Posts Tagged ‘MICs’

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

Friday, May 17th, 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.   Per CMS and as per the Federal Register, “The  Coding Clinic by AHA is the US Official Clearinghouse for Coding.”

Agencies have hired coders, some are credentialed, some not.  All usually do not have audits of their coding compliance.  As a result, when asked, “Are you leaving dollars on the table?” most administrators pause.  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, but that is changing.  In the past, agencies have hired coders, certified or otherwise. Some coders are routinely reviewed and audited, most are not.  Most agencies rely on their coders. They put a portion of their financial welfare in the hands of unreviewed coders.  Lessen the worry regarding dollar loss and the quality of your agency coding by instilling specific processes. At the very least, contract for routine third party coding and billing audits.

If you were to use a third party coding firm, be certain they have external audits performed on their coding.  Quality third party coding firms should have quarterly internal audits and annual external audits completed in their firms. Who has audited them? What are the firm’s names?  Yes, the audits are an increase cost, but ar $e you losing 200-$400 per episode of care delivered? Are you flagging your firm for a RAC, MAC, or Z-PIC audit?

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 really 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 internal 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 as stated by an independent auditor.  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.

For more information, call 714.524.2500

ICD-9-CM Official Guidelines for Coding and Reporting

Effective October 1, 2008

The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S.

Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO).

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are includedon the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself.

The following are the CMS ICD-9 Site:

  1. CMS ICD-9 Site

  1. Attachment D

  1. Coding Clinic

Operational coding advice and guidelines for ICD-9-CM are published quarterly by the American Hospital Association (AHA) in Coding Clinic for ICD-9-CM (Coding Clinic). The Editorial Advisory Board (EAB) for Coding Clinic consists of representatives of AHA, the American Health Information Management Association (AHIMA), NCHS, CMS, the American Medical Association (AMA), the American College of Surgeons, and other hospital coders and physicians. Four of those parties (AHA, AHIMA, NCHS, and CMS) are identified as Cooperating Parties for Coding Clinic. The Cooperating Parties must agree on the coding guidance before it can be published in the Coding Clinic. Anyone may send issues to AHA for EAB discussion.

Expect CMS Unannounced Visits after Filing the Revalidation Application

Monday, April 30th, 2012

Do not be surprised if a CMS representative visits your agency after you apply for revalidation. Leaders are identifying that the visitors are taking pictures of the agency building and signage; taking pictures of the state license; as well as requesting copies of agency business documents.

Administrators and owners have cited the CMS representatives presenting CMS badges.  Some have termed themselves as revalidation inspectors, site inspectors, and Medicare representatives while others termed themselves as Medicare Fraud Inspectors. Be certain to obtain a business card and look at the CMS badge closely. But, if you have recently sent a revalidation application, do not be surprised at the visit.

In order to be compliant with the Patient Protection and Affordable Care Act (PPACA) Section 6401, all new and existing providers must be reevaluated under the new screening guidelines delineated in the Act. These new procedures are expected to reduce fraud and abuse. For some providers, the new screening procedures will be more intense, involving the unannounced site visits, fingerprinting, and owner background investigation. For others, such as publicly traded providers, site visits are not designated.

Three Levels of Risk Assigned

In early March, 2011, CMS began basing the above interventions on a rated level of risk. There are three levels of risk per CMS; “limited,” “moderate,” and “high.”

Limited -risk providers, such a physician practices. Because there will be verification that the provider is in compliance with Federal and State guidelines, such as current licensure verification and periodic database checks prior to and following enrollment, the practices are rated limited-risk.. Also, included in the limited -risk category are ambulatory surgical centers, Indian Health Service Centers, mammography screening centers, and rural health clinics.

Moderate – risk providers, can anticipate unannounced visits. This level of provider includes community mental health centers, hospice organizations, and comprehensive outpatient rehabilitation facilities (CORFS). Home health agencies had been placed in this category however,  CMS has recommended this group to be moved to the high risk category.

High – risk providers will be expected to have unannounced site visits as well as fingerprinting and thorough background reviews. Providers in this category include new DME companies and new home health agencies.

Limited and moderate risk providers can be moved to high-risk under various conditions including: allowing one provider to use another provider’s identifier within the CMS program or if a provider has had their billing privileges denied within the last 10 years.
Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) CR 7350 provides the complete list of these three screening categories, and the provider types assigned to each category, as well as a description of the screening processes applicable to the three categories  and procedures to be used for each category. Have your state license posted. Make certain signage is clear.  Demonstrate your compliance with regulation.

We have all read about the stated recent fraudulent activities involving 78 Texas agencies and a physician who, allegedly bilked hundreds of millions from CMS. This new regulation is an additional attempt to minimize the risk of that type of fraud and abuse

To learn more about this new rule, visit:

The Surveillance and Utilization Review Subsystem (SURS)

Thursday, April 26th, 2012

Predictive Analytics or Provider Profiling? Call it what you want, is your agency being monitored by CMS and/or state Medicaid etal? And, have you directly triggered an alert? Or, are physicians that sign orders for your agency patients being investigated?

Should you be aware that your agency could trigger a PPS RAC, MAC, or Z-PIC audit and that a related party or a referral source under review could trigger an audit of your agency? Yes, that could be a reality.

CMS and related agencies are using predictive analytics to identify aberrant care delivery and utilization patterns for PPS. At the time the claim is dropped, an assessment of multiple patient factors is conducted. These factors may include diagnoses, frequency, and disciplines involved in care. Your agency practice patterns are now being compared to peer groups and may include a comparison to validated benchmarks. Physicians who refer to your agency may be having their practice patterns monitored also, especially if the payor source is Medicaid.

The Surveillance and Utilization Review Subsystem (SURS) is responsible for monitoring claims process for Medicaid, seeking indicators of fraud.  They look for duplicate, inconsistent, or excessive visits in relation to diagnoses and visits provided in State systems.

Section 456.25 of Title 42, Code of Federal Regulations writes that “States are required to have a post-payment review process that allows State personnel to develop and review: (1) recipient utilization profiles, (2) provider service profiles, (3) exception criteria; and (4) identifies exceptions so that the agency can correct misutilization practices of recipients and providers.”

No two state Medicaid systems are the same, thus, there are a variety of post- payment review SUR systems. Some state systems are routinely using tools that can statistically use random sampling with extrapolation for provider reviews. This allows the auditor to identify a current trend and apply the findings retrospectively for a specific past time point. Recoupment dollars can add up quickly using this methodology.

The SURS are also using tools that flag inconsistencies and over-utilization of visits in relation to care delivered at those visits. At times, they may be focusing on specific discipline practices.

States have different practices.  Personnel in the New Hampshire Surveillance and Utilization Review Subsystem (SURS) monitor financial claims for the NH Medicaid plan. SURS review provider claims for fraud, waste or abuse and may refer cases under suspicion to the Medicaid Fraud Unit of the State Attorney General.

The unit also recovers overpayments by using predictive analysis algorithms that search its data warehouse for aberrant claim information. “In addition, SURS in New Hampshire also conducts reviews to determine if recipients are inappropriately using certain types of medications.” This can trigger other areas of investigative need.

Some states are querying relational databases which provide flexible and easy access to years of paid claims and the ability to query real time data along with trending patterns and profiles.

The SURS also use exception profiling as a starting point for case development. Ranked reports can quickly identify outliers. A sample profile might include the following elements:

-Average patients per agency

-Average reimbursement per agency

-Average disciplines per patient

-Average diagnoses per patient

-Average number of patients with labs

-Average number of patients with injections

-Evidence of upcoding

-Evidence of downcoding

Medicaid is monitoring payment for care and now closely monitoring physician practices. Agencies need to be certain that they strictly adhere to the regulations for care provision. A physician who is being monitored now can bring review and audits to those for whom he or she may provide referrals.

Compliance risks have always existed. But now, agencies need to expand those risk mitigation practices to their referral sources as well as their marketing departments. Be certain you and your referral source philosophies are similar.

Quality oriented physicians are also seeking agencies with like philosophies. They too want to improve the patient transition of care.  The bad press regarding 78 Texas home health agencies and the linked Texas physician has raised some physicians concerns nationally re this industry.

Showcase your agency quality programs and excellent outcomes.

  • Work to improve bi-directional communication flow.
  • Establish points of accountability for sending and receiving patient information.
  • Increase the use of case management and professional care coordination.
  • Develop performance measures that encourage better transitions of care that are well documented.
  • Let it be known that your agency supports a strong regulatory culture that offers accountability and effort toward solid patient outcomes.

That well-stated philosophy and agency culture exhibited through employee conversation, patient care, and marketing materials tells all stakeholders involved that your agency strives to be a quality-oriented care delivery provider.

ACOs and Patient Centered Medical Homes: Home Health, Have You Prepared?

Wednesday, February 29th, 2012

CMS has, for years, suggested to healthcare providers across the care continuum that they must refine old and create new methods of providing care. Providers are expected to collaborate and coordinate to minimize the fragmentation in healthcare. They need to work together to improve care delivery, efficiency, and effectiveness. Home health care providers should be aware of the new Chronic Care Management Models that include Accountable Care Organizations (ACOs) (see Select Data ezine, January, 2012 ) and Patient Centered Medical Homes (PCMH).

Through collaboration amongst stakeholders, with coordination of expensive chronic care, and with partnership developments, strategic alliances are being encouraged. Is your home health agency ready? What specific programs do you have in operation? Are they evidenced-based? What have been the outcomes? Do you have reliable statistics?

As stated in the January, 2012 ezine:

“Home health agencies should be paying VERY close attention to the latest requirement for home health found in the Affordable Care Act. The Act encourages development of Accountable Care Organizations (ACOs) and provides for “incentives to enhance quality, improve beneficiary outcomes and increase value of care.” (CMS Q&As Section 1899 of Title XVIII)  The ACO becomes a type of managed care organization that may use fee-for- service or capitation payment, and is accountable to patients and the third party payor for the quality, appropriateness, and efficiency of the care provided. Because of the Affordable Care Act, CMS must have an ACO in place by January, 1, 2012.

Some home health agencies have begun aligning with physician offices, hospitals, rehabilitation facilities, and long term care providers to coordinate care across the health care continuum. Home health agencies are becoming members of hospital teams in both general and specialty areas. Agencies which cannot seem to form the alliances may find themselves with declining referrals in the near future. Home health needs to demonstrate their personalized approach to care so they may be appealing to the PCMH team.

Home health agencies should be encouraging discussions among provider leaders of all levels of the care continuum. Patient ultimate outcomes should be shared by all providers. Establishing those mutual patient outcomes is a primary step in a strategic alliance between ACOs and PCMHs.

Hospitals know that the bundled payment pilot begins January, 2013. It is expected that hospitals will be responsible for the patient three days prior to hospitalization, during hospitalization, and 30 days after hospitalization. They will more likely want to work with agencies with proven hospital reduction programs, quality care clinical programs, and positive patient outcomes. Agencies with those types of programs are already aligning to form care transition models to be ready to bill the new CMS ACO.” (Select Data ezine, 1/2012)

Hospitals are also expected to be working closely with primary care practices which have the PPC- Patient Centered Medical Home Recognition. Many practices approved using the 2008 Standards have now applied to meet the 2011 National Committee for Quality Assurance (NCQA) Standards.

The PCMH is defined by NCQA as an innovative program for improving primary care using clear and specific criteria centered around patients and their care needs, working in teams coordinating and tracking care over time. The PCMH program is for practices that “provide first contact, continuous, comprehensive, whole-person care for patients across the practice.” (NCQA, 2011)

Per the NCQA:

“The Patient Centered Medical Home is a health care setting that facilitates partnerships between

individual patients and their personal physicians, and when appropriate, the patient’s family. Care is

facilitated by registries, information technology, health information exchange and other means to assure

that patients get the indicated care when and where they need and want it in a culturally and linguistically

appropriate manner.”

The PCMH is being touted as an excellent way to improve healthcare in this country by “transforming how primary care is organized and delivered. The Agency for Healthcare Research and Quality (AHRQ) defines the PCMH as a model of the organization of primary care that delivers the core functions of primary health care.”

The Patient Centered Medical Home must encompass five core functions and attributes:

  1. Comprehensive Care: The PCMH is accountable for meeting “the large majority of each patient’s physical and mental health needs, including prevention and wellness, acute care, and chronic care.” To meet required standards, comprehensive care must include a patient-centered team that may include physicians, nurses, PAs, pharmacists, social workers, and care coordinators. Large primary practices may have large teams while smaller practices may “link themselves and their patients to providers and services in the community” (NCQA, 2008).
  2. Patient Centered: The PCMH must provide “primary care that is relationship-based with an orientation toward the whole person.”  The standards require a partnering with patients and families that demonstrates an understanding of their unique needs, values, and preferences. The PCMH primary physician and team are expected to assist patients to manage and organize their own care.
  3. Coordinated Care: Care is required to be coordinated across “all elements of the health care system.” This care is considered critical during transition between levels of care with clear and open communication.
  4. Accessible Services: The PCMH is expected to deliver care in shorter timelines with individualized hours of care and 24/7 phone or electronic access to a member of the PCMH team demonstrating responsiveness to patient needs.
  5. Quality and Safety: The PCMH is committed to quality and quality improvement with ongoing evidence-based medicine and “clinical decision-support tools to guide shared decision making with patients and families.

CMS believes that for too long patients have been provided care by disparate systems; a hospital here, a home health agency there, and yet long term care over there. An ACO (created by health care reform law) is expected to include a broad network that will share responsibility for providing care. The ACO must be able to show they can provide care better than the singular services. Home health agencies should consider establishing patient populations of mutual interest and present evidence-based practice interventions that are likely to improve quality, diminish decline, and improve patient satisfaction not merely in one level of care but across that continuum.  NCQA released its ACO Accreditation Standards in 2011.The NCQA approach to ACOs emphasize patient-centered primary care; use of measurement techniques that improve health care, and high standards for care coordination.

The CMS ACO initiatives were launched January 1, 2012, but ACOs were already being explored not only for Medicare but for other payor sources as well.  ACOs, theoretically, would make the providers jointly responsible for care and offer incentives to achieve quality outcomes yet, make a profit. There would need to be a seamless way to share information.  They would encourage standardizing care to reduce variable clinical practices. It is expected that those who would achieve the quality and financial goals would retain a portion of the savings.  The amount or percentage is yet to be determined.

To work together with agencies with like values, goals, and evidenced-based processes could challenge present regulation. Would this mean the regulation regarding the hospitals discharge policy involving a referral list of local agencies would be changed? It would seem that would be needed since the hospital would be working with agencies that were a part of their ACO. Also, under a hospital led bundled payment, hospitals it would seem, would want to transition patients to agencies with specific programs in place to prevent readmissions. Agencies should be developing programs NOW that can significantly reduce emergent and inpatient care. Outcomes will play a larger role as to which agencies will be chosen as ACO members.

NCQA views primary care as the foundation of the health care system. The primary care physician/team is frequently the first point of contact. The NCQA new standards require a patient survey to help drive quality improvement. It also requires involvement of patients and family in quality improvement. In addition, tracking care over time is necessary. Reducing fragmentation, involving patients and families actively, while transitioning through levels of care is a primary goal of the PCMH and the ACOs.

Home health agencies should be prepared to statistically present outcomes and be ready to participate actively in devising a plan for sharing information. The need to dramatically alter home health care delivery is upon us. Agencies need to be prepared for this change. Be open and receptive to collaborative practices. Be prepared to assist in standardizing teaching and discharge planning instruction. And one other point: CMS is subtly suggesting that discharge planning will soon evolve into transitional planning as the patient moves from one level of the care continuum to another. Be prepared for that transition or face the potential consequences.

Before and after home health care could well be the PCMH. Home health agencies may need to blend into that model. No matter what, data, statistics, and analytical analysis will be vital and an integral part of any Chronic Care Management Model. Are you prepared…or preparing?

Auditors are Making Their Presence Known: Prepare for RACs, MACs, and Z-PICs

Wednesday, February 29th, 2012

Because we have received calls asking about RAC audits, we have included a PowerPoint regarding RACs and suggested below preparation you may consider doing NOW. We are also re-releasing segments of a prior ezine.  Click here to view PowerPoint slides


Below are some questions that you may already know, but of course, need to know about your agency and delivery of service:

What are your agency case mix averages by admission?  by clinician? by diagnosis?

Do you know your top five diagnostic patient profiles?

How do you set visit frequencies? Formula-based or just “what seems right” or a formula plus reflective clinical assessment?

Are you making visits that have no impact on patient outcomes?

Are you auditing for homebound status?

Are you auditing documentation for medical necessity?

What is your cost per visit by discipline?

What is your recertification percentage?

Do you know your supply utilization per patient?

Does supply usage have adequate supportive documentation?

Do you know what coding, operational, or billing edits you are routinely triggering?

How are you applying the data collected to your business processes?


The RACs, MACs, MICs, and Z-PICs are now in place. The auditors are expected to perform. They have been chosen based upon performance.

Algorithms and Matrices are in place using Predictive Analytics.

Per Wikipedia, predictive analytics “encompasses a variety of statistical techniques from modeling, data mining and game theory that analyze current and historical facts to make predictions about future events”.

CMS is using predictive models to identify patterns found in transactional data gathered to identify risks and potential future behaviors.  They are looking at diagnoses in relation to visit frequencies and recertifications. They are looking at HIPPS scores compared to visit frequencies and durations. They are looking at predictive models that capture relationships among many factors to allow assessment of risk or potential associated with a particular set of assessment/care frequency/payments expected. In other words, what are the guiding decision-making factors for agency transactions? This is one reason why there needs to be rhyme and reason for visit frequency and patient diagnoses and care needed.

Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future. That behavior is then compared to other agencies’ behavior in order to calculate risk, then encompasses models that seek out subtle data patterns that  answer questions about that agency’s overall  performance. These analytics quickly become fraud detection models.

The MACs are using predictive models to perform calculations during live transactions to evaluate the risk or opportunity of a given agency transaction, in order to guide a decision. Individual agency modeling systems can simulate likely human behavior or reaction to specific situations.  The new term for animating data specifically linked to an individual in a simulated environment is avatar analytics. Hopefully, CMS is not there yet but gaming experts ARE employed by CMS.

The government is serious about attacking fraudulent behavior. The danger that exists is that some agencies not intending to commit fraud, but who are not auditing their data submitted, may be triggering alerts. Home Health Agencies can no longer afford to provide care without auditing the assessment, the care predicted, and the care provided.

The RACs have also identified that insufficient documentation for medical necessity will be one of the first area of focus for their audits. But, no agency should believe that only therapy documentation will be scrutinized. Skilled nursing with observation and assessment O/A continues to be high on the list for visit and episode denials.

What happens if compliance measures are not employed? Targeted Medical Reviews (TMRs)/(ADRs) Additional Documentation Requests will rise. There will be claim denials and Medicare audits.

CMS has Unleashed the Auditors

Annually, CMS receives 1.2 billion claims. That breaks down to 4.3 million claims per work day, 574,000 claims per hour, and 9,579 claims per minute. Fraud and abuse are on the rise and the pressure is on.

CMS has unleashed the age of the auditor with the advent of the RACs, MACs, CERTs, MICs, Z-PICs, and now, the HEAT.

RACs- The contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, mostly due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, these auditors are expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only 22 cents for every $1.00 recovered. They are now in place and ready to go at measure. Certain RACs have been held back until all MACs were in place. That is now completed.

MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There are 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for over payment estimation of claims (current and prospective focus). MACs have power and Congress is encouraging them to use it.

Z-PICs – Zone Program Integrity Contractors will perform Medicare Program integrity functions for CMS. They will interact with each MAC to handle fraud and abuse issues within their jurisdictions. ZPICs are seen to consolidate the work of present CMS Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) and are divided into 7 zones.

The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time.  That power can cripple or financially devastate an agency.

CMS states that their mission includes, “providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and the private sectors.”

Can Audits be Prevented?

Maybe not, but exposure for paybacks can be limited by enacting solid compliance measures.

Prepare now. Be aware of what other providers have faced with auditors.

Be certain a clinical documentation chart audit is available for all disciplines for clinical records.

The following items should be included in every clinical note:

Homebound status: Identify what taxing effort was exerted if a patient left the house since the last clinical visit. Be certain all assistive devices are listed and/or the caregivers needed, the purpose for leaving the home, and if this was expected and/or a part of the careplan.

Identify what skilled the visit. If teaching was conducted, was it initial teaching, reinforcement teaching, or was it re-teaching? Identify in objective terminology measureable progress towards goals; ie for the psych nurse, what evidence toward cognitive structural behavior was identified? For physical therapy, how many feet were walked since the last visit and where does this relate to the plan? For the SN, did the patient identify at least two key side effects for their medications? Does the patient know what their medication is for and what it is expected to do for them? Do they know how to safely take their medications?

Compare the Visit Notes to the POC: Compare the visit note to the plan of care that is developed by the clinician based upon the assessment. Have physician orders or notification for changes in condition. Note all change of condition clearly.

SN should be reviewing the body systems noting VS and pain assessments.

When Teaching: Note if the teaching is New, Reinforced Teaching, or Reteaching of the same subject to, perhaps, another caregiver. Note the caregivers willingness and capacity to learn and carry out the learning skills. Note the patient and caregiver’s learning in percentage; ie 10% or 70% or 80%.

Interdisciplinary communication: Comments to the physical therapist or the home health aide or other disciplines should be clearly noted. The visits should show the progress of the care in relation to the plan of care.

Specificity of wounds, skin conditions, falls risk, depression, and the focus of care are necessary. Auditors look for detail; for reasons that support skill. No skill can mean denial of visit payment.

For Diabetics Receiving Insulin


Be certain homebound status is clearly and adequately documented.

Skilled Visits must have skill identified such as specific instructions.

Return demonstration responses by the patient or caregiver should be documented. Note the patient or caregiver’s ability to follow their diet. Give examples to support diet and meal planning learning.

Caregiver willingness and availability should be specifically noted on each visit.

More Strategies

Review all claims against known edits prior to submission.

Have a system that prevents claims from being submitted without a signed physician order.

Counsel and hold clinicians accountable for accurate, complete, and concise documentation that matches the planned care expectation.

Clinicians must now be aware that surveyors are looking at their assessments, discipline specific plan of care, the overall plan of care, the visit documentation outlining care provided and patient response, and the outcomes at the episode conclusion. The diagnoses listed in M1020/M1022 must be compliant with ICD-9 coding guidelines, be unresolved, must read as the table of contents for the clinical record, and must be supported by the clinical documentation.

RAC auditors use clinicians and coders on their team to provide more specific auditing. Ask your clinicians: could their visits withstand that kind of auditing review?

Consider peer review sessions at your agency. Proud clinicians want their peers to think highly of them. Peer Review audits can be an excellent defense against a RAC audit and can be enlightening to clinicians as to what is expected as well as a motivation for excellence.