Viewing posts categorised under: Frequently Asked Questions

Home Care and Home Health…What’s the difference?

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Frequently Asked Questions

Home Care and Home Health…What’s the difference?

Skilled care givers verus unksilled care providers. Which type are you looking for?

 
Home health care is an umbrella term that describes a wide range of health care services that can be provided in your home. Home health care can be divided into two additional descriptors “Home Care” and “Home Health” Home Care describes unskilled care provided by caregivers, usually referred to as home health aides, personal care givers, or homemakers. These individuals are trained in the intricacies of senior care. Home care aides can provide assistance with activities of daily living or provide companionship. Home care is classified as personal care or companion care and is not considered “skilled” care. Home Health is a phrase that describes clinical medical care provided by a Registered Nurse, Occupational Therapist, and Speech Therapist, Physical Therapist or other skilled medical professionals. Home Health is typically prescribed as part of an interdisciplinary, multi-setting approach to medical care following an acute illness, exacerbation of chronic illness or surgery. The fundamental difference between Home Care and Home Health is who pays for the service. Due to its unskilled nature Home Care is typically privately paid with some state programs providing assistance with the cost. Home Health is a service that is paid for by Medicare, Medicaid and private insurance. Agencies can find it difficult to meet the regulatory demands of the Centers for Medicare/Medicaid Services (CMS). CMS doesn’t recognize the patient as Jane Smith but instead views Jane Smith through a series of codes. These codes are diagnosis codes, OASIS items, G-codes from claims, and procedure codes. These codes are also used in different formulas that are important in measuring outcomes and re-hospitalizations. Select Data provides professional coding services to Home Health agencies and are industry experts in the language of CMS. We assist agencies with the accurate representation of their patient. To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services click here.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. 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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Good Coding v. Bad Coding: What It Could Mean For Your Agency

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Coding, Frequently Asked Questions

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 co morbidities. 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.  

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How will the new RAC audit group affect my agency?

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Frequently Asked Questions

Four regional Recovery Audit Contractors (RACs) presently conduct audits for CMS for all levels of healthcare: hospitals, physician groups, home health, and others billing Medicare and Medicaid. In the summer of 2013, CMS announced the appointment of a new RAC audit group focused exclusively on home health, hospice, and DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies). The new RAC is to be operational this year, 2014. RACs, in general, have an interesting history. Using the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and the Tax Relief and Health Care Act of 2006 (TRHCA) to fight fraud and abuse, CMS was granted the authority to make recovery audit contractors a permanent nationwide program, but only after demonstration of effectiveness. MME directed the DHHS to demonstrate the use of RACs in identifying underpayments and overpayments, as well as in recoupment of overpayments under the Medicare program. A demonstration program was initiated. From the inception of the RAC demonstration project through March 27, 2008, providers appealed only 14% of the RAC determinations. Of those appealed, only 4.6 % were overturned. Over $1.3 Billion was recovered.  As a result of the RAC findings, Congress required the DHHS to make the RAC program permanent and nationwide by January 1, 2010. Four RAC Regions were chosen and four RAC audit groups appointed.  Region A was assigned to Diversified Collection Services headquartered in Livermore, CA with the RAC department address in San Angelo, TX. Their contingency fee was placed at 12.45% of dollars recovered.

  • States covered include: Connecticut, Delaware, Maine, Maryland, Massachusetts, New York, New Jersey, Pennsylvania, and Rhode Island
Region B was assigned to CGI Technologies and Solutions of Fairfax, VA. Their contingency fee was placed at 12.50%.
  • States approved in Region B re Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin.
Region C was assigned to Connoly Healthcare headquartered in Atlanta, GA. Their negotiated contingency recovery fee is 9%.
  • States in this region include Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.
Region D was assigned to Healthdatainsights headquartered in Las Vegas, NV with a contingency fee of 9.49%.
  • States assigned to this region included Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming.
The new RAC audit group will cover all home health, hospice, and DMEPOS throughout the US. It is anticipated that there will be similar regulations and processes. Presently, there are two types of RAC reviews termed automatic and complex. The automatic audit requires no person to review the records because a computer generated algorithm drives the audit with a focus on the easier incorrect claims, where an obvious overpayment exists; e.g. medically unlikely. The complex reviews are more time consuming and require the RAC team of clinicians and coding specialists to actually review the records of the audited claims. A second request of the agency may be made. The focus of these RAC audits has involved medical necessity, therapy utilization, and coding errors. RACs forward a detailed review results letter following all complex reviews. Following that letter, the RAC will notify the MAC who can issue an electronic Remittance advice  (RA) to the provider and the appeal timeline begins. Overpayments are recouped by offset unless the provider has submitted a check or valid appeal by day 30.

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What is the Case-Mix Adjustment Model?

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Coding, Frequently Asked Questions, OASIS

In OASIS, there are three domains:

Clinical Domain

(Federal Register/ Vol 72 Table A Lines 1-45) The clinician determines the patient’s plan of care and how much the agency will receive in payment to deliver that care. CMS is looking for congruence. Do you have congruence between assessment, plan, and codes?
  • M1220, M1222, and M1224- Diagnoses codes are included in risk factors. No E codes and 35 V codes are risk factors. They are included along with symptom control to assist in determining patient improvement likelihood. It is imperative that there is an understanding by the coder of the impact of codes on risk adjustment. The understanding of codes on risk adjustment impacts reimbursement.
  • M1030 Therapies
  • M1200 Vision
  • M1242 Pain All M questions must be reviewed methodically
  • M1308 and M1324 Pressure Ulcers
  • M1334 Stasis Ulcers
  • M1342 Surgical Wounds
  • M1400 Dyspnea
  • M1620 Bowel Incontinence
  • M1630 Ostomy
  • M2030 Injectable Drugs
The above M codes account for C1, C2, C3

Functional Status

 (Federal Register/Vol 72, Table 2A Lines 46-51)
  • M1810 Dressing Upper Body
  • M1820 Dressing Lower Body
  • M183 Bathing
  • M1840 Toileting
  • M1850 Transferring
  • M1860 Ambulation
The above M questions account for F1, F2, and F3

Service Utilization Domain by Visits

(Not a part of the Treatment Authorization Code but is necessary to determine the equation of the claim) There are three therapy thresholds: 6, 14, and 20 visits and graduated payment increases with therapy utilization reflect the following equations:
  • Early and late episodes 0-13 visits: 6, 7-9, 10, and 11-13 visits
  • Early and late episodes 14-18 therapy visits: 14-15, 16-17, and 18-19 visits
  • Early and late episodes 20+ therapy visits

The above M questions account for S1, S2, S3, S4, and S5

Equation 1 Equation 2 Equation 3 Equation 4
S1

0-5

14-15

0-5

14-15

S2

6

16-17

6

16-17

S3

7-9

18-19

7-9

18-19

S4

10

10

S5

11-13

11-13

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What is the HIPPS Code?

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Coding, Frequently Asked Questions, OASIS

Health Insurance Perspective Payment System (HIPPS) rate codes represent specific patient characteristics (or case-mix groups) on which payment determinations are made. The HIPPS Code has five positions. This data is required to complete a HIPPS Code.

_1_ _2_ _3_ _4_ _5_
  Position 1 = Equations (1,2,3,4,5) Position 2 = Clinical Domain (C1, C2, or C3) converted to A, B, or C Position 3 = Functional Domain (F1, F2, or F3) converted to F, G, or H Position 4 = Service Domain (S1, S2, S3,S4, or S5) converted to K, L, M, or P Position 5 = Non Routine Supplies (S, T, U, V, W, or X) converted to 1, 2, 3, 4, 5, or 6 As seen, the HIPPS code will have five digit/letter coding positions. The first position will always begin with a number. It will identify the grouping according to M0110; 1 if early episode and low therapy; 2 if early episode and 14-19 therapy visits; etc. Positions 2-4 reported will have a letter that will represent the scores of the clinical, functional, and service domains. Position 5 will have a letter or number depending on the severity of diagnosis and the supplies provided or not provided. The value of the OASIS M0 items will be different for each equation. An equation includes the combining of OASIS questions and OASIS and diagnoses as well as the number of therapy visits and the episode timing. Since 2008, many diagnoses can now be deemed primary or secondary. There can be a combination of M0 items and diagnoses. Functional domain items have not changed, but the service utilization domain is now based entirely on therapy.

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What is HEAT?

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Audits, Frequently Asked Questions

This auditing body is considered the more aggressive investigator of essentially DME and Home Health.  There has been expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay and as recently as September, 2011, they have struck, arresting 91. The HEAT is the technologically oriented auditing body using state of the art analytics to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector. 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.” Clearly, with all of the auditing bodies, CMS is making a bold statement; fraud and abuse will not be tolerated. Unfortunately, in this kind of environment, innocent casualties can occur. Agencies need to take action now.

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What is the summary of key points of the proposed 2012 Home Health PPS Rate Rule?

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Frequently Asked Questions

Agencies will need to be efficient as there is a proposed 2.5% inflation update, a 5.06% case mix creep adjustment, and a 3.56% rate reduction for 2012. In addition there is a recalculation of case mix weights proposed that includes elimination of two hypertension codes (401.1 Benign essential hypertension and 401.9 Unspecific essential hypertension). Also, there would be lower therapy episode coding weights. This would include a deceleration of a higher number of visits with a removal of the therapy visit step indicators. There will also be a recalculation of points to clinical and functional scores. Additionally, if an agency failed to complete a successful dry run  in Q3 of 2010 for HHCAHPs, they risk a 2% reduction in payment.

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I am hearing about bundled services. Should I be concerned?

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Frequently Asked Questions

Home Health Agencies should be aware of potential Accountable Care Organizations (ACO) formation in their respective markets.  Does your agency have a specialty you should be marketing to local hospitals? Some hospitals are looking at the bundled payment options as well as ACOs. Read more at the CMS website but know that the proposed pilot gives participants the opportunities to make choices regarding patients to include, length of episodes of care, whether acute inpatient care should be included, and the target payment to be established. There are a variety of proposed models. Go to www.CMS.hhs.gov to learn more.

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Can you explain the survey levels?

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Frequently Asked Questions

Standard Survey focuses on Level 1 standards (9 of 15 CoPs) which focus on the delivery of high quality patient care using not only clinical records but inclusive of interviews. If the home health agency is in compliance with all Level 1 standards and there are no identified concerns requiring investigation, the survey will be concluded and form CMS 2567 is issued. Partial Extended Survey begins/expands when expected outcomes are not met for one or more Level 1 Standards. It requires a review of Level 2 standards. It should be expected that related information would be sought for areas of concern such as agency policies and procedures, personnel competency evaluations, and inservice training Condition-Level Deficiencies can occur with serious findings related to or not related to Level 1 and 2 standards. Immediate patient jeopardy is always cited at the condition level. All conditions are reviewed.  Refer to the State Operations Manual, Appendix B Guidelines.

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