This Just (snuck) In!


Hospice Providers, take note

To be quite honest, I have never seen a ‘no code’ list in hospice.  If anything, I would expect to see a ‘full code’ list as any code status besides DNR would be the exception.

And yet, there is a new list of codes that hospices may not use when determining the primary reason for hospice care.   A list of codes at the end of this document will be automatically returned to providers when used as a principle code for hospice for claims billed after October 1.

This information comes from CMS change request 8877 which also contains very important information about the Notice of Election.

Home Health Providers:

An updated Local Coverage Determination has been published by Palmetto GBA for Alzheimer’s Dementia.  Among the insightful gems included in this guidance is the following passage begging the question of, ‘does someone have too much time on their hands?’

Behavioral disturbances often complicate the medical management of beneficiaries with Alzheimer’s disease. At baseline many individuals with Alzheimer’s disease manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline – resulting in sub-optimal clinical outcomes.

Wow.  I’m glad we cleared that up.  Seriously, look how often the word, ‘baseline’ is used.  If you really want to get paid, consider using the FAST scale to stage Alzheimer’s on admission and recert.  There are also numerous documentation requirements.  Please review and document accordingly.

If you recall, numerous claims once denied for Face-to-Face documentation are now being denied for lack of both long and short term goals.  The reference to short and long term goals is listed as the Physical Therapy LCD.  I am quite certain that the Alzheimer’s documentation LCD will be used in the same way.

Both of these regulations will take place on October 1.  Be ready.

 

The Hospice No Code List

290.0 Senile Dementia Uncomplicated
290.10 Presenile Dementia Uncomplicated
290.11 Presenile Dementia With Delirium
290.12 Presenile Dementia With Delusional Features
290.12 Presenile Dementia With Delusional Features
290.13 Presenile Dementia With Depressive Features
290.20 Senile Dementia With Delusional Features
290.20 Senile Dementia With Delusional Features
290.21 Senile Dementia With Depressive Features
290.3 Senile Dementia With Delirium
290.3 Senile Dementia With Delirium
290.40 Vascular Dementia Uncomplicated
290.41 Vascular Dementia With Delirium
290.42 Vascular Dementia With Delusions
290.43 Vascular Dementia With Depressed Mood
290.8 Other Specified Senile Psychotic Conditions
290.9 Unspecified Senile Psychotic Condition
293.0 Delirium Due To Conditions Classified Elsewhere
293.1 Subacute Delirium
293.81 Psychotic Disorder With Delusions In
293.82 Psychotic Disorder With Hallucinations In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.89 Other Specified Transient Organic Mental Disorders Due To Conditions Classified Elsewhere
294.20 Dementia, Unspecified, Without Behavioral Disturbance
294.21 Dementia, Unspecified, With Behavioral Disturbance
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
310.0 Frontal Lobe Syndrome
310.1 Personality Change Due To Conditions Classified Elsewhere
310.2 Postconcussion Syndrome
310.89 Other Specified Nonpsychotic Mental Disorders Following Organic Brain Damage
310.9 Unspecified Nonpsychotic Mental Disorder Following Organic Brain Damage

Incarcerated Prisoners


 

 

The telephone is often our most sacred source of amusement.   We love email, texts and blog comments but there are some things that people will not commit to writing.  When we need a break, we simply turn our volume up and answer the phone.

The question of my day was, ‘If a patient moves, can we still see them if they are in the service area?”

The answer was too obvious so the caller was answered with a question.  “Where did the patient go?”

The answer was less than articulate but the word ‘jail’ was in there somewhere.  Apparently, the patient got a little tipsy and loud and someone called the police and there were outstanding warrants and he is taking a little vacation courtesy of the county.

Not wanting to give bad advice, a little research was done on behalf of the caller – after all, this was cheap entertainment.  What we found, though, was not as amusing as we had hoped.  The definition of incarcerated includes beneficiaries who are:

‘• Imprisoned;
• Escaped from confinement;
• Under supervised release;
• On medical furlough;
• Required to reside in mental health facilities;
• Required to reside in halfway houses;
• Required to live under home detention; or
• Confined completely or partially in any way under a penal statute or rule.

The patient is not eligible for services.  This is important.  If someone is incarcerated, the incarcerator picks up the tab for all medical expenses.  (Consider that if you don’t have insurance and need surgery.)

If you are providing services to someone who has escaped from confinement, you have bigger problems and my recommendation is to pretend you do not know that your patient is an escaped convict.  If you let on that you know, you may experience a sudden reduction in staff.   If your conscience bothers you, don’t bill for the care and enter into a Corporate Integrity Agreement with the OIG when you are able to safely discharge the patient.

The risks to home health and hospice providers are further down on the list.  The United states has more prisoners per capita than any other country and Louisiana tops the list of states with 867 people per 100,000 meeting the definition of ‘incarcerated’ as provided above.  And yet, earlier in the week, researchers from Harvard University together with the University of British Columbia announced that they have determined that the five happiest cities in the nation were in Louisiana.   (Mardi Gras?)

In fact, it appears as though CMS Region 6 is well represented in the list.  In addition to being Region 6 states, it is noted that all of them are in the South and none of the very cold states have many prisoners.

Medicare Regional Map and Density of US Prison Population

image

But, you have a bigger problem than the weather in Region 6.  Specifically, it appears as though the various prison systems across the states are very slow to update their systems.  In some states, Medicaid is auto-cancelled when someone is incarcerated.  Released prisoners do not always know to reapply.  In other states unless someone applies to be taken off of probation they will remain on probation until a judge approves their release.

Medicare is denying claims for the incarcerated.  States can decide if they want to use Medicaid dollars but most don’t.  The ones that pay for prison healthcare forego the matching Medicare funds.  In Louisiana, we don’t have to worry about those required to reside in Mental Health facilities because our jail is our mental health facility but like everyone else we need to be concerned about halfway houses, supervised release and those on Medical Furlough.  If a patient on House Arrest gets past you, shame on you for not checking pedal pulses.  You don’t deserve to get paid if you missed the ankle bracelet.

If you inadvertently bill for a a person who is under the jurisdiction of the court, it will result in a denial.  If you live in one of the northern states, this should be an isolated incident.  If you live down south, it could become an expensive issue.  Medicare is supposedly getting on to states to tidy up their prison rosters but meanwhile, if you live in a state like Louisiana or Mississippi, my suggestion is, quite frankly, to include an assessment of their legal history at time of admission.  Don’t be rude about it.  Just ask something like, ‘Are you able to transfer from both the top and bottom bunk?’

THE Hospice Quiz


If you own or work at a hospice, there has never been a better time to make sure that you understand the rules and regulations just like Medicare intended.  The quiz below is a very basic quiz designed for you and your staff or co-workers to take to ensure that you are not denied payment or worse,  step on a regulatory landmine.

10 Common Documentation Flaws


untitled-97-1

Stop and use caution before documenting your visit!

 

If you are not concerned about poor to mediocre patient care, getting paid or your license, read no further.  If any or all of these issues are of concern to you, keep reading.  Below are ten of the most frequent flaws in nursing documentation reviewed by the coders.  We know that these oversights and omissions are most often the result of a busy schedule or inattention to documentation because we know our clients.  State surveyors, Medicare contractors and agencies named with 3 letters and an Eagle (OIG, FBI, DHS, CMS, etc.) do not express any great interest in the underlying causes of poor documentation.

1.  No MD Contact Documented when appropriate

Many times, the MD is not called at the house due to time constraints or other issues.  When orders are received, they do not tie back to any communication in the chart.  Documentation of two way communication is critical to both sound clinical practice and payment.

2.  Contradictory Information

The 486 summary indicates that the patient lives with a daughter but the OASIS states the patient lives alone.  The OASIS data states that the patient becomes short of breath with minimal activity but the plan of care does not include shortness of breath in the functional limitation.

3.  Blind Adherence to Rules of Thumb

Somewhere along the way, nurses were told that they must always document on the primary diagnosis on every visit and follow the clinical pathway written by someone who has never visited the patient.  This has led to visit notes that read like, “Pt found on floor with scalp wound bleeding profusely.  Reports she fell yesterday and wasn’t wearing life alert button.  Taught to avoid soda and other concentrated sweets to manage blood sugar.”

4. Failure to Document Sensitive Information

A chart found in one the best agencies I know of had multiple notes reading that the patient complained of extreme pain.  The physician was notified after every visit with a fax and a copy of the med list.  No new orders were received.  The Director of Nursing explained that the patient had recently been the subject of an evening news story involving the sale of her pain meds to supplement her Social Security check. 

5. Missing the Little Stuff

When little things like vital signs, weights, and blood sugars are omitted from the clinical record, it causes problems.  A weight gain of ten pounds after two weeks of forgetting to weigh the patient is negligent but not as bad as forgetting the third week when the patient is hospitalized.  Most nurses take vital signs.  I spend many nights staring at the ceiling wondering why they aren’t on the chart.  Then I remember that I tend to write them on my arms and if I bathe before I chart, they are lost to the water supply.  What’s your reason?

6.  Missing the Big Stuff

Missing new orders, teaching on medications that have been discontinued and not notifying the MD for problems is more common than you think.  It is what feeds many malpractice attorneys.  It is why state surveyors might not trust anything you say during survey.  It is why nurses find themselves answering very difficult questions to the state board of nursing.  If you do not have a current care plan, refuse to see the patient until you have a verbal report.  Document the verbal report.  If you see a patient without looking at prior orders, shame on you.  If the prior orders taken by another nurse are not written and as a result you teach a patient to take a med that has been discontinued, write an incident report.  This is stuff that kills patients.

7.  Lack of Follow-Up

Lack of follow leaves gaping holes in the chart, and often, results in missed opportunities to provide better care to patients.  Consider a clinical record where you read one week that the patient has a doctor’s appointment the following day and that’s the last time it is mentioned.  Did anyone call to see if there was lab or new meds ordered?  It’s hard to believe but sometimes patients don’t tell you these things. 

8.  No Ongoing Medication Reviews

One of the easiest way to prevent re-hospitalizations, adverse reactions, and non-compliance with medication is to simply review all medications against the med list on each and every visit.  Every time a med is missing, a new med appears, or there seems to be confusion in dosing, there lies an opportunity to improve the care of a patient and to increase your level of skill ensuring payment. 

9.  Taking the patient’s word at face value

If a patient tells you they had a lab or diagnostic test and the results were fine, by all means document it.  Also call the physician who ordered the test and get the scoop.  The physician may have told the patient it was ‘fine’ or ‘no change since the last MRI’ but in the context of the specific patient, that same test could show degenerative disease, a low hematocrit or some other information important to support eligibility for your patient.  If possible, always get copies of the final reports for lab and diagnostic tests.

10.  Evidence of Ignorance

This sounds harsh but it is evident en masse in the clinical records reviewed by The Coders.  A new medication will be ordered specific to a disease that is not documented anywhere.  Eye drops for glaucoma, Zemplar for hyperparathyroidism secondary to renal disease, Invokana for Type II diabetes are all medications seen within the last week that have no corresponding diagnosis.  These meds both have serious side effects and teaching to ‘take medications as ordered’ will not help the patient avoid untoward adverse reactions or recognize side effects. 

All of these shortfalls in clinical documentation can be avoided by simply reviewing the charts.  The average time for a skilled nursing visit is 30 minutes and the average payment is equal or more to what nurses would make in the hospital.  This means that nurses have the time to review the clinical records, go to case conference meetings and call physicians.  If a nurse has ten fingers and a keyboard or two thumbs and a smart phone, enough information regarding medications is available around the clock.  Medscape has a great completely free app for mobile phones that has data that can be stored on your phone when you are away from Internet connectivity.

We all want to get paid.  If agencies don’t get paid, they have no money to pay consultants and coders and that reason to document well falls second only to improving patient care.

Elizabeth Hogue Educates Us About Fingerprints


It seems as though some of you might be fingerprinted in the near future.   Elizabeth Hogue did such a good job of explaining it last week, we thought we would repost her email.  Elizabeth can be reached at:

(877) 871-4062
ElizabethHogue@ElizabethHogue.net

CMS Begins Fingerprinting “High Risk” Medicare Providers and Suppliers

The Centers for Medicare and Medicaid Services (CMS) issued MLN Matters Number SE1417 on April 11, 2014. This Special Edition MLN Matters is intended for providers and suppliers who submit claims to Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) and Home Health and Hospice MACs for services provided to Medicare beneficiaries. CMS makes it clear in this article that it will begin fingerprinting all owners of these types of providers with a 5% or greater ownership interest. The ultimate goal is to fingerprint all owners with a 5% or greater ownership interest in all providers or suppliers in the high risk category that receive reimbursements from the Medicare Program. According to CMS, the implementation of fingerprint-based background checks as part of enhanced enrollment screening of providers is based on Section 640 of the Affordable Care Act (ACA).

When fully implemented, the fingerprint-based background check will be required for all individuals with a 5% or greater ownership interest in a provider or supplier that falls under the high risk category. The high level of risk category applies to all providers and suppliers who are newly enrolling DME suppliers or home health agencies. This category will also apply to providers and suppliers who are elevated to the high risk category in accordance with enrollment screening regulations.

Fingerprint-based background checks will be implemented beginning in 2014. Providers and suppliers subject to fingerprinting will receive notification of the requirements from their MAC. The MACs will send notification letters to providers and suppliers that include a list of all owners with a 5% or greater ownership interest who are required to be fingerprinted. Letters will be mailed to providers’ or suppliers’ correspondence addresses and special payments addresses on file with Medicare. Individual fingerprinting will normally be required only once, but CMS reserves the right to request additional fingerprints, if needed. Owners will have thirty days from the date of notification letters to be fingerprinted. Providers and suppliers that find discrepancies in the list of owners sent to them by the MACs should communicate the discrepancies and take appropriate action to update enrollment records to reflect corrected ownership information.

Notification letters will include contact information for the Fingerprint-Based Background Check Contractor (FBBC). Individuals required to be fingerprinted are required to contact the FBBC prior to being fingerprinted to ensure that fingerprints are accurately submitted to the Federal Bureau of Investigation (FBI) and that the results are properly transmitted to CMS. Providers and suppliers subject to fingerprinting will be able to contact the FBBC by telephone or by accessing the FBBC’s website. Contact information for the FBBC will be included in notification letters sent by the MACs. The FBBC will provide at least three locations convenient to individuals’ locations where they can be fingerprinted. One of the locations must be a local, state, or federal law enforcement facility.

Individuals required to be fingerprinted must bear all expenses related to being fingerprinted.

CMS encourages providers and suppliers to provide fingerprints electronically, but CMS will accept the FD-258 card instead. FD-258 cards submitted will be converted to electronic submissions to the FBI by the FBBC.

Fingerprints will be sent to the FBI for processing. The FBI will compile background history based on fingerprints within twenty-four hours of receipt and will share the results with the FBBC. The FBBC will review each record and make recommendations to CMS regarding fitness. CMS will assess recommendations from FBBC and make final determinations. CMS may deny enrollment applications or revoke existing Medicare billing privileges based on its final determinations of the results of fingerprint background checks.

Providers and suppliers regularly face a number of hurdles in the enrollment process. The above addition to the process is bound to increase providers’ frustration. Meticulous compliance will be the name of the game!