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.


Changes to Palmetto’s Diabetes Guidance

Palmetto’s Local Coverage Determination regarding Diabetes has a significant update effective May 5, 2016.  From the LCD:

For other beneficiaries with stable glycemic control (defined as two consecutive HbA1c results meeting the treatment goals specified in the plan of care) performing the HbA1c test at least two times a year may be considered reasonable and necessary.

For other information on how these changes came about, check out ‘Care for the (whole) person with Diabetes‘ on the Haydel Consulting Webpage.

The entire text for the revised LCD can be found at the Medicare LCD database.  Remember these changes only apply to care provided after May 5.



Friday, we posted a quiz about OASIS.  In the next week or so, we will publish the answers to all questions but one question is being answered incorrectly so consistently that we feel obligated to explain the answer as it is likely costing you money and lowering your outcomes.

56 percent of you missed this question.

Upon admit, Mr. Jones states he is feeling better after a trip to the MD this afternoon. He denies dizziness and is able to walk unassisted with a walker, get in and out of his chair and use the restroom independently. According to his wife, he suffered severe vertigo and vomiting most of last night until he was finally seen late this afternoon. On admission you document:

His ability to transfer based on your observation of Mr. Jones independently getting in and out of the chair.  (50% of you chose this answer)

His inability to walk or transfer, get to the toilet, or bathe based upon his severe vertigo last night and this morning.   (42% of you chose this response)

His wife’s assessment of what he can usually do . (8% of you put your faith in his wife)

He is not homebound because he was able to get to and from the MD.  (Nobody questioned homebound status)

In order to arrive at the correct answer, you must know two things.  For functional limitations such as walking, ambulating, transferring, etc., your response must be based on what is true on the day of the assessment and….

You must know what is meant by a ‘day’.

So, how did 58 percent of you answer this question incorrectly?  Maybe because you are unfamiliar with an OASIS day which is quite different the usual day.  We couldn’t possibly make this stuff up so we are going to cut and paste from the OASIS Guidance Manual, Chapter 1, page 6.  We made the text bold – don’t give CMS credit for that:

Understand the time period under consideration for each item. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.

In the scenario mentioned, the patient had been violently ill all night and most of the day until he went to the MD in the afternoon.  The same manual (OASIS Guidance Manual) on the same page (chapter 1; page 6), states:

If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual status” or what is true greater than 50% of the assessment time frame, unless the item specifies differently.

Without counting minutes and seconds, this means that if Mr. Jones spent 12 of the 24 hours in question unable to walk, transfer, get to the restroom, etc. safely, his OASIS assessment should reflect it.  Assuming his night began as late as Midnight and he continued to be violently ill until the afternoon when he saw the MD, the time span covered more than 12 hours.

Your answer, therefore should reflect his epic vomiting and vertigo.

Here’s another explanation of how to assess the intoxicated patient which should be considered in Louisiana as Mardi Gras gets under full swing.

Why This Matters

If this was a rare and unusual situation, it would not matter very much but it is not – especially on admission.  Anesthesia, pain meds following a procedure, reactions to medications all have the potential for taking a patient out of commission for a day or so, prompting a physician to order services to monitor and treat the patient.

With only 42% of you answering this correctly, it didn’t seem right to wait until we publish the rest of the answers to prevent further damage to your published outcomes or payment.  Congratulations to everyone who got this question right, including Lori Hopwood of Lane Home Health – a 4.5 Star agency right here is South Louisiana.  Laissez bon temps rouler in Cajun Country.

Coding and Coverage for Hospice

It should be simple, right?  Choose from a list of codes that describe why your patient is receiving services and go on about your business…..  Piece of cake, right?

Somehow, that isn’t how it goes these days.

The first challenge is to determine what should be put in the diagnosis list.  The answer is quite simple at first glance.  Code every diagnosis that is related to the terminal condition of the patient.  At second glance, how does a diagnosis make the list?  Medicare says that pretty much any diagnosis in the zip code of the patient makes the list.  Old school providers say that only the terminal diagnosis makes the grade.  The real answer is somewhere in between.  Some questions to ask when determining which diagnoses makes the elite list:

  1. Is the diagnosis the reason the patient is terminal?

  2. Is the diagnosis one of the risk factors or underlying causes of the terminal diagnosis?

  3. Is the diagnosis a direct result of the terminal diagnosis?

  4. What happens if you don’t treat the diagnosis?

  5. Does the diagnosis affect the way that a patient responds to or participates in their plan of care?

Obviously, the terminal diagnosis will be included but on occasion, the terminal diagnosis is not clear.  A patient with end stage Alzheimer’s disease and NY Class IV heart failure doesn’t have a long future but it may be difficult to tell which of the diagnoses is terminal.  Use your judgment and if you are compliant in the rest of the coding process, neither the patient nor the hospice will suffer.

A patient who is terminal due to a stroke caused by long-standing hypertension would have Hypertension in the list.  The same patient may be confined to the bed in the final days of life and some skin breakdown towards the end of life is not unusual.  In these examples, the hypertension is an underlying cause of the stroke and the skin breakdown is a result of the stroke.  Both would be coded.

If pain, confusion or other discomfort is a result of not treating the diagnosis, it should be included.  Extremes in blood sugars may be encountered by a patient with a pre-existing diagnosis of diabetes.  Include it.

We see patients taking Statin medications which are generally used to lower cholesterol to prevent heart attacks in the future.  When the future is limited to a few weeks or so, it may not be important to treat the hypercholesteremia because nothing happens if it isn’t treated.

Patients with dementia are unable to respond to the plan of care as well as their clear headed counterparts.  Even when Alzheimer’s disease or other dementias are not the terminal diagnosis, they should be coded.

In the past, there have been hospice providers who have chosen the primary diagnosis based on the perceived cost of treating the diagnosis.  This has never been the correct approach to hospice care.  The hospice is tasked with covering essentially all care related to the terminal condition of the patient.  That does not mean that curative care should be offered for secondary and contributing diagnoses or even that the treatment prior to hospice admission must be followed.

Consider the following examples:

1.       A patient with a diagnosis of diabetes is admitted for services but her terminal diagnosis is heart failure.  Prior treatment was Lantus insulin.  In the interest of comfort, it may be reasonable to check blood sugars much less frequently and treat with a short acting insulin only when the patient is uncomfortable due to symptoms.  Because appetites and medications can interfere with blood sugar levels, longer acting insulins may not be appropriate.  Tight control of blood sugar is not going to help the patient in the long run.

2.       A patient with Alzheimer’s disease becomes severely agitated when his Namenda is withheld.  In order to provide the patient with the greatest level of comfort, the Namenda would continue.

Should a patient be reluctant to discontinue a medication, the family is free to purchase the medications.  However, it most likely will not be covered under the hospice benefit.   If the family has some of the medication from prior to admission, it can be continued while they are approached gently over time about the need for the medication vs the need to reduce the pill burden and potential for side effects.

Keeping these principles in mind, hospice patients can be accurately depicted in the diagnosis list and a care plan addressing the individual patient needs can be created.  It is not difficult but it will never be a reflexive and automatic process, either.  Until patients standardize dying, there will be no standard care plan.

Needless to say, we highly recommend certified ICD-10 coders to ensure that accurate coding is included on claims, changes in the patient condition are reflected in the coding list and you and your staff have time to spend with patients.

Targeted for ADRs

Every so often, Palmetto posts a list of the claims that will be of interest to them on their website. This is the list that was published on August 4.

Note the last letter of the HIPPS code. The letter ‘L’ indicates 16 – 17 therapy visits and the dreaded ‘K’ means that 20 or more therapy visits are scheduled. Only one of the edits is for therapy below 14 visits. In that edit, Palmetto GBA is looking for the lowest clinical and functional scores together with therapy.

Palmetto is asking why a patient who appears to be clinically stable and can walk, talk, bathe, transfer and dress themselves needs any therapy. It’s a good question. There could be a perfectly legitimate explanation but if it is not documented well, you are looking at a denial.

Pretty much all episodes with 20 or more therapy visits are being scrutinized. These are the expensive claims and people who are ‘gaming’ the system will often use high utilization as a method to do so. This does NOT mean that a patient should not receive 20 therapy visits if needed. For most agencies, these episodes will be few and far between.

16 and 17 visits are very profitable as well even if the dollar amount is not the same. The profit starts to drop off at 18 and 19 visits until 20 visits are made.

All clinical documentation should support the services billed but in an agency where staff is limited or compromised at time of billing, claims with these HIPPS codes might be prioritized for review prior to dropping claims.

1BGP* 0 – 13 Visits, Lowest Scores in the Clinical and Functional Domains and Maximum Score in the Service Domain
2BGL* 16-17 Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
2CGL* 16-17 Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
2CHL* 16-17 Therapy Visits, High Score on Clinical Domain, High Score on Functional Domain
5AFK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Low Score on the Functional Domain
5AGK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Moderate Score on the Functional Domain
5AHK* 20 or More Therapy Visits, Low Score on the Clinical Domain and High Score on the Functional Domain
5BFK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Low Score on the Functional Domain
5BGK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
5CGK* 20 or More Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
5CHK* 20 or More Therapy Visits, High Score on the Clinical Domain and High Score on the Functional Domain
All Aggregate Length of Stay and Disbursement/Beneficiary
All Home Health Services


The OIG on Medical Director Payments

The Office of the Inspector General recently issued a fraud alert regarding physician relationships with providers.  In case you don’t know any criminals, the Office of the Inspector General (OIG) is that government agency which prosecutes Medicare fraud and abuse and a lot of other things.  They are the ones who dispatch the FBI and other investigative agencies to catch bad guys.  It is never a good idea to get on the bad side of the OIG.

Now that everyone understands that it is foolhardy and dangerous to mess with the OIG, perhaps the recent warning regarding physician relationships, found here, will be of interest to you.

The essence of the alert is that you can only pay medical directors ‘fair market value’ for work they actually do for your agency.  You cannot simply agree to pay a doctor a flat sum each month to be your medical director.  The physician must work for the money and payment must be reasonable for the work done.  Fair market value differs for each community and a healthcare accountant might be a good place to start when determining the fair market value for your area.   Hint:  Most doctors do not make $1,250.00 per hour and two hours of work over lunch does not satisfy a Medical Director’s contractual responsibilities towards the agency.

The alert goes on to say that an agreement may violate the anti-kickback statute if ‘even one purpose of the arrangement is to compensate a physician for his or her past or future referrals’.  That’s right, folks.  You heard it here, first.  Any and all medical director agreements are to be entered into regardless of where the physician sends his patients.   It does not prohibit a physician from sending patients to an agency where he or she serves as a Medical Director but no part of the agreement should be contingent upon referrals.

There’s more!  The OIG is very clear that they have recently reached settlements with 12 physicians who entered into questionable agreements.  This works for me.  We have had over a million phone calls from clients and other agencies complaining because their physicians just don’t get why they have to do things as medical directors.  These phone calls usually are an attempt to get us to contradict what their lawyers have told them about entrance fees for golf tournaments or the new hunting rifle given as a Christmas present.  We never do.

There have been recent cases where jury convictions have been based upon ‘sham’ agreements where the list of services listed in a contract for a Medical Director were never really performed nor did the provider expect them to be performed.  Employees have been placed on the stand and asked about the frequency in which the medical directors were seen at a nursing home.

The Executive Director of a home health agency in Lexington, KY agreed to pay $1,000,000.00 back to Medicare for an ongoing fraud case involving kickbacks.  Note that the Executive Director is paying back the money – the case against the agency is ongoing.

The kickbacks in the Kentucky case are not what you might imagine.  The agency was a corporate sponsor of Kentucky football and physicians were given tickets to Kentucky football games.  Some were given bottles of tequila, as well, and tickets to see Journey play in concert.  This is not the type of financial exchange that many of us associate with ‘bribes’ and ‘kickbacks’.    In the South, football tickets tend to be a currency of their own.

Now would be a good time to have all of your contracts reviewed by a healthcare lawyer.  We can certainly recite the contents of the OIG fraud alert and news articles but we are not qualified to answer questions regarding nuances of the law and your specific contracts.   There are varying degrees of cost in these gifts and the specific conditions upon which a gift was given matters.

If you are too cheap to get your contracts reviewed by a qualified lawyer who specializes in healthcare, a good rule of thumb is to give nothing at all.  We cannot support any exchange of cash or kind without a healthcare lawyer blessing your contracts.  We have worked with several and will be glad to give you a name upon request.

Please remember that your cash will be cut off before you actually go to jail or write 7 figure checks.  As such, your coders and consultants will not be paid.   That’s completely unacceptable.