Posts Tagged ‘Home Health’

« Older Entries

HOSPICE 2014 Proposed Rule and CODING

Thursday, June 13th, 2013

Medicare Program; 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform

In the May Select Data ezine, we commented re the overall proposed rule. In this article, let’s discuss specifically the CMS clarification of a number of coding requirements.

Clarifying Diagnosis Coding in Hospice Claims 

The proposed rule solicits comments with the intent of clarifying a number of coding requirements in Hospice; especially regarding non specific diagnoses such as Debility and Adult Failure to Thrive (AFTT)

Longstanding policy requires that hospices as well as home health agencies adhere to ICD-9-CM coding guidelines.  CMS clarifies that hospice providers should not use certain non-specific diagnoses such as Debility and Adult Failure to Thrive which are essentially symptom syndromes and that, under coding guidelines, are not principal diagnoses. Claims submitted with these diagnoses would be returned to the provider, under the proposed rule, for a more definitive appropriate diagnosis. Hospices should code the principal diagnosis using the underlying condition that is the main focus of the patient’s care. However, Debility and Adult Failure to Thrive can be listed on claims as secondary diagnoses that can support prognosis, if appropriate.

According to the Proposed Rule, these actions are being taken as root causes are not being listed in at least 13.9% of Hospice claims where Debility has been the principal diagnoses listed on claims. CMS stated concern that individualized patient-centered plans of care are difficult to develop for patients with ill defined principal diagnosis and that the patient may not receive the full hospice benefit allowed.  CMS is interested in gaining a better understanding of those who are served by the Medicare hospice program.

What is the Impact of this Segment of the Proposed Rule?

Agencies should cease the use of Debility and Adult Failure to Thrive as primary diagnoses as, at the very least, the diagnoses are symptom codes and when used as a primary diagnosis, are not in keeping with ICD-9-CM Coding Guidelines. Instead, choose a primary diagnosis that is more descriptive of the patient’s disease and/or describes the disease trajectory and end-of-life palliative interventions.

Use other comorbidities and health conditions that support the prognosis, as needed.

Agencies should use, if appropriate, these Debility and Adult Failure to Thrive diagnoses in a secondary diagnosis position on the claim.

When assessing to code, remember to review the full Plan of Care to determine body system, signs and symptoms, psychological, emotional, and spiritual issues that have been identified as requiring the greatest need for palliative interventions.  Review physician orders as well as the medication profile. Each of these segments contribute to the primary and overall focus of care.

Patients under the Hospice benefit with ill defined diagnosis will soon have claims rejected under this proposed rule. Ill defined diagnoses and a POC that has changed little for a long period of time will soon be chosen for audit or claim denial. Don’t let your agency have claims denied because of poor coding. Take steps NOW!

Tags: , , , , , , , , , ,
Posted in coding, Hospice, ICD9-CM Coding | No Comments »

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 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.

 

 

Tags: , , , , ,
Posted in Billing, CMS, CMS Guidelines, Compliance | No Comments »

HIPAA Rules and the HITECH Act- Patient Privacy

Tuesday, April 30th, 2013

Compliance officers were awaiting the Office of Civil Rights (OCR) final rules on Breach Notification, Enforcement, and the modification to Privacy and Security Rules of HIPAA HITECH. Now that we have the regulations, it is time to review the basics in this ezine and additional requirements in the next article. HIPAA may be one of your largest potential liabilities for your agency.

Key Definitions

Protected Health Information (PHI)

  • Individually identifiable health information
  • Transmitted or maintained in any form
  • Created or received by a covered entity, business associate, or employer

Covered Entity

  • Health Care Providers
  • Insurers
  • Clearinghouses
  • Covered entities may only use and disclose PHI according to Privacy Rule provisions

Disclosures

  • Treatment and  payment sources
  • Individual has opportunity to agree or object
  • Limited data set (facially de-identified, requires data use agreement between parties
  • With authorization

HIPAA Privacy Rule controls privacy unless a state law is stricter.

Treatment

  • CE may disclose PHI for treatment activities to another healthcare provider

Payment

  • CE may disclose PHI to another CE or healthcare provider for the CE payment

Health Care Operations

  • CE may disclose PHI to another CE for specific activities such as QI

Authorization

  • Individual may authorize the release of the PHI in writing with the signature and data provided

Compliance Officers need to keep HIPAA and compliance in front of personnel. Finding ways to do that can be challenging but well worth the effort. For most organizations, some of their greatest risks are those tied to PHI.

Build security into hardware, software, and processes to the greatest extent possible. Make security provisions operate automatically where possible. When replacing manual processes with technology, validate the process and the fact that it does not increase risk. Technology for the sake of technology needs to be monitored also. Review your processes. Educate personnel to be privacy alert.

Build a meaningful HIPAA and Compliance audit system foundation that has value for the organization. It is mandated by the OCR.  Agency audits of organizations  began last year.  Remember, not having an audit program can be costly, the OCR state fine can go up to $1.5 million.

Required elements of a Patient Authorization

When reviewing the patient authorization, be certain it includes:

  • A description of the PHHI to be used or disclosed. Be specific
  • The persons authorized to use or disclose the PHI
  • The person or agency  to whom the CE may disclose the PHI
  • The purpose of the disclosure use
  • The patient’s right to revoke the authorization
  • The consequences if the patient refuses to sign
  • An expiration date of the form
  • Signed and dated by the patient
  • PHI may be re-disclosed by a third party and if a business associate, subject to the same HIPAA regulations
  • Must be written in clear language

HIPAA continues to pose a growing liability for agencies. Review agency policies, procedures, and processes now. More to follow on that topic

Tags: , , , , ,
Posted in HIPAA, HIPPA HITECH, PHI | No Comments »

Free Presentation Slides on Documentation, Edits and Auditors – Are You at Risk?

Wednesday, February 27th, 2013

We are happy to include for free this month a free downloadable presentation titled “Documentation, Edits and Auditors – Are You at Risk?”. This presentation is provided to assist you with documentation for compliant billing. Leave us a comment if you have one. We are always happy to hear from you.

 

Download Here –> Documentation, Edit’s and Auditors – Are You at Risk?

Tags: , , , ,
Posted in Presentations | No Comments »

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?

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

« Older Entries