Category / documentation

by Julianne Haydel

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

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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?’

by Julianne Haydel

10 Common Documentation Flaws


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Stop and use caution before documenting your visit!

 

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

1.  No MD Contact Documented when appropriate

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

2.  Contradictory Information

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

3.  Blind Adherence to Rules of Thumb

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

4. Failure to Document Sensitive Information

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

5. Missing the Little Stuff

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

6.  Missing the Big Stuff

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

7.  Lack of Follow-Up

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

8.  No Ongoing Medication Reviews

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

9.  Taking the patient’s word at face value

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

10.  Evidence of Ignorance

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

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

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

by Julianne Haydel

Computer Charting


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Computers are tools.  They give your staff the ability to surf the net, check FaceBook or even work.  Sometimes, surfing the net would be preferable to the computer documentation I have had to suffer through lately.

This is not a new pet peeve but it is regularly exacerbated.  One idea is to turn off the software’s ability to carry over visit note content from one day to the next.  Agencies are afraid their nurses would quit if they did that.

Just two weeks ago, I wrote a plan of correction for an agency that addressed essentially duplicate notes.  It seems the surveyors are also noticing very little original content in visit notes.  The plan my client decided on was to disable the ability to cut and paste for one week for an initial offense for a nurse, a month for the second and permanently for the third.  This only works if you system allows you to individualize each user’s abilities.

Everyone uses templates and revises old documents and contracts to make new ones.  Everyone’s phone rings and has distractions.  The difference with clinical documentation is that typo’s are the stuff of Medicare Fraud and Abuse.

Do you know Daniel R. Levinson?   He holds the position of Inspector General of the United States.  When someone refers to the OIG, they are referring to his office.  Unless you are paid handsomely to defend someone against charges brought by the OIG or you play tennis with him, you never want to hear your name in the same sentence as Daniel Levinson’s.  So, having said all that about the Inspector General, let’s hear what he has to say about your computer documentation.

Experts in health information technology caution that EHR technology can make it easier to commit fraud. Certain EHR documentation features, if poorly designed or used inappropriately, can result in poor data quality or fraud.

This next one kind of gets under my skin a little but he is absolutely correct.  I just wish he would remember that the most important reason to document is to improve patient care by committing to writing pertinent facts about the patient and their treatment.

When doctors, nurses, or other clinicians copy-paste information but fail
to update it or ensure accuracy, inaccurate information may enter the
patient’s medical record and inappropriate charges may be billed to
patients and third-party health care payers.

The Inspector General highly recommends the use of audit tools, as well.  I’m not sure that is an effective solution to all but the most egregious offenses.  The nurses I know sign their name to duplicative documentation.  I know nurses who share passwords all the time.

The only time that I have ever detected the appearance of actual fraud is when nurses documented more visits than are possible on a single day with over lapping times.    I know from frequent experience that it is easy misdate a handwritten signature or document.  Computers are far more reliable than most humans in getting the date straight.

The best audit tool begins at the hiring process.  People with integrity do not commit fraud.  We have all been desperate for someone to fill an urgent need in the schedule and plugged in the wrong person who had not been vetted properly.   That’s a painful mistake because ultimately, the agency is responsible for what happens inside its organization.

The second best audit tools are the back office people and coders who read scores of documentation.  They will notice duplication and unlikely events sooner than a QA nurse who is reviewing a smaller percentage of clinical records.  Coders and billers spend hours of time at computers each day.  They make scores of errors, correct them and move on to the next plan of care.  When they see an obvious typo, they don’t see it as Medicare fraud because, get this –nobody is actually trying to commit fraud.

The only people who view these typos and occasional duplicated notes as fraud are the ones who can deny you payment or arrest you.  If I were you, I might take a second look at your computer documentation practices.

Just saying…. 

by Julianne Haydel

Weights


The Oxford English Dictionary defines weight as a body’s relative mass or the quantity of matter contained by it, giving rise to a downward force; the heaviness of a person or thing.

What the OED fails to mention is that weights are a critical measurement of overall health.  Symptoms of many diseases cause a person to shed weight.  Other diseases cause people to add body mass or weight.  It is a good thing to know what your patient weighs but more important to know how their weight changes over time.

Nobody gets concerned about weight loss of a pound or two.  Some of us are even thrilled when we notice the needle on the scale drift downwards a bit.  What we occasionally see when I look at episodes in their entirety is significant weight loss over the period of 60 days that is unexplained by diet or increased activity.  Nurses in the field sometimes fail to realize that the pound or two here and there over several weeks could point to an unresolved health issue.

It seems almost pointless to tell nurses to weigh their patients with congestive heart failure and yet over the week, we have reviewed numerous charts from different agencies where no weights were recorded.  This lack of attention to a basic measurement of congestive heart failure can and does lead to unnecessary hospitalizations. 

Sometimes, it seems that orders are written to prevent that burdensome task of notifying a physician of a decline in a patient’s condition.  A frail elderly woman weighing 103 pounds should not have to gain five pounds before the physician is called for orders.

What you may not know is how much this is costing you in terms of denials.  If you are a manager or administrator responsible for ensuring compliance to Medicare coverage rules, pay close attention.  

Observation and assessment is only a skill for three weeks unless there are credible findings that a patient is at risk for exacerbation.  For our purposes, an exacerbation is a worsening of a condition that involves changing the care plan.  In order to change the plan of care, the physician must be involved and new orders received.  Not every order must be for medications so be prepared to ask the physician if he needs lab or if you can make an extra skilled visit to check on the patient.

Each order you receive is like a ticket to ride the episode train a little longer.  Skills are provided and they are reasonable and necessary because there is documented information upon which decisions regarding care are made.

Without a documented information, the same skills may very well be provided without meeting the reasonable and necessary criteria.  Or, the weight gain may not be noticed especially if a different nurse sees a patient. 

None of this is anything that can’t be handled but the first step is to take it seriously.  The easiest way to do this is to begin weighing all patients.  Reserve written orders only for those patients with diagnoses or conditions that require weights to prevent unnecessary tags on survey in the event one is overlooked.  Habits are powerful things.  You will know the habit is real when you just don’t feel comfortable until a weight is documented.

Every patient should have a scale in their home.  No home health agency has ever filed for bankruptcy because scales were purchased for patient care.  It doesn’t even have to be a good scale.  It just needs to be the same scale in the same place at the same time each day. 

If you want to provide telemedicine but don’t have the resources, you can get the patients to call their weights into the voicemail of an unused line at your office by three o’clock every day.  Those patients who have not called can then be contacted by a part time student.  Imagine the delight of a surveyor when they see pretty little spreadsheets with weights on them and orders in the chart corresponding with increases or decreases.  Better yet, imagine the horror of the MAC reviewer who desperately wants to deny your claims because care was not reasonable and necessary and sees the very same thing. 

This low-tech telemedicine program also allows you to be more conservative with visits so you can attack weight changes like a SWAT team.  Go ahead and make daily visits for two to four days and cut out some of those visits where the patient is taught that one side effect of Lasix is frequent urination as if they didn’t know after taking it for a year or more.  The worst that could happen by scheduling conservatively while following weights telephonically is that patients will develop the habit of weighing themselves and become more compliant with meds and diet.  Then you actually save money by making fewer visits.  How cool is that?

Don’t stop with failure patients.  The sad fact is that some people don’t have enough to eat.  Your patients are confined to the home and may be too embarrassed to tell you that they do not have enough money for food.  Other elderly people seem to lose their desire for food and still more have side effects from medications that cause increased or decreased appetite.   Whatever the underlying reason, it can only be addressed if you know about it.  Assuming your patients are not wearing tight yoga pants and a sports bra during nurse visits, the easiest way to determine weight changes before harm comes to the patient is by weighing them.

You are nurses.  You can do this.  I promise. If you are one of those nurses who habitually forgets to weigh your patients, think of us for a change.  It will be so much easier to code charts if there are orders and exacerbations.  We’re not asking you to cause an exacerbation by slipping some salt in their tea or moving the needle of the scale up a few pounds.  We just want you find out about an exacerbation and get some orders while the problem is manageable and get paid well for taking good care of patients.