The Countdown Begins


Here’s a rundown of the first section of the new Home Health Conditions of Participation.  Check back for additional information.  We’ll be adding more later.  Let us know if you have anything to add.

Patient Rights and Responsibilities

The Condition of Participation concerning patient rights and responsibilities will require that:

  1. The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.
  2. There must be a complaint log that documents the existence and resolution of complaints about care furnished made by the patient or their representative and family.
  3. The agency must let the patient know in advance of the disciplines that will furnish care, the plan of care, the anticipated outcomes of care and changes in the care to be furnished.
  4. The agency must advise the patient of agency policies regarding disclosure of patient records.
  5. The agency must advise the patient of any financial liability.
  6. The agency must advise the patient of the home health hotline number and explain its purpose, hours of operation.
  7. The names and telephone numbers of specified state and federally funded entities. (See Below)
  8. The right to access auxiliary aids and language services and how to access these services.

Specified numbers

  1. Agency on Aging
  2. Center for Independent Living
  3. Protection and Advocacy Agency
  4. Agency and disability resource center
  5. Quality Improvement Organization

These new and revised rights are in addition to other patient rights that are currently being used so you will have to edit your current forms before January 1.  We expect that most forms will patient rights 2 taken from the regulations and edited slightly for clarity.

We suggest that when the forms are replaced that old forms be removed from the office and archived on your computers so they are not accidentally used in 2018.

Complaints

Another thing you can do immediately is prepare your complaint binder for 2018.  Remember that the complaints that you must record and address are those having to do with patient care and mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the agency.

Anyone employed by the agency in any capacity who identifies, notices or recognizes anything suggestive of mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, MUST report the findings to the agency immediately and other appropriate authorities in accordance with state law.  Notice that it states the employee who identifies mistreatment must report it.  Be supportive of your staff but keep in mind that the person who suspects any neglect or abuse must report it.

Communication

Every agency who is Medicare Certified has completed a Section 504 packet for submission to the Office of Civil Rights.  The penalty for not doing so is having payment withheld so it’s a The Office of Civil Rights investigates claims of discrimination and assures that healthcare providers and others understand and attest to their non-discrimination policies.

Now the section on limited English proficiency has become a standard in the Conditions of Participation.

If your agency is very old, you may not be aware of what is in the packet but you can obtain sample policies and explanations on the Office of Civil Rights webpage.  If you scroll down to the third section  of the linked page, you can find the tools that The Office of Civil Rights has for Medicare Certified Healthcare Providers.

The available resources that you must plug in such as translators, etc. will vary according to your location.  Now is the time to task somebody with identifying these resources if you haven’t already.

So, here are three new requirements that your agency can address in a week.  Instead of being overwhelmed by all the changes, complete a few to the best of your ability and move on to the next.  Keep checking back for more advice on how to get in a position to be compliant by January and send to us any ideas that you have on how to best comply with the new Conditions of Participation.

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30-Day Episodes and More…


To be certain, I would have not written the 2018 proposed regulations in the manner in which they were posted earlier in the week.  The document which is technically not published because it hasn’t been certified, starts with the basic rate changes that are proposed beginning January 2018 and some important changes to the scoring system.  The most significant of these involves therapy.  Then it jumps into a couple of hundred pages (not including charts and attachments) describing a new system proposed for 2019.  By the time you finish reading about the 2019 changes and are wondering if you would look good in a Taco Bell uniform, the document once again returns to the changes for 2018.

There’s a lot of material to digest, folks.   Shall we begin?

2019 Payment System

Unlike Medicare, we are going to start with the 2019 payment system.  To call this an update or refinement is taking liberty with the concepts.  It barely stops short of introducing an entirely new payment system.  Even though the proposed implementation date isn’t until 2019, it is important that you become familiar with the payment system now so that your comments can be considered.

The document, posted here, gives the following contact information.  Whether you agree with our views or not, everyone’s voice should be heard if they have an opinion on the proposed regs.  The last day for comments is September 25, 2017.  Mark your calendars.   Here’s where comments should be submitted.

Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions under the “More Search Options” tab.

By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1672-P,
P.O. Box 8016,
Baltimore, MD 21244-8016.

There are additional addresses for overnight and in person delivery in the document.

Home Health Grouping Model

If all goes according to plan (doubtful but let’s pretend that it will), we will see the advent of Home Health Grouping Models.   Patients will fall into one of six groups depending on their primary diagnosis.  If there is a problem with an assessment falling into one these groups, the claim will likely be sent back to the provider who will have to produce coding with improved accuracy.

These groups are:

  1. MMTA                                            Medication Management and Teaching
  2. MS                                                  Musculoskeletal Rehabilitation
  3. Wound                                          Includes ulcers, surgical incisions, skin lesions, etc.
  4. Complex Nursing:                     Determined by diagnosis code
  5. Neuro, Stroke, Rehab              Self Explanatory
  6. Behavioral                                  Usually called psych

Therapy

Here’s a change that might interest you.  There will be no adjustment for therapy in this system.  The payment is built into the grouping models.   Please feel free to leave your comments below.  We want to know what you think.

Admission Source

Then there’s the Admission Source component of payment in 2019.   You will have four choices:

  1. Institutional Early
  2. Institutional Late
  3. Community Early
  4. Community Late

The rationale for these admission source criteria is that patients admitted from the hospital generally require more resources than those admitted from the community.

Comorbidities

There are 841 diagnoses that will bump up payment if they entered as a comorbid condition.   Here’s how you find them.  Go to https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html.

The first section is called, ‘Spotlights’.  There are three paragraphs followed by four links.  The link called, HHGM Grouping Tool has a nifty little spreadsheet where you can calculate payment according to the proposed rules.  Download it and extract all the files.  The very last extracted Excel file (above the Help file which I didn’t bother to read) is a ‘toy’ grouper.   That’s a very fun tool and I’m sure you’ll be using it a lot.  However, to find the significant comorbidities mentioned above, look at the tabs on the bottom of your screen.  One is called, ‘ICD-10 DXs’.  Click it.  There you will find almost 70,000 diagnosis codes.  Do not be alarmed.  Click Ctrl and the letter F at the same time.  A search box will appear on your screen.  Type ‘yes’ in the search box and ‘Find All’ at the bottom of the search box.  The comorbid conditions will be presented to you.

If anyone can tell me how to extract only those codes, feel free to let me know.

Functional Level

 This is the last step of the proposed payment system is similar to the current system with two notable additions.  M1033 –  Risk for Hospitalization and M1800 – Grooming have been added as contributors to the functional level.   The rest of the questions are the same:

  • M1810: Dressing Upper Body.
  • M1820: Dressing Lower Body.
  • M1830: Bathing.
  • M1840: Toileting.
  • M1850: Transferring.
  • M1860: Ambulation/Locomotion

Using the Medicare Grouper tool, you can enter data for your patients and see how they compare to your current case mix weights.  Alternatively, you can call us for assistance and for a very reasonable price, we will come up with a comparison of your case mix weights as they stand now to how they would fall out in 2019.  No dollar value has been assigned.

Questions

  1.  Medical Boards across the country are monitoring prescriptions of narcotics. According to the National Clearinghouse for Alcohol and Drug Information, as many as 17% of adults age 60 and over abuse prescription drugs. Narcotic pain killers, sleeping pills and tranquillizers are common medications of abuse.  An increase in the use of therapy, often ordered for pain management, can reduce the need for these meds.  Has anyone tried to determine with a large amount of data if this is the case?
  2. More to the point, does this payment system create an environment where agencies are given incentive to reduce therapy to the detriment of patient care?
  3. Billing for home health is a complex process. 30-day episodes will result in almost double the amount of work for the office staff increasing expenses without contributing to patient outcomes.  Will billing requirements be lessened?
  4. With 60-day episodes, there is occasionally a situation when an agency admits a patient who is a patient of another agency because the prior agency did not drop a RAP timely. The likelihood of this happening will greatly increase in a 30-day episode.  Will there be any protection for agencies who admit a patient of another agency unknowingly?
  5. In the early years of PPS, points were only awarded for the primary diagnosis resulting in widespread upcoding. Many nurses were upcoding in good faith because their supervisors had told them to put Ortho, Diabetes, Neuro or Trauma codes first.  Is the 6-clinical group method creating a similar situation?

 The current political environment casts doubt on whether any of this will be implemented and raises the chances that it will be postponed.  This does not cancel our obligation to make our opinions known because there are changes on the way.

Do not hesitate to contact us if you have any questions or comments.  The Coders will be submitting comments about the 2019 payment system and we hope that you do, too.

2018 Changes

Our Cliff Notes version of the 2018 payment updates is coming soon.  We promise.  We find it easier to understand one year at a time and think you will, too.  And because your deadline for comments is only a few weeks away for 2019 payment system, we tackled that first.  So, for today, that’s all, Folks.  Keep us posted with any news that you hear.

Star Light, Star Bright


Everyone wants more referrals but even the best marketer in the world is at a loss when the agency marketed is a two-star outfit.  Whether it’s Amazon or TripAdvisor, people are making purchasing decisions based upon Star Ratings.  The same holds true for insurance companies and hospitals.  They want the next provider of care for their patients to be five star agencies and yet, only three percent of agencies meet that criteria for quality of care issues.

Four stars are good, too and three stars is an indication that agency is trying.  One and two star agencies are often overlooked and discharge planners will try to find a patient an alternative if they choose one.   Remember, the hospitals are penalized for readmissions.  There’s no denying that star ratings are a powerful weapon in the fight for referrals in markets where competition is tough.

So, have you figured out that you need to improve or maintain your Star ratings?  Are you wondering where to begin?  Here’s your answer.

First, know what data factors into your star ratings.   There’s exactly nine of them.

Process Measures:

  1. Timely Initiation of Care
  2. Drug Education on all Medications Provided to Patient/Caregiver
  3. Influenza Immunization Received for Current Flu Season

Outcome measures:

  1.  Improvement in Ambulation
  2. Improvement in Bed Transferring
  3. Improvement in Bathing
  4. Improvement in Pain Interfering with Activity
  5. Improvement in Shortness of Breath
  6. Acute Care Hospitalization

Next, go to Medicare’s Home Health Compare page.  Find your agency and see which of these questions falls short of the national and state averages.  Begin with a plan to address the three worst and set it motion.  If you fall short in Drug Education, move it to the top of the list even if there are three more that are worse.  Poor compliance to medications will affect all the other outcomes.

Easy, right?  Your plan should look like a state survey plan of corrections with columns for the Star Factor, Interventions. Responsible Party and Follow-Up.  There should be one person who oversees the plan and that person should be a cheerleader and have the authority to call meetings.  He or she should be meticulous about follow-up and be respected by his or her peers.  If you don’t have a person like that, hire one because they will come in handy in a lot of different ways.

This is data taken from a random agency’s online published data.  It was easy to find because searches on the Home Health Compare site list all agencies that meet your criteria with their star ratings.  The last two columns are state averages and the National Average.

How often patients got better at walking or moving around 56.6% 69.6% 70.2%
How often patients got better at getting in and out of bed 51.6% 64.2% 67.1%
How often patients got better at bathing 71.5% 74.6% 73.6%
How often the home health team made sure that their patients have received a flu shot for the current flu season 22.3% 69.6% 74.4%

There are actually two types of outcomes reflected.  The first three all depend on two points in time.  The last one – flu shots – is defined by only the discharge or transfer OASIS.

People unfamiliar with OASIS may look at these outcomes and wonder what is wrong with the people running that agency.  Who could blame them?  I’m a little more cautious in judging this agency.  In fact, I am betting that the problem is OASIS data collection which hurts the agency more than the patient.

If this agency wanted to improve their star ratings, they might have an action plan that included some of the following interventions.

Education regarding the functional domain.

  • The importance of assessing rather than interviewing patient
  • The importance of reading physician or hospital notes on admission
  • Review of Medications to determine if any meds would render the patient unsafe to ambulate, transfer or bathe. If they are PRN meds, the nurse should review how often they are taken.  Remember to include antihypertensives, antihistamines, and other meds and the length of time the patient has been taking them.
  • A visit to the bathroom and bedroom to assess for structural barriers

Education of the OASIS conventions that affect the functional domain

  • Know what a ‘day’ is in OASIS land – the 24 hours prior to the visit and the visit itself.
  • Consider safety
  • Understand the ‘majority of tasks’ instructions in the conventions.

Discharge to Community Review

  • Determine if a discharge visit has been made. When a visit is not possible, the OASIS data must be taken from the last OASIS assessment.  Short lengths of stay will reflect a ‘static’ patient with no changes.
  • Determine if information on discharge conflicts with information on admission. Example:  The admit nurse noted the dates of pertinent immunizations and the discharge assessment states that vaccination status was not addressed indicating that a chart review was not performed.
  • Considering the course of care for the patient, was the admission assessment correct. All admission, resumption of care and recertification assessments resulting in a score of F1 in the HHRG should be reviewed for accuracy.  The very low score could indicate that the patient is not homebound or the clinician did not understand how to answer the questions.  Both possibilities need to be explored and explained.

Review of the OASIS data regarding flu shots.

If I could only choose one outcome to improve it would be the frequency that the agency assessed for flu shots.  It is easy and does not require a lot of agency resources to monitor and manage.

  • For this question, dates are critical. Any patient admitted after March 31 and discharged prior to April 1 should not be reflected in this question.  Ensure that the clinician answers ‘No” to:

(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu season?

  • The time frame under consideration is an episode of care.  An episode of care, often confused with a payment episode, begins upon admission and ends on transfer or discharge UNLESS the patient is hospitalized. If that happens, a new care episode will begin at Resumption of Care and continue to discharge or the next transfer.

Understanding these concepts will not only improve outcomes but they will also increase payment in some instances and the integrity of your data will be maintained or heightened.  Because payment system recommendations are made based on the data that agencies submit, everyone has the responsibility to submit accurate data.

Call us if you need help with understanding and monitoring your Star ratings.  It takes a while to wash out old data but sharing your data with your staff on a quarterly basis as it becomes available will go a long way motivating your staff to pay close attention to the OASIS data.  Better yet, your marketers will be armed with an explanation of why your agency pales in comparison to others and be able to tell prospective referral sources your plans for improvement.

Medicare’s Pre-Claim Review Demonstration Project


Imagine if every one of your Face-to-Face documents and plans of care were scrutinized prior to payment.  Would 90 percent of them be found compliant with existent rules?  If a non-clinical person determined that your documentation did not meet Medicare coverage guidelines, would you take their word over your nurses’?  How would you feel about submitting a perfectly valid claim for eligible services and being paid 25% less than your peers?

Agencies in Illinois do not have to use their imagination.  It is already happening through the Pre-Claim Review process.  This process involves submitting plans of care, face to face documents, physician and hospital notes and sometimes more to Palmetto prior to dropping a claim for ‘affirmation’.  Once affirmed, a secret code is given to the agency which is placed on the claim. Without the code, final claims are reduced by 25 percent.

And while Medicare is reporting a 90 percent ‘affirmation’ rate, it does not report that there were over 80,000 RAPs submitted compared to 23,000 final claims.  Agencies are apparently reluctant to submit their pre-claim review documentation.

Because a RaP will be taken back after 120 days if not answered by a final claim, I expect that many agencies are going to drop an enormous number of claims in the coming weeks which means the number of pre-claim reviews will far exceed that ever imagined by Palmetto, GBA.  Maybe Palmetto really can process an additional 60k reviews without any interruption in services to the rest of us.  Maybe; but I doubt it.

In April, Florida will come on board.  Texas, Michigan and Massachusetts will follow at undetermined dates.

Agencies in states other than Illinois might not be impressed with all this stuff and nothing.  They are busy with the changes to the OASIS data set, the impending Conditions of Participation and perhaps their own audits or surveys.  Hopefully they will take pause and consider the magnitude of this demonstration project to understand the egregious nature of this intrusive and burdensome little project taken on by Medicare.

The new conditions of participation expected in July of this year explain that the prior Conditions focused on identifying agencies with poor performance.  The updated Conditions of Participation take a much-needed step away from this punitive approach.  As written in the new regulations:

Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.  

There is nothing about the Pre-Claim Review process that stimulates broad-based improvements in healthcare.   How could the Pre-Claim Review Project be so far removed from the intent of the home health Conditions of Participation?

Consider that the demonstration project is resulting in difficulty meeting the educational demands in Illinois and that resources have already been relocated from Florida to Illinois.  Do agencies in other states have the same access to education as the agencies under pre-pay review?

According to the Medicare Pre-Claim Review Q & A:

The demonstration establishes a pre-claim review process for home health services to assist in developing improved procedures for the investigation and prosecution of Medicare fraud occurring among Home Health Agencies providing services to Medicare beneficiaries.

Nobody can deny that a small number of agencies operate without any regard to Medicare rules and only a passing acquaintance with ethics.  This inconvenient acknowledgment of fraud amongst the ranks does not justify excessive scrutiny on 100 percent of providers.  Somehow it does not seem fair to involve home care agencies in a demonstration project designed to enhance their prosecution.

And yet, agencies who fail to submit documentation for a Pre-Claim Review are put on a 100 percent review – a level of scrutiny previously reserved for agencies operating far outside of Medicare rules for an extended period.

The documentation required for a pre-claim review is reviewed for clerical errors and dare I say, elements that cannot be established with limited documentation by reviewers who are not nurses.  The reason for denial given most often per Palmetto GBA is lack of medical necessity.  We see care plans daily that are very poorly crafted supported by excellent nursing and therapy notes.  Conversely, we see plans of care worthy of a Pulitzer prize supported by 9 visit notes at weekly intervals documenting that a skilled nurse taught meds – presumably meds ordered for the patient but who knows?  Nobody asked us if it was possible to determine Medical Necessity without a complete review of the chart.

In the same vein, we see homebound status documented on visit notes that is contradictory to plans of care.  In one recent chart, we found that a patient was shopping weekly.  On another, a therapist documented the patient was driving.  Sufficient documentation on a plan of care that a patient meets the homebound criteria does not make it so.

But, the reviewers are also quick to note when a signature is not dated or the date of encounter is omitted from the Face-to-Face encounter document.  I agree that dates are an important step towards compliance but lack of a date is often nothing more than an oversight; not a tell-tale sign of fraud on behalf of the agency, especially since it is the physician who responsible for the dates.  If this keeps up, the federal prisons will be filled with healthcare providers who forgot to date a couple of documents.

The burden to the agency is extensive.  On a recent CMS conference call, many agencies reported that the PCR process was costing them $25,000.00 per month.  Another agency stated it was taking them about an hour per claim.  Even if these estimates are overstated, they are still far above Medicare’s estimation that it would take minimal time and expense to get the pre-claim reviews submitted.

If Tom Price is confirmed as the new secretary of HHS, there may be some relief but the Georgia representative will oversee 13 different agencies including CMS, the CDC, the FDA, National Institutes of Health and more.  While he has been outspoken against the Pre-Claim Review Process as a senator it is hard to imagine that the Pre-Claim Review process will find its way to the top of his priority list upon confirmation.

So, who benefits from this circus?  Is Palmetto being honest when they say the project is going well?  Are our patients happier and healthier because of frantic efforts to assemble and transmit paperwork?  Could the resources being consumed by The Pre-Claim Review project be put to better use?  What can you do?

I can only provide an answer for the last question.  The first thing you should do is to contact your elected officials in Washington.  After that, get your care plans and Face-to-Face documents in order because there is now an abundance of reviewers at Palmetto who are fluent at reviewing (and finding cause to deny) them.  If you are in Illinois and have claims that you believe are non-affirmed due to incompetent reviewers at Palmetto, contact NAHC.  Under no circumstances do we recommend ignoring the Pre-Claim Review Process because your state is not in the demonstration project.

Many Thanks to Tim Rowan, founder of the Home Care Technology Report. who has extensively and  investigated the Pre-Claim Review process and its effect on providers.  His articles are linked within the content of this post and you can find additional information on his website.

And of course we want your comments and questions.  You can leave a comment here or email us with questions.  We particularly want to hear from Illinois agencies (after you contact your elected officials).

Survey Readiness


Because you are bright and shiny home health employees with enthusiasm to spare, it goes without saying that you are ready for survey all day, every day.  But just in case you fell behind, here’s a few tips on being ready when those cheerful surveyors come calling.

  1. Make sure your annual advisory meeting is held timely. There is nothing you can do when it’s time survey and your PAC meeting is six months late.
  2. Get your CLIA waiver updated if it within three months of expiration. If it is current, put the expiration date on your calendar with a reminder three months from the date.
  3. Plans of care for all patients should be current and updated and reflect the actual needs of your patients – not just what the computer thinks.
  4. Medication lists should be current. Obviously, you and your colleagues are checking meds on every visit but just in case it never hurts for the DON or QA nurse to spend an afternoon doing supervisory visits and checking medications.  If meds are okay, relax.  If you find errors, implement an agency wide plan to have the meds of all patients reconciled within a week.   After the initial medication campaign, follow up.
  5. Do the QA thing. At a recent Home Care of Louisiana meeting, the state agency responsible for whipping home health agencies in line gave a presentation about what they were finding on surveys.  Although tags were not frequently issued for Quality Assurance plans, almost every other tag could have been prevented by reading notes as they came into the agency against the plan of care.  Consider the difference between seeing a missed visit cross your desk compared to a chart with numerous missed visits.  You must read your charts if you want to know what is in them.
  6. Most importantly, call the physician.   Almost every survey with deficiencies includes at least one tag resulting from a change in the patient’s condition that was not communicated to the physician.  I have spoken with nurses who are unwilling to call physicians because they have been chastised in the past for ‘bothering’ physicians.  Communication is not the same as harassment.  If you reserve phone calls for emergent situations and fax or secured email for updates, everyone can be on the same page without overwhelming the physician.
  7. Consider a coding company. Although the primary purpose of The Coders is to ensure correct ICD-10 codes and OASIS responses, a registered nurse reviews the clinical records to determine what those codes and responses should be.  So, while we don’t specifically look for QA indicators, we notice the more serious omissions and make note of them for the agency.  Another side effect of a Coders contract is that our coders notice when assessments are incomplete or late.  Getting caught up can make an enormous difference for agencies with a backlog.

Notice what is not on the list.  There is no minimum standard for face-to-face encounters.  Surveyors may comment about excessive lengths of stay but rarely is a tag issued for redundant teaching or failure to provide reasonable and necessary services.  The state agencies do not pay your bills.  The hoops you must jump through for payment are in addition to the minimum standards for your state.

Some of you may know some people at an agency that is utterly unprepared for state survey.  If this is a long-standing problem, there is probably not much they can do in a short period.  On the upside, in the absence of patient harm and extreme irresponsibility on the part of the agency, the state will allow for an opportunity to clean up any messes in the form of an action plan.  Or they can pay a consultant to come in and have them write an action plan.  We prefer the latter but you won’t receive an invoice from the state surveyors.  Just saying.

Here’s what you don’t do.  Don’t call a consultant in the weeks before survey is due and expect them to make the changes required for a flawless survey.

Three Little Questions


Because the OASIS C database has become easier for you, Medicare has taken measures to ensure that 2017 offers some challenges in the way of OASIS C2.  In turn, we have taken measure to ensure that you understand at the very minimum the three new questions.  They come complete with their own conundrums, confusion and lots of reformatting and subtle shifts in definition.  It’s not as simple as it seems but it certainly isn’t out of your range of capabilities.

New Questions

Written by someone who is comforted by redundancy, MO1028 assesses (again) whether a patient has diabetes or peripheral vascular disease.

(M1028) Active Diagnoses– Comorbidities and Co-existing Conditions—Check all that apply

See the OASIS Guidance Manual or click here for a list of relevant ICD-10 codes.

  • Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
  • Diabetes Mellitus (DM)

Additional guidance is not much different from coding conventions.  The diagnoses must be documented in the medical records produced by the physician or NP.

Having the condition is not enough to win a checked box.  The C2 manual states that the diagnosis must be active and the manual infers that ‘active’ means that there are orders written or monitoring of the disease process ongoing.

So, that’s two criteria –

  1. Does the patient have the condition and
  2. Is anyone watching it or writing orders for it.

Worth noting, if only for a laugh, the OASIS Guidance manual for the C2 dataset provides the following rationale for this question.  We are not kidding.

Disease processes can have a significant adverse effect on an individual’s health status and quality of life.

Section GG

Another new question is (GG0170C) Mobility.  The question occupies an entire page in the manual and if you are like me, it may take you a while to understand what they are truly asking.  Look the column in the body of the table to the very most right where it says something about the patient moving from a completely supine position to sitting on the side of the bed, feet flat on the floor with no backrest.   Everything else on the page refers to that single activity.

The answer reflecting the greatest impairment is 01 and a patient who can complete the tasks independently gets a 06 score.  Note that this is a new opportunity to make a careless error as the level of severity for every other question is reversed with 00 being the least impaired and the last possible response being the worst level of severity.

But there’s more.  The dataset asks for a goal.  If your patient is able to do this task at admission, it is not a problem.  Your initial response and your goal will be the same.  However, if some improvement is expected by the grace of your carefully crafted careplan, there will be a second response describing your patient’s expected ability upon discharge.  Take your best shot and don’t fret about not being able to predict the future.  It is true that all kinds of things can happen between admit/resumption of care and discharge but it is not reasonable to downgrade your goal in the event of a zombie attack.  On the other hand, remember that you are not so good that you can take a person who is totally dependent following a cerebral vascular accident and have them independent at discharge.

Getting Personal

Medicare wants to know the patient’s height and weight in M1060.

(M1060) Height and Weight—While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up.

The Coders assume that you know how to round off numbers but Medicare does not and includes explicit instructions within the question.

Guidance for this question includes a helpful tip to measure your patient’s height and weight in accordance with the agency’s policies and procedures, which should reflect current standards of practice.  So, how many of you have a policy addressing how to measure the height and weight of a patient?

Assuming that such a policy exists in your agency, is it based upon sound clinical practice standards?  On your behalf, we have scoured the internet for practice standards for measuring height and weight and like the CDC Antropometry Procedures Manual.  Sadly, the manual refers to the Integrated Survey Information System anthropometry computer application (ISIS).   Do not be alarmed when you see this.

Also, when determining how height will be measured, plan on buying a stadiometer.  This is the apparatus seen in Physician offices that measures height.  Most of the affordable ones are wall mounted and we suggest that wall mounting is not recommended in your patient’s home environment.  Also, note that anything with brightly colored giraffes and ruler-like markings cheering on big boys and girls is not likely to be received well by adult patients or meet the practice standards. Call your medical supply company and plan to spend about $150.00 per portable stadiometer.

The Dash

There’s more – so much more but you have patients to see and notes to write.  We are going to leave you with information about The Dash.  This is not a simple dash as found in other places like a date or a social security number.  According to Medicare,

a dash (–) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged or dies before assessment of the item could be completed. CMS expects dash use to be a rare occurrence.

This definition is consistent throughout the manual.  When a dash value is an available option for questions, OASIS guidance generally indicates if the dash is a valid response.

For your convenience, we have uploaded some of these documents.  Hopefully, you will read them and then fill us in.  As always, we welcome your questions.  Maybe we’ll even answer a couple.

5 ADRs – Your Risks


Home health care agencies that bill Palmetto GBA are currently in the midst of receiving five ADRs each across the board.  As such, clinical record review has been ongoing at our office.   What we’re finding is almost typical but not identical to what we have been seeing in clinical records in the past.  Here are the top five risks for denial that we have identified.

  1. No physician statement of how long services will continue for second or later episodes. This is occurring even when the agency’s software has a blank for the information.  Remember, if your physician’s estimate is a little too optimistic, it is not mandated that you discharge or otherwise do away with the patient.  Help your physicians arrive at a reasonable time frame based on your combined experience.  If you have no experience, consult your DON.   If new needs arise, revise the end date on the following POC if any.
  1. Unsupported diagnosis codes. If a physician documents that a patient is forgetful and your assessment reveals that the patient is not oriented to person, place or time, you are likely both correct.  However, in a case like this, a code for dementia is not supported by the MD.   Another thing – it really is okay to let a diagnosis of hypertension stand-alone if the patient has hypertension.  It does not need to be dressed up with additional diagnoses such as hypertensive heart disease or heart failure.   It only ‘looks better’ at first glance until someone realizes that there is no MD support the code. When a physician’s documentation does not support your codes, it really is okay to ask.  Send a fax to the MD asking if your codes might be accurate.  There is always a chance that the doc’s documentation is not accurate and your question may be the catalyst to better overall care for the patient.
  1. Unmet needs for additional disciplines. When we look at ADRs, we ask for a copy of the packet that will be going to Palmetto or whomever.  In limiting our view to only what Palmetto reviewers see, we sometimes see glaring omissions that may not be obvious to clinicians up to speed on the patient.  We see patients with falls and no therapy and patients with difficulty with ADLs and no home health aide ordered.

Usually these services were provided in a previous episode or admission or refused by the patient but unless documented, it is impossible for a reviewer to see these omissions.  A lot of agencies have moved away from 486 summaries (against our better judgment).  If your agency does not write summaries as a rule, be sure to at least include that the patient is being ‘readmitted’ to indicate that there is more to the patient’s story.  When you see the word, ‘readmitted’ when preparing documents for an ADR, ensure that you mention prior disciplines and treatment modalities in a cover letter to accompany the ADR.

  1. Signature issues. It seems that most agencies understand the signature requirements imposed by Medicare but not all.  Ineligible signatures a ‘gimme’ for Palmetto GBA where the reviewers of clinical records deny entire episodes based upon one undated signature.

What’s curious about signature issues is that until an agency receives a denial, they don’t believe they have a signature issue.  They have strict policies about billing and have created a work environment where fraud is not tolerated.  When someone reminds them about signatures, they are confident in the high ethical bar the agency has set.  They don’t see the problems we do.

The truth is that without diligence, inadequate signatures slip through.  Stamped signatures, NP signatures and the signatures not matching the name on the plan of care are found occasionally and when those charts are reviewed by a payor source, a denial results.

There is no great clinical skill in checking signatures and agencies without signature problems encourage everyone who sees a signed 485 to verify the presence of a date and the correct name on the signature line.  If the problem is pervasive, pay a bounty for every ineligible signature.  Remember, it is far easier to convince a physician to sign an attestation when he or she clearly remembers when they signed a document.

  1. Lack of Communication. There are numerous instances when we believe an MD should have been notified that just sit there in the chart.  In the past couple of months, we have seen an established PEG tube that was leaking, blood pressures and blood sugars that are outside of the stated parameters and increased pain that is not reported to the physician.  New meds show up on recertifications and we can only assume a physician ordered them.   Nobody takes

Some clinicians feel as though they are ‘bothering’ the physician when they call for orders.  Others are confident that the physician does not want to be called.  Our all-time favorite is the statement, ‘MD Aware’ and better yet, ‘MD fully aware’.

These examples of lack of communication will almost certainly result in a survey deficiency.  They may also result in a denial if the episode has no new exacerbations, orders, meds, hospitalizations, etc.  The patient becomes ‘static’ or ‘chronic’ and it becomes unfair to say that the patient has an acute, intermittent need that can be met by home health.

Faxes are wonderful things.  So is secure email if you are lucky enough to have an MD who uses it.  You can write up your non-critical concerns and send to the doc at the end of the day with a phone call to verify receipt.  (Don’t trust the fax verification sheet because who knows what happens to faxes once they are received at the MD office.)  That will certainly take care of any deficiencies on state survey.

To make payment for claims more likely, ask for orders if none are forthcoming.  Not every high blood sugar or blood pressure requires a change in medications but when changes are warranted, it is usually because of a trend.  Ask the MD for an extra visit to ensure that the errant numbers fall back to within parameters.  Think of it this way.  If your assessment reveals numbers that are the start of a new problem requiring a change, would you want to wait a week or more to get a second reading?

Ask for lab if indicated.  A patient who is no longer responding to Lasix may have kidney disease.  You can ask if the MD wants a metabolic panel or for you to advise the patient to schedule an apt.

When a patient reports severe pain, ask for therapy orders or non-pharmalogical relief.  Do your homework by verifying pain meds are taken as ordered.  More than one patient has stayed in pain because they are afraid of getting ‘hooked’ on pain meds.   Work with the patient and the MD to find non-narcotic pain relief.

If the MD complains about your frequent communication, consider if you are overdoing it.  Review the information with peers.  If the communication was necessary for good care, ask the MD for suggestions on how to minimize it.  If none or forthcoming, it may be time to accept the fact that he will be referring to another agency in the future – at least until a patient is hospitalized because the MD was not notified of a serious problem with his patient.

So far, all we have done is review the ADRs.  No results have been forthcoming.  We would be interested to know what you are finding as you review your charts and/or hear from Palmetto about your ADRs.