Viewing posts categorised under: Clinical Practices

Prepping for PDGM

Clinical Practices, Coding, Payment Rate Updates, PDGM

Prepping for PDGM

PPS final rule increases agencies' payments for 2019, finalizes PDGM

Now in the third week of January, 2019 and the PDGM model will be here in less than a year. Medicare-certified home care agencies need to begin NOW to prepare for the 2020 transition to a Patient-Driven Groupings Model. The proposed PDGM model, required by the Bipartisan Budget Act of 2018, is intended to remove current incentives to over-provide therapy services and changes the 60-day episode of care unit of payment to 30 days according to CMS. Also, a new set of groupings for the patient – diagnosis and functional levels – will be introduced that determines the patient’s reimbursement for the new 30-day episode. The PDGM model is planned for implementation on January 1, 2020 (Harris, 2018). Home care agencies should focus on several areas within their agency in order to prepare for PDGM. The fits area of concern should be the referral systems. According to Home Health Care News' Kaitlyn Mattson, "CMS’ move to shake up case mix specifically in regard to referral source is, at least in part, due to data and the agency’s belief that patients coming from institutional settings are typically sicker and, thus, need more care and resources." Moreover, "“60% of referrals come from the community,” Gina Mazza, director of the regulatory and compliance division at Fazzi Associates, told HHCN. “Every agency needs to understand how they specifically will be impacted by this new payment model. This is an area agencies really need to think about—what’s my patient population look like? Where do my referrals come from? Are there opportunities for me to make any changes?” Mazza added, “Referral source is always an area agencies want to work on, cultivate” (Mattson, 2018). Another area is staff education which is key to smoother PDGM transitions. Supporting on-the-ground staff may be the key to an easier PDGM transition. “Having the resources available to do the education—to stay on top of making sure nurses understand and are able to still spend the amount of time they want with their patients while fulfilling all the new requirements [will be paramount],” Susan Adams, vice president and administrator at Masonicare Home Health and Hospice (Mattson, 2018). Now finalized by CMS, there will be a learning curve with PDGM until staff becomes more comfortable with the intricacies of the rule. Agencies need to set aside a significant amount of time and attention so they can work with staff, so that assessments and documentations are really tight, Joy M. Cameron, vice president of policy and innovation at ElevatingHom said (Mattson, 2018). Confused? Frustrated? Not sure where to begin prepping for PDGM? Don't worry. SelectData has you covered. Contact our Business Development team to find out how SelectData can help you smoothly transition into PDGM today! Call 800-332-0555 or email and ask about our PDGM solution today! Resources Harris, T. (2018). OASIS-D GG0100B OASIS Home Health - Prior Mobility Functioning and Physical Therapy. Home Health Blogger. Retrieved from: Mattson, K. (2018). PDGM Likely to Shake Up Patient Populations for Home Health Agencies. Home Health Care News. Retrieved from:

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CoP Interpretive Guidelines: Are You Compliant?

Clinical Documentation Improvement, Clinical Practices, Compliance, Conditions of Participation (CoPs), HIPPA

CoP Interpretive Guidelines: Are You Compliant?

Are You Compliant With CoP §484.60?

Home Health Agency Condition of participation (CoP) went into effect January 13, 2018 (CMS, 2018). However, some agencies are still struggling when it comes to Condition of participation (CoP). According to the CoP Interpretive Guidelines, to be compliant with CoP §484.60, home health agencies must have established standards of practice issued by a nationally recognized organization with expertise in the field. If your organization fails to meet these minimum standards when audited, you may be assessed a monetary fine or lose your Medicare certification.

§ 484.60 Condition of participation: Care planning, coordination of services, and quality of care.

Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.

(a)Standard: Plan of care.

Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan.

(2) The individualized plan of care must include the following:

(i) All pertinent diagnoses;

(ii) The patient's mental, psychosocial, and cognitive status;

(iii) The types of services, supplies, and equipment required;

(iv) The frequency and duration of visits to be made;

(v) Prognosis;

(vi) Rehabilitation potential;

(vii) Functional limitations;

(viii) Activities permitted;

(ix) Nutritional requirements;

(x) All medications and treatments;

(xi) Safety measures to protect against injury;

(xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.

(xiii) Patient and caregiver education and training to facilitate timely discharge;

(xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;

(xv) Information related to any advanced directives; and

(xvi) Any additional items the HHA or physician may choose to include.

(3) All patient care orders, including verbal orders, must be recorded in the plan of care.

(b)Standard: Conformance with physician orders.

(1) Drugs, services, and treatments are administered only as ordered by a physician.

(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications.

(3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies.

(4) When services are provided on the basis of a physician's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA's internal policies.

(c)Standard: Review and revision of the plan of care.

(1) The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. The HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.

(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care.

(3) Revisions to the plan of care must be communicated as follows:

(i) Any revision to the plan of care due to a change in patient health status must be communicated to the patientrepresentative (if any), caregiver, and all physicians issuing orders for the HHA plan of care.

(ii) Any revisions related to plans for the patient's discharge must be communicated to the patientrepresentative, caregiver, all physicians issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any).

(d)Standard: Coordination of care. The HHA must:

(1) Assure communication with all physicians involved in the plan of care.

(2) Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.

(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.

(4) Coordinate care delivery to meet the patient's needs, and involve the patientrepresentative (if any), and caregiver(s), as appropriate, in the coordination of care activities.

(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the u, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge.

(e)Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining:

(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA.

(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA.

(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services.

(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs.

(5) Name and contact information of the HHA clinical manager (Cornell Law School, 2018).

Need Help with your agency's Condition of participation (CoP) compliance?

For more information about how Select Data can ensure CoP Interpretive Guidelines have been met email or call 800-332-0555.

Resources Centers for Medicare & Medicaid Services (2018). Center for Clinical Standards and Quality /Quality, Safety & Oversight Group. Department of Human and Health Services. Retrieved from: Cornell Law School (2018). 42 CFR 484.60 - Condition of participation: Care planning, coordination of services, and quality of care. Legal Information Institute. Retrieved from:
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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CMS Finalizes PDGM: PPS Final Rule Increases HHA’s Payments for 2019

Clinical Practices, Healthcare, Legislation, Payment Rates, PDGM, Value-Based Purchasing

CMS Finalizes PDGM: PPS Final Rule Increases HHA's Payments for 2019

PPS final rule increases agencies' payments for 2019, finalizes PDGM

Wednesday, October 31, 2018, according to Decision Health, CMS has finalized a plan to launch a budget-neutral payment model for home health that utilizes 30-day periods of care and stops using the number of therapy visits to determine payment. That’s according to the 2019 PPS final rule posted Oct. 31 on the Federal Register website. The Patient-Driven Groupings Model (PDGM) will launch “on or after” Jan. 1, 2020, according to the final rule. That language differs from the proposed rule, when CMS indicated PDGM would start on Jan. 1, 2020 (Decision Health, 2018). Additionally, another major change with the final rule is that PDGM will have 432 HHRGs - which is of course double the number of HHRGs outlined in the proposed rule. Home health agencies have spoken and CMS has listened. The change is also likely to the 12 clinical groups that capture the most common primary diagnoses in home health. In the proposed rule, CMS only had sought six clinical groups: musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, behavioral health care, complex nursing interventions and medication management, teaching and assessment (MMTA) (Decision Health, 2018). CMS wrote, “We note that although we are categorizing patients into [12] groups according to the principal diagnosis, these groups do not reflect all the care being provided to the home health patient during a 30-day period of care,” CMS states in the final rule. “Home health care remains a multidisciplinary benefit. Additionally, as stated in the CY 2019 HH PPS proposed rule, we will continue to examine trends in reporting and resource utilization to determine if future changes to the clinical groupings are needed after implementation of the PDGM in CY 2020” (Decision Health, 2018).

Payments to Rise in 2019

Decision Health writes, "Adjustments to Medicare’s home health payments under the final rule will increase agencies’ total reimbursement by 2.2%, or $420 million. What this increase means is that the effects of a 2.2% home health payment update percentage are now reflected from a 0.1% increase in payments due to decreasing the fixed-dollar-loss ration mandated by the Bipartisan Budge Act of 2018. Additionally, in order to pay no more than 2.5% total payments as outlier payments, a 0.1% decrease in payments due to the new rural add-on policy by the mandate. In contrast, the 2018 PPS final rue included a 0.4% or $80, payment reduction. The PPS final rule for 2019 now opens the  door for home health agencies to get paid by Medicare Part B to administer home infusion therapy for certain payments who don't qualify for the home health benefit. However, that change would not benefit home health agencies until 2021.

Other Changes Finalized in the Rule

  • No more requirement for a physician estimate - On or after Jan. 1, 2019 the requirement that the certifying physician estimate are required to estimate how much longer skilled services are needed for continued care. Thank you CMS.
  • Value-base purchasing changes (again) - Among the biggest changes to value-based purchasing is CMS’ decision to remove two OASIS-based measures and replace three other, existing OASIS-based measures with two new composite measures designed to evaluate improvement in activities of daily living (ADLs) (Decision Health, 2018).
  • Remote patient monitoring update - It seems CMS is embracing innovation and modernization of health care by allowing the cost of remote patient monitoring to be reported by home health agencies as allowable coast on the Medicare cost report. CMS stated in the final rule, “This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data are shared among patients, their caregivers and their providers" (Decision Health, 2018).
Read the final PPS rule at: Resources Centers for Medicare & Medicaid Services (2018). Center for Clinical Standards and Quality /Quality, Safety & Oversight Group. Department of Human and Health Services. Retrieved from: Cornell Law School (2018). 42 CFR 484.60 - Condition of participation: Care planning, coordination of services, and quality of care. Legal Information Institute. Retrieved from:
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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CoPs Breakdown on the New QAPI Regulations

Clinical Documentation Improvement, Clinical Practices, Coding, Compliance, Conditions of Participation (CoPs)

CoPs Breakdown on the New QAPI Regulations

Adopt New Techniques

On January 13th, the rules for CoP's Quality Assessment and Performance Improvement regulations changed. Section 484.65 QAPI has replaced sections 484.16 (Group of Professional Personnel) and 484.52 (Evaluation of the agency’s program). The new section does a great deal to highlight the responsibilities of the agency's executive team and expects the governing bodies to focus on technology concepts like data- driven indicators to identify, track, and measure quality initiatives for high risk, high volume or safety issues. The program includes 5 standards: • Program Scope 484.65 (a) • Program Data 484.65 (b) • Program Activities 484.65 (c) • Performance Improvement Projects 484.65 (d) • Executive Responsibilities 484.65 (e) Program Scope Agencies are required to develop a data-driven QAPI program with measurable improvement indicators. The organization must measure, analyze, and track quality indicators including a patient’s adverse events, as well as other signs of performance to assess processes, services, and operations. However, it is not enough to just create the indicators. Agencies must use data to provide evidence that the improvement has led to improved health outcomes (ex: reduced hospitalizations, ED visits), safety and quality of care for patients. Program Data The QAPI program must utilize quality indicator data, including measures derived from OASIS that CMS has reported, to assess the quality of care provided to the patients and identify, prioritize, and manage opportunities for improvement. The QA efforts, including data collection, should focus on high-priority safety and health conditions. Like the program scope, data collected should support the quality measures and identify opportunities for improvement. Agencies will need to focus on those areas of past performance which have proven problematic for the agency over time or areas where there was clear evidence of poor patient outcomes as well as high risk and high volume. Program Activities The QAPI activities should include incidence, prevalence, and severity of problems in those areas. So that preventative actions and mechanisms can be implemented, agencies must track and analyze activities over time to ensure sustained improvements. Management should immediately correct any issues identified that directly or potentially threaten the health and safety of patients. Performance Improvement Projects The QAPI program requires that agencies performance improvement projects be conducted annually, at a minimum. The plan should reflect each agencies unique scope, complexity, and past performance. There should be clear documentation of the QAPI projects including the reason for conducting these projects and the measurable progress achieved. The agency’s governing body must define, implement, and maintain a program for quality improvement and patient safety that is ongoing and agency-wide. Executive Responsibilities The governing body for each agency is responsible for ensuring the QAPI reflects the complexity of the organization and its services, including contract and arrangement, are focused on indicators related to improved outcomes. They must also approve the frequency and level of detail in data collection. The governing body should establish clear expectations for patient safety and address issues in performance across the spectrum of care including the prevention and reduction of medical errors. For more information on this topic or on our Document review and Coding Services or Revenue Cycle Management, please call Select Data at 1.800.332.0555.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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Making the Most of Your Home Visits

Clinical Documentation Improvement, Clinical Practices, Coding, Conditions of Participation (CoPs)

Making the Most of Your Home Visits

Advocate For Your Patients and Yourself

The Clinician's Role Home health patients are often referred from a facility. Therefore, transitioning from a well-equipped, well-staffed environment to receiving care at home can be a daunting task for the patient and his or her care givers. Home Health clinicians play a huge role in making this transition go smoother. It is imperative that clinicians are strong in their communication, education, assessment, and leadership skills. With experience, clinicians will develop a skillset that assists in completing a visit systematically. With ever increasing regulatory demands and a growing senior population, it’s easy, especially for less experienced clinicians, to become overwhelmed during the flurry of activity that can happen during a home visit. From time to time even veteran clinicians should reevaluate their routines to make sure they are delivering excellent care while being efficient and methodical. This article has some tips to help clinicians evaluate and improve their routines. Accurate Documentation Visits need to be completed in a timely manner and in accordance with CMS regulations. Be sure to follow MD specific orders for admissions and/or discharges. OASIS item M0102 and M0104 (MD ordered SOC & Date of Referral) are process measure items and impacts star ratings, therefore accuracy is very important. Make sure your great care is well represented with great documentation. Be organized and have structure for the patient’s assessment and care. Set an appointment with the patient for visits. Consider the patient’s preference regarding the visit time. Their input may assist in a more productive experience. Once an appointment is set, plan accordingly. Map out the driving route to the home and consider any potential weather impact or road construction to prevent unnecessary delays. Prepare for the visit by reviewing all paperwork, including the referral and physician documentation. Knowing about the patient’s recent procedures, medical and social history, and current living arrangement will be beneficial. These topics are often discussed in the physician’s History & Physical documentation. Keep supplies organized, readily available for care during the visit to prevent wasted time. Once in the patient’s home, stay on task and have a plan. Remember why you are there and execute the job at hand, while also making the patient feel important and involved. Focus on the patient and their needs. Do not allow the visit focus to turn to anyone else. Build trust and a good rapport with the patient as the opportunities present themselves. Assist the patient in understanding what to expect. Be attentive to their concerns, but do not allow the visit to be consumed by Q & A. Remove distractions as needed. Personal distractions should be avoided, such as cell phones or a preoccupied mindset. Distractions within the home may also need to be addressed (for example: pets, a loud TV or music, too many people around). Go into every visit with end goals in place and conduct the course of the visit in a way to get closer to meeting those goals. If the visit begins to veer of off the course you have planned, politely redirect its path. Accurate Documentation Is Good For Patients and Clinicians  Paint a true picture of your patient and their living conditions. This can often lead to an MSW or therapy referral to meet types of needs that may never be identified in a facility setting. Remember, if it isn’t documented, it didn’t happen. Therefore always be thorough in this part of your care. Make eye contact as much as possible, but attempt to jot down important information that you are gathering as you go. Start observing as soon as you pull into the driveway. Look at the yard, front porch and the condition of overall surroundings for safety hazards and concerns. Note who answers the door. If it is the patient, assess their speech, gait, demeanor, etc. from the very beginning to assist you in your overall assessment. Observe the cleanliness of the home and how it may impact the patient and their care. Be aware of the other people in the home. Keep the patient’s safety and your own safety as top priorities. Make sure you speak clearly and in a manner that the patient can understand. Use common terms and explain procedures, plans, and paperwork. Exhibit warmth and empathy through your communication. Overcome barriers – speech, hearing, and vision then note whether specific therapy referrals are appropriate. Listen to the patient and address their needs, requests, and concerns. Their involvement in the visit, development of Plan of Care, and overall outcome will be determined by the visits. Communication extends to within the home health agency as well. Always provide a report time to other clinicians that will follow you into a home. It is also a good practice to attempt to inform the patient of who will be included in the care. The new Conditions of Participation place a strong emphasis on care coordination. Watch For Signs Patient safety is an essential factor that the visiting clinician must assess. Monitor family members to gauge any suspicious behavior that is indicative of abuse or neglect. Be aware of what the signs are of elder abuse. Be mindful of animals, especially dogs. Anticipate problems and position yourself close to the door with ease of exit at any point during the visit. Maintain your car and gas. Be available to leave on a second’s notice. Keep your cell phone charged and always have a plan. If a situation arises, stay calm. Do not be manipulated by anger, fear, or sadness. Plan the visit in a way that eases the patient into the uncomfortable subjects at the right times. Be empathetic by stating the obvious, that things are personal and somewhat uncomfortable to talk about. Make sure to document any behavior that is aggressive. Report concerning behavior to the Clinical Manager and physician, as these situations need to be addressed quickly to prevent escalation. Patients of advancing age fear the loss of independence. Assure your patient that they are still involved in their care and remind them of their rights. Being a provider can take a toll on someone physically, emotionally, and mentally. Take time off when needed and minimize the time you take work home. Don’t be afraid to ask for help or for a break. Advocate for your patients and yourself. References:
To watch Tips & Trips on Making the Most of Your Home Visits live presentation fill out your name and email address

Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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CMS Updates Pricer to Support Value Based Purchasing Model

Clinical Practices, Compliance, Healthcare, Payment Rates

CMS Updates Pricer to Support Value Based Purchasing Model

New Payment Adjustments to HHA's

The 2016 Home Health Prospective Payment System (HH PPS) final rule required the implementation of the Home Health Value Based Purchasing (HHVBP) Model in nine states that represent each geographic area in the United States. All Medicare-certified HHAs that provide services in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee and Washington will have their payment adjusted based on the HHA’s total performance score on a set of measures already reported with the Outcome and Assessment Information Set (OASIS) and the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) for all patients serviced by the HHA. Three new measures are included in which performance points are achieved for reporting data. The HHVBP Model, now finalized, will be tested by CMS and revisions are needed to update the HH Pricer program to accept the necessary adjustment factor and capture the adjusted amount on the claim record. MACs will place the HH VBP adjustment amount on the claim as a value code QV amount. This may be a positive or negative amount. The Pricer has been updated to reflect standardized payment amounts. CR 10167 requires that standardized amounts be calculated by Medicare systems and passed on to claims history databases using the field created for hospital standardized payment amounts. Standardized claims payment amounts are actual payment amounts adjusted to remove sources of variation not directly related to decisions to utilize care. Examples of these variations include hospital wage indexes, geographic cost indexes (GPCIs), incentive payment and penalty adjustments. CR 10167 requires system changes to ensure HH and hospice claims processing are consistent. CR 6550 created edits on hospice claims to ensure that G-codes for service visits are reported with the corresponding revenue code for the service discipline. Editing does not exist for HH claims even though the same G-codes and revenue codes are required. The system has been updated to include these edits. Providers should be aware that the MACs will return to the HHA the following claims:
  • Home health claims (TOB 032x other than 0322) reporting revenue code 042x if the HCPCS code is other than Q5001, Q5002, Q5009, G0151, G0157, or G0159
  • Home health claims (TOB 032x other than 0322) reporting revenue code 043x if the HCPCS code is other than Q5001, Q5002, Q5009, G0152, G0158, or G0160
  • Home health claims (TOB 032x other than 0322) reporting revenue code 044x if the HCPCS code is other than Q5001, Q5002, Q5009, G0153, or G0161
  • Home health claims (TOB 032x other than 0322) reporting revenue code 055x if the HCPCS code is other than Q5001, Q5002, Q5009, G0162, G0299, G0300, G0493, G0494, G0495, G0496
  • Home health claims (TOB 032x other than 0322) reporting revenue code 056x if the HCPCS code is other than Q5001, Q5002, Q5009, or G0155
  • Home health claims (TOB 032x other than 0322) reporting revenue code 057x if the HCPCS code is other than Q5001, Q5002, Q5009, or G0156
References The official instruction, CR 10167, /R3933CP.pdf
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CoP Compliance – You Can’t Do It Without Your Clinicians!

Clinical Documentation Improvement, Clinical Practices, Coding, Compliance, Conditions of Participation (CoPs), HIPPA, Uncategorized

CoP Compliance: You Can't Do It Without Your Clinicians!

CMS expects Conditions of Participation (CoPs) 100% Compliance on January 13th.

"January Funk" Shortly after ringing in the new year, people have been known to get the blues. Winters are cold, days are short, there’s not another holiday for months, and many people fall into what some call “The January Funk.” If you work in an industry that involves a lot of regulatory involvement, like healthcare, you may fall into a “January headache.” In healthcare, guidance, policy, and regulations are often updated, and new programs are launched at the beginning of the calendar year. For home health providers, saying “goodbye” to 2017 means saying “hello” to updated Conditions of Participation (CoPs) from CMS in 2018. After researching hundreds of pages of documentation, your head may be spinning as you lament over where to start. After all, just working in the home health business can keep your mind busy 24/7, never mind having more heaved onto your plate. With the new CoPs implementation quickly approaching, we’re in the warm up phase right now. If it hasn’t happened yet, it’s time for you to gather your team and start your pep talk. The success of any home health agency depends on teamwork. That’s now a new concept. Now is the time that your clinicians need to start wrapping their heads around how their life is going to be changing because of the updated regulations. Do you already have a plan in place for communicating to patients with limited English language skills? Do your clinicians know what the Patient’s Rights are? Since clinicians are just weeks away from having to give a verbal explanation of the Patient’s Rights to the patients, it’s time to start rehearsing. Clinician competency will be a key to your success, or the lack thereof will be the torpedo that sinks your battleship. Call your team together and let’s get the planning started. First, your team needs to know that these changes are coming, and that they are nothing to be afraid of. It seems that in healthcare when new policies (or regulatory changes) come around there is the feeling of impending doom. “What do we have to do now?” I recommend that you do an overview with your clinicians and let them know what exactly are the conditions of participation and why they are being updated. It’s time to discuss the paradigm shifts regarding CMS’s approach to patient care. It also may take a certain degree of convincing to get your long time veteran clinicians to buy into the idea of patient centered healthcare that is driven by the patient’s strengths and preferences. If your staff doesn’t buy into this new philosophy, there’s little chance that your patients are going to be convinced to shift their thinking. Eliminate Potential Anxiety For Your Clinicians After you get past the “why”, it’s time to get your paper out and start sketching out the “how.” Your clinicians need to clearly understand what part of their routine must change. What signatures do they need to get and when? What’s the phone number for the interpreter’s line? Are you going to publish your agency’s literature in different languages? How do you explain a patient’s right to people with different educational backgrounds and different cognitive ability? Your clinicians are much more likely to be compliant with the updated Conditions of Participation if you help eliminate some of the potential anxiety that accompanies change. Start talking about these things now. It’s not fair to throw clinicians into a new situation without the proper preparation. We’ve all been there, and we all know that it stinks to be there. Start coaching them now so they’re set up for success. Develop tools to get the job done right. Are there different fields that need to be custom added to your EMR so that the additional required information will have a home? If that’s not possible, you should work with your team to develop check lists (or worksheets) so that they are reminded of everything they need to ask or say during that home visit. Look at the tools you have now and decide what changes need to be made. When clinicians are forced to “do things on the fly” without the proper tools, they often find themselves jotting down random information in a disorganized and in a “non-HIPAA compliant” manner. Eventually, when this all of this becomes more familiar, your clinicians will probably develop their own system. While they’re just becoming accustomed to these new requirements, make sure they have the tools to be organized and efficient. Five-Day Window Coordination is a huge factor in the new Conditions of Participation. For coordination to be successful, good communication is a must. Unfortunately, communication is where many teams take shortcuts. The Clinical Manager role that is defined in the CoPs is immense. An agency’s Clinical Manager is only going to be successful if your team has a great communication plan. Communication about a patient’s care plan will be ongoing but it will be especially hectic at the time of admission. The communication plan among clinicians of different disciplines, multiple doctors’ offices, and the administrative staff, must be well thought out, organized and adhered to. Figure out how you’re going to manage all the information in the beginning five-day window, or your Clinical Manager may end up climbing out of the office window to escape. Practice, Practice, Practice! Finally, it’s time for your team to start practicing. There’s nothing that prevents you from implementing some of these changes before the beginning of the year. CMS expects you to be compliant with the updated Conditions of Participation 100% of the time on January 13th. Don’t wait until early one January morning to try and throw these ideas together. You’re not making a quick regulatory snack. You’re creating a huge feast of regulatory changes. Some of us know from experience that you shouldn’t be making your grocery list the day before Thanksgiving as your in-laws are in route to your home. Don’t wait until the beginning of January to bring in donuts for your clinical team so that you can “brainstorm this new thing.” Your clinicians are a key to your Conditions of Participation compliance. Invest in them. Train them. Listen to them. Invite them to join in on important conversations. Their success will lead to good patient outcomes. Isn’t that why we’re doing this after all? For more information about the implementation of the new Conditions of Participation please view our webinar from October. For more information on this topic or on our USA based Document review and Coding Services or Revenue Cycle Management, please call Select Data at 1.800.332.0555.
Related Article - CoPs Breakdown On The QAPI Regulations
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New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

Clinical Documentation Improvement, Clinical Practices, Coding, Healthcare, ICD-10 CM, OASIS-C2, Uncategorized

New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

CMS releases updates to the ICD-10-CM coding manual

Every October, the CDC and CMS release updates to the ICD-10-CM coding manual. These updates include both codes in the tabular and alphabetical indexes as well as official guideline changes. The following is a summary of some of those changes that Home Health Agencies need to know about.
  • Non-pressure ulcers now have 3 new code subcategories to include those ulcers that are down to the muscle or bone but do not have necrosis and for those ulcers that have tendon/ligaments showing. The clinician should always document the severity of the non-pressure ulcer in terms of skin breakdown, fatty layer, muscle exposed, muscle exposed with necrosis, bone exposed, bone exposed with necrosis, or other appropriate descriptive terms (tendon/ligament, hard eschar, slough obscuring wound bed, etc.).
  • C Diff is now being captured as being recurrent or not stated as being recurrent. Recurrence is defined by complete resolution of C diff symptoms while on appropriate therapy, followed by subsequent return of diarrhea and other symptoms after treatment has been stopped. Recurrence usually occurs within one week after treatment stops but may happen up to 8 weeks later. The physician would need to confirm whether C diff is recurrent or not.
  • Types of myocardial infarctions now play a role in determining the appropriate ICD-10 code. Type 1 is the most common MI which is associated with ischemia and due to primary coronary even. Type 2 MI is due to imbalance in supply and demand of oxygen. Type 3, (which we wouldn’t see in home health), is sudden cardiac death, including cardiac arrest. Type 4 MIs are associated with percutaneous coronary intervention while type 5 MIs are associated with a CABG procedure.
  • Secondary pulmonary hypertension diagnosis code has been further detailed to describe what the condition is that is causing the secondary pulmonary hypertension, including left heart disease, lung disease, etc.
  • Lumbar stenosis should be classified with or without neurogenic claudication. Neurogenic claudication is leg pain with walking. The physician must confirm neurogenic claudication for it to be coded.
  • Bowel obstructions can now be captured as complete or incomplete/partial. Complete bowel obstructions would need surgery to correct while incomplete/partial bowel obstructions can be sent home for it to resolve. The coding specialists need to know whether a bowel obstruction is resolved upon discharge from the hospital. Resolved conditions cannot be coded in home health except for in OASIS items M1011 and M1017 when they reflect the patient’s recent history.
  • New coding guidelines state that if a patient’s visual category is not documented then coding specialists can only code unqualified visual loss. It would be beneficial to query the physician to determine patient’s visual category to be more specific with coding of low vision and blindness. Also, the laterality of the low vision and blindness is necessary in retrieving the most specific code.
Along with these changes come the need for increased specificity for diagnoses. To assign specified codes, coding specialists rely on clinicians and physicians to provide adequate detailed information about each diagnosis being listed on the plan of care. Without this important step, coding specialists are left to code only unspecified diagnoses, which could impact reimbursement, or cause a delay in coding as a query may be necessary. To reduce queries to your clinical leadership and clinicians, here are some tips on being proactive with detailed information:
  • Query the provider for specifics that are not included in the physician documentation prior to completing assessment.
  • Specify sites and laterality of wounds
  • Specify etiology of wounds (surgical, traumatic, diabetic, arterial, venous, etc)
  • Query the provider for late effects of CVA if there are none documented in clinical paperwork
  • List the type of MI the patient experienced
  • Always document patient’s smoking/tobacco use status (current or history of, and what product)
  • Don’t list diagnoses on the plan of care that are not actively being addressed or impacting the plan of care
  • If there are diagnoses listed on the plan of care that will likely impact it, but no direct interventions regarding those conditions are present, document how they will impact the POC
  • Document if patient’s substance disorders are in remission per physician documentation or query to determine this.
  • Document the specific type of heart failure a patient has been diagnosed with
  • Specify which type of diabetes a patient has been diagnosed with, and what, if any, manifestations are present.
For the coding specialists to capture more specific diagnoses based on the clinician’s documentation, clinicians should document in the clinical note that this specific information was provided by the physician. Clinicians can document specificity but unless there is verbiage stating that the condition is physician confirmed, the coding specialists cannot code that specific condition. Select Data enjoys working closely with clinicians to provide the codes being captured in the plan of care. It is truly a team- work experience. If you have any OASIS review or Coding questions please call Select Data at 1.800.332.0555.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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The Clinician’s Role in Conditions of Participation (CoPs) Compliance | Select Connect with Clinicians

Clinical Documentation Improvement, Clinical Practices, Coding, Compliance, Conditions of Participation (CoPs)

The Clinician's Role in Conditions of Participation (CoPs) Compliance

Live Recording from October's Select Connects With Clinicians

In this session, attendees will be able discuss the importance of Conditions of Participation (CoPs) and compliance with Home Health patient care.

Conditions of Participation (CoPs) Compliance Overview:

    • A New Model for Home Health Patient Care
    • How did we get there?
    • Reducing Risk
To watch The Clinician's Role in Conditions of Participation Compliance live presentation fill out your name and email address

Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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