatives | No Comments »

Summary of the CMS Released 2013 Final Rule

Tuesday, November 27th, 2012

Market Basket and Payment Rate Update

On November 2, 2012, CMS released the Medicare Home Health Final Rule for the Home Health Prospective Payment System 2013. The proposal includes the 2013 Market Basket Index (MBI) update of 2.3%, the required 1 point reduction under the Obama Affordable Care Act, and the reduction in rates of 1.32%, which is approximately a $10M decrease to payments for the home health 60 day episodes for 2013. The main change, per NAHC, from the July 5th proposed rule adjustment is an adjustment of the MBI from 2.5 to 2.3% occurring as a result of more current data. Proposed payment base episode rates are set at $2137.73 from a current $2138.52.

Though a small increase, the gain is that it is not the decrease CMS had proposed if  a full creep adjustment had been incorporated. The base rates are adjusted up by 3% for service to patients in rural areas.

 

LUPA RATES

For agencies submitting the required quality data, the LUPA rates are :

HH Aide $  51.79

MSS       $ 183.31

OT          $ 125.88

PT           $ 125.03

SLP        $  135.86

SN          $  114.35

 

For those agencies that have not submitted quality data, their rates will be reduced by 2 percentage points.

 

The outlier eligibility standards are changed from 2012. The Fixed Dollar Loss Ratio is lowered from 0.67 to 0.45. This will increase the number of episodes that will qualify for outlier payment.

 

Sequestration

Home Health agencies should expect payments subjected to a 2% sequestration, as part of the deficit reduction law. Though this is not a rate change, in and of itself, it will be a withhold of 2% from the claims payment. This is another  home health  reduction. Be prepared for expected significant changes for 2014 when CMS rebases the HHPPS rates as required under the Affordable Care Act.

 

Therapy

CMS finalized three revisions regarding qualified therapists completing a functional reassessment of the patient at the 14th and 20th visit and every 30 days.

 

First: CMS states that if a qualified therapist misses a reassessment visit, therapy coverage would resume with the visit during which the qualified therapist completed the late reassessment, NOT the visit after the qualified therapist completed the late reassessment.

 

Second: CMS states that in cases where there is multiple therapy disciplines involved, if the required reassessment by the qualified therapist was missed for any of the therapy disciplines, therapy coverage would cease for only the therapy discipline involved.

 

Third: CMS states that in cases where the patient is receiving more than one type of therapy, qualified therapist must complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and they must complete the 19th visit reassessment during the 17th, 18th, or 19th visit. CMS also states that in instances where the beneficiary receives more than one therapy type, if the frequency of a particular discipline does not make it feasible for the reassessment to occur during the specified times without providing an extra unnecessary visit or would delay a needed visit, then it is acceptable for the qualified therapist from each discipline to provide all of the therapy and functionally reassess the beneficiary during the visit associated with the discipline that is scheduled to occur closest to the 14th Medicare covered therapy visit, but no later than the 13th Medicare covered visit. Likewise for the 20th Medicare covered therapy visit but no later than the 19th covered therapy visit.

 

Thus, the revised rule states that if, in multiple therapy visit cases, the required reassessment was missed for any of the therapy disciplines, therapy coverage would cease only for that particular therapy. Therefore, as long as the required therapy assessments are completed timely for the remaining therapy disciplines, therapy services would continue to be covered for those therapy disciplines, unlike presently.

 

Face to Face

CMS finalized adjustments allowing non-physician practitioners in an inpatient setting to perform the encounter and inform the inpatient physician who can then become the certifying physician.

 

M1024

M1024, effective January 1, 2013, is to only be used for acute fracture codes for case mix points. Patient resolved conditions are not to be coded in home health. Citing Attachment D, CMS has clarified the only codes not allowed in homecare are acute fractures. These, then will be the only resolved codes allowed in M1024. Neoplasms, diabetes codes, neuro codes, and skin will no longer garner case mix points if placed in M1024, although CMS has stated an agency may continue to place resolved conditions in M1024 to present a more complete picture of the patient.

 

The final rule can be found at

http://www.ofr.gov/inspection.aspx

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Posted in Affordable Care Act (ACA), CMS, Face to Face Encounters, Home Health, LUPA Rates, M1024, Market Basket Index, Medicare, NAHC, Therapy | No Comments »

Long Term Care in Home Health Possibility Due to Class-Action Suit

Monday, November 26th, 2012

A nationwide class-action lawsuit brought by Medicare beneficiaries would eliminate the present CMS policy requiring Medicare beneficiaries to show a likelihood of medical and/or functional improvement before Medicare will pay for skilled nursing, physical therapy, speech therapy, occupational therapy, medical social services or home health aide. The proposed settlement of the suit would require Medicare to pay for such services based on the beneficiary’s need “to maintain the patient’s current condition or prevent or slow further deterioration regardless of whether improvement is expected.” The settlement will allow beneficiaries with chronic diseases to continue to receive home care with the belief that prevention of further deterioration and institutional care will be the result. This settlement can also reduce the cost of institutional care.

 

If the change is approved by the US District Court Judge in Rutland, Vermont, where the case was filed, the Medicare Benefit Policy Manual will require updated clarification that coverage for home care need not depend on the beneficiary’s condition improving. The changes would apply to both fee for service and Medicare Advantage programs.

 

Once the settlement is finalized CMS stated they will mount a nationwide educational campaign to alert providers and adjudicators on the changes in home health care reimbursement requirements. CMS stated they plan on a nationwide educational campaign involving both written material and interactive forums describing the new policy changes. Eventually, the Medical Benefit Policy Manual will be updated.

 

The Center for Medicare Advocacy in Willamantic, Conn. And the Vermont Legal Aid represented the beneficiaries in this case. Other plaintiffs in the case include the Parkinson’s Action Network, the Paralyzed Veterans of America, the National Multiple Sclerosis Society, as well as the National Committee to preserve Social Security and Medicare. The groups created a statement identifying that the proposed settlement would improve Medicare access to care “for tens of  thousands of Americans, especially older adults and people with disabilities, whose Medicare coverage is denied or terminated because they are considered “not improving” or being “stable” in care needs.

 

It is thought that payment for the extended services will come from payments usually made for institutionalized care but other consultants and agency leaders state home health costs could explode with CMS seeking ways to lower reimbursement for one area of home care in order to pay for this chronic care need. They also fear CMS may decide to seek aggressive co pays from beneficiaries who would not have normally sought institutionalized care because of lack of reimbursement capabilities, thus denying them of care the settlement proposed to provide. Others state this home care is needed for Medicare beneficiaries suffering from chronic diseases could actually save Medicare the dollars they have been seeking considering long term care facility costs are minimally $1500-$2000 each day.

 

To read more, visit:

http://www.medicareadvocacy.org/wp-content/uploads/2012/10/Proposed-Settlement-Agreement.101612.pdf

 

The legal comments by Elizabeth Hogue can be read at:

http://vnaa.org/vnaa/g/?h=html/doc/Elizabeth.Hogue_HH_Proposed_SettlementAnalysis.pdf

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