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.

 

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.

 

The OASIS Day


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.