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

 

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Home Health Conditions for Payment


We have looked and have been unable to find specific guidance on the new CoPs.  There was a phone conference scheduled with NGS that was cancelled and nothing so far from Palmetto GBA.  Help us out if you know anything.

Meanwhile, some people who are very knowledgeable and well respected in the industry differ from us in how we interpret what ‘estimating how much longer the patient will be on service at the time of recertification’ means.  Look for it below in larger bold text.

§424.22   Requirements for home health services.

Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.

(a) Certification—(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s eligibility for the home health benefit, as outlined in sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, as follows in paragraphs (a)(1)(i) through (v) of this section. The patient’s medical record, as specified in paragraph (c) of this section, must support the certification of eligibility as outlined in paragraph (a)(1)(i) through (v) of this section.

(i) The individual needs or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services as defined in §409.42(c) of this chapter. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification form, in addition to the physician’s signature on the certification form, the physician must sign immediately following the narrative in the addendum.

(ii) Home health services are or were required because the individual is or was confined to the home, as defined in sections 1835(a) and 1814(a) of the Act, except when receiving outpatient services.

(iii) A plan for furnishing the services has been established and will be or was periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)

(iv) The services will be or were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.

(v) A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in paragraph (a)(1)(v)(A) of this section. The certifying physician must also document the date of the encounter as part of the certification.

(A) The face-to-face encounter must be performed by one of the following:

(1) The certifying physician himself or herself.

(2) A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health.

(3) A nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(4) A certified nurse midwife (as defined in section 1861(gg) of the Act) as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(5) A physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(B) The face-to-face patient encounter may occur through telehealth, in compliance with section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.

(1) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.

(2) [Reserved]

(2) [Reserved]

(b) Recertification—(1) Timing and signature of recertification. Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Recertification should occur at the time the plan of care is reviewed, and must be signed and dated by the physician who reviews the plan of care. Recertification is required at least every 60 days unless there is a—

(i) Beneficiary elected transfer; or

(ii) Discharge with goals met and/or no expectation of a return to home health care.

(2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the recertification form, in addition to the physician’s signature on the recertification form, the physician must sign immediately following the narrative in the addendum.

(c) Determining patient eligibility for Medicare home health services. Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. This documentation shall be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described in paragraphs (a)(1) and (b) of this section. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.

(d) Limitation of the performance of physician certification and plan of care functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of care may not be established and reviewed, by any physician who has a financial relationship as defined in §411.354 of this chapter, with that HHA, unless the physician’s relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements.

(1) If a physician has a financial relationship as defined in §411.354 of this chapter, with an HHA, the physician may not certify or recertify need for home health services provided by that HHA, establish or review a plan of treatment for such services, or conduct the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act unless the financial relationship meets one of the exceptions set forth in §411.355 through §411.357 of this chapter.

(2) A Nonphysician practitioner may not perform the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act if such encounter would be prohibited under paragraph (d)(1) if the nonphysician practitioner were a physician.

[53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70334, Nov. 21, 2005; 72 FR 51098, Sept. 5, 2007; 74 FR 58133, Nov. 10, 2009; 75 FR 70463, Nov. 17, 2010; 76 FR 9503, Feb. 18, 2011; 76 FR 68606, Nov. 4, 2011; 77 FR 67163, Nov. 8, 2012; 79 FR 66116, Nov. 6, 2014]

Incarcerated Prisoners


 

 

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

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

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

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

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

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

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

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

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

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

Medicare Regional Map and Density of US Prison Population

image

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

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

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

Documentation Myth


 

When you code, what do you review?

One myth that is prevalent in home health is that the nurse must chart on the primary diagnosis.  This is a good rule of thumb but it is not a law or anything.  You will not go to jail if you venture off into another relevant area of patient care.

These are some of the errors we see because the focus of the nurses and coders is narrowed to the ‘primary diagnosis.

  1. The patient experiences an exacerbation or a new diagnosis and the clinician documents something like, ‘Pt reports falling this morning when trying to get out of bed.  Taught that concentrated sweets can raise blood sugar.”
  2. The patient is on multiple medications for hypertension but miraculously the patient does not have a diagnosis of hypertension anywhere.
  3. A poorly chosen primary diagnosis makes it to the initial plan of care and the obedient nurse documents on it throughout the episode.   When it comes time to code the second episode, the coder reads through the notes and determines that most care went to the bad diagnosis and re-codes with the same error.
  4. We continue to see low vision coded without a supporting diagnosis that cannot be corrected with lenses.
  5. Hospital paperwork mentions diseases and conditions that are nowhere to be found in the home health care chart.

So, back to the original question.  What are you reviewing?  If you are looking a the diagnoses that the nurse wrote on her assessment and simply applying the coding conventions, you need to find out where she is getting her information.  If she is repeating the same diagnoses as before, they may be wrong.  If there are no changes, the patient appears to be static to the Medicare computers that run edits on your claims placing you at high risk for scrutiny.

Coding that is compliant with all regulations doesn’t happen in one place.  The clinician must document accurately regardless of the coding sequence was at the beginning of the episode.  If necessary, complete a Significant Change in Condition Assessment.  Alternatively, if you believe that the coding was performed incorrectly, contact the person who does your coding and make clear why you think it is wrong.

Medicare expects you to code accurately but they do not expect you to be clairvoyant.  If your patient with diabetes as a secondary diagnosis has a sustained blood elevated blood sugar, it should not be ignored in the notes.

When the visit note content is a true and accurate reflection of the patient and you have all the supplemental information such as lab, hospital documents, etc., then true and correct codes may be assigned.  Coders need to learn to look for clues that the documentation isn’t as it should be. 

Initially, this may delay dropping a RAP for a day or so but it is better than leaving hundreds of dollars on the table or putting yourself at risk for denials. Good coding will eventually be the starting point of a more efficient process which will result in your agency fine tuning multiple processes improving patient care, communication and cash.  What’s wrong with that?

If you need help coding or billing, don’t hesitate to give us a call.  We can help you get your processes streamlined and improve your cash.  See the coupon below for a special offer for the first five readers who respond. 

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Face to Face Answers


If you have not already taken the quiz on Face to Face encounter for home health, please do so by clicking here before continuing.  The answers are as follows.

When should the face to face encounter occur?

The face to face encounter should always occur within the 90 days prior to admission for home health services or within 30 days following the admission.  However, if a physician visit in the prior 90 days was not for reasons related to home health services, an additional visit is required related to home health services.

Who may sign the face to face encounter? 

The physician who orders home health services must always sign the face to face encounter. 

How can you  best assist the physician in the face to face process?

The best way to assist the physician is with education.  Not only do physicians resent the additional paperwork but if your agency is following the guidelines, there is a really good chance that you are competing against other agencies that complete the face to face documentation for the physician.  By educating your referral sources, you are also protecting them from inadvertently participating in fraudulent activity. 

A physician documents that a patient is confined to the home because they do not drive.  What should you do?

The correct answer is to visit with the physician and ask him to document why the patient does not drive. Assuming the reason that the patient does not drive is related to their health and not lost keys, the physician will hopefully understand homebound status a little better after your discussion.

Which of the following is not true about Face to Face Documentation?

Although it seems redundant as it is repeated so many times, a common reason for face to face denials is that the physician who certified the plan of care did not sign the face to face document. 

Which of the following is not true about Face to Face Documentation?

Yes, there are two questions that read the same.  This refers to question 8 and the only untrue answer is that the face to face should not be sent by the hospitalist while the referring physician sends the certification.  The face to face document is considered a part of the initial certification.

Everything else is true.  The physician may use drop down boxes in his or her software if they adequately describe the patient.  The entire face to face document may be computer generated and recent denials because the date of the encounter was not handwritten are erroneous on the part of the MAC. That is not a requirement.

Which is true regarding the physician narrative?

The correct answer is that it should contain the patient’s condition at the time of the encounter.  When the face to face documentation differs from the agency documentation, a denial may result.  For instance, a physician states the patient needs therapy and upon admission, the patient refuses therapy.  Because the patient is new anticoagulation therapy, the patient is admitted from services.  This type of discrepancy has resulted in numerous denials.

When is it acceptable to bill without a face to face encounter?

The only time it would be considered acceptable to bill without a face to face encounter would be if the patient dies prior to the 30th day and the agency can show that efforts were in progress for the patient to see the physician.  Please note we are not suggesting that you introduce your patient to the great hereafter if the patient does not go to the physician as planned.

When the referring physician is unavailable, the Medical Director may sign the Certification and Face to Face documentation.  (T/F)

False.  The only time the Medical Director may sign the face to face documentation is on those occasions when the patient was seen and referred by the Medical Director.  These referrals must fall under the confines of Stark and Anti-kickback laws that prohibit the sale of patients.

The face to face documentation is required on all patients admitted to a Medicare certified agency regardless of payor source.  (T/F)

This is actually a trick question because Medicare clearly states that only Medicare patients require a face to face document.  Try telling Humana that.  They are denying claims based on the language in their contracts with agencies that all Medicare rules apply to Humana patients as well.  Get one on everyone just to be safe.

The physician who signs the plan of care must also sign the face to face encounter. (T/F)

If you started this Face to Face adventure believing anything else and you now know better, you have not wasted your time. 

What is true about face to face documents prepared by a hospital physician who then handed off the patient to a community physician?

A final, often overlooked reason for denial is that any document that is used as the face to face document must be clearly labeled as the face to face document.  If the physician merely staples a discharge summary with all the pertinent parts on it to the plan of care, it will not suffice.  ALF’s often have a form that contains al of this information but if it is not labeled as a face to face, it will not count.  Finally, some hospitals have software that generate a document that looks like a face to face without being labeled.  This is an easy fix and I trust you will never be denied for an unlabeled face to face in the future.

How did you do?  Did you learn anything?  Feedback is always welcome and criticism is swallowed whole when offered with our best interests in mind.

The Coders want  you to get paid.  Together with our affiliated companies, HCMB billing and Haydel Consulting Services LLC, we are prepared to offer billing, coding and clinical consulting services tailored specifically to your needs.  Contact us today by email or click here to get your questions answered.  And be sure to subscribe to our blog so you won’t a single post.