Category / essentials

by Julianne Haydel

Hospice Updates


I had the privilege of attending an educational session with Jamie Boudreaux with the Louisiana-Mississippi Hospice and Palliative Care Organization this week.  I highly recommend taking advantage of any opportunity that comes your way to attend any LMHPCO events.

During Jamie’s talk, he referenced numerous changes that were proposed for 2016 in Hospice.  After hearing so much about this exciting document, I couldn’t wait to read it.  You should read it, too and send your comments should you have any.

The highlights – or at least those points that we find interesting as coders and clinicians, are found below.  This is not an all inclusive account of the regulations and I strongly encourage you to read them for yourself.

Good News First

You are getting a raise.  It is projected that hospice payments will rise almost 2 percent.  But that’s not all.  Remember that talk about a U Shaped curve?  It isn’t exactly a ‘U’ but you now have a change in how you will be paid.

There are two factors that will increase your payment.  In the current system, due to the increased expenses in admitting a patient and establishing a care plan, a patient will be on service for approximately 21 days until the hospice breaks even.  As time goes by, the payment stays the same and hospice providers are collecting the same payment for long stretches of time when the patient has minimal needs.  This is traditionally when the hospice made money.  As death approaches, the costs usually increase again.

As such, two new provisions have been added.

During the first 60 days of hospice, payment will be at a rate (adjusted for your area) of $187.63

After day 60, per diem payment will fall to $145.21

Important:  An episode of hospice care is considered to be all episodes that are separated by no more than 60 days.  You cannot discharge and readmit a patient prior to 60 days and expect the higher rate.  Hospice providers who pick up patients from other hospices as in a transfer will be similarly unable to claim the higher rate.

But there’s more!

During the last seven days of care, hospices will be able to bill a Severity Intensity Add-on or SIA.  In addition to the hospice per diem rate, for Registered Nurse and Social Work visits during those last 7 days, an additional rate equivalent to the continuous care rate may be billed up to 4 hours.  That means that in addition to the daily rate, a hospice can receive almost $160.00 more.

There are conditions:

  • The additional rate is only available for Registered Nurse and Social Work visits.
  • The SIO is not available for patients in nursing homes.
  • The beneficiary is discharged due to death
  • The care occurs in the last seven days of life.

The reported reason for this change is to encourage providers to provide additional care when it is needed the most.  A full 20 percent of patients did not receive a visit on the day of death.

So that’s the good news.  Hospice providers will be receiving additional cash when expenses are the highest. Back to the beginning of the document where the news isn’t quite so exciting.

Background

Normally, we would not bore you with the background of any proposed regulations but in this case, the continual references to the 1983 hospice benefit rules probably indicate that some of the recent changes and proposed changes are an indication that hospices haven’t gotten it right, yet.

The tone of this document is well worth your time to read so you can heed the inherent warnings.

Attending Physician

The rule is one per patient.  The fact that over one third of patients have multiple physicians submitting claims indicating they are the attending physician results in Medicare paying the physicians when in fact, the hospice is the correct payor source.  Don’t get caught doing this.

A signed document is required when a patient chooses to change physicians.

The Joy of Scrutiny

Medicare is not mandating surveys to be conducted at least every three years as opposed to the every 6 year rule now.  Select hospices who have long lengths of stay can expect to find themselves on a private list where all claims for services past 180 days of admission are routinely reviewed.  Do not get on this naughty list.

Remember, the data exists for Medicare to look at the average length of stay in addition to the percentage of patients on service greater than 180 days.  That’s a really good number to keep handy, by the way.  You can have a lot of patients on service for a year or more offset by some short lived admissions so your average length of stay may be okay but you might still have far too many patients on service longer than would be considered reasonable and necessary.

Utilization

Obviously this is not a regulation but it is an indication of the overall ‘tone’ being set by document.

The number of Medicare beneficiaries receiving hospice services has grown from 513,000 in FY 2000 to over 1.3 million in FY 2013. Similarly, Medicare hospice expenditures have risen from $2.8 billion in FY 2000 to an estimated $15.3 billion in FY 2013

…..this increased spending is partly due to an increased average lifetime length of stay for beneficiaries, from 54 days in 2000 to 98.5 days in FY 2013, an increase of 82 percent.

Cost Savings?

image

This chart shows how many dollars per day were spent on patients in the 180 days prior to hospice admission and how many days spent in the care of a hospice.  As it turns out, both of these numbers are critical for determining potential savings to the Medicare trusts.

On the vertical column, you can see the grand total of days a patient spent in hospice.  The horizontal line shows what the average daily cost of the patient was prior to admission.

This is Medicare’s work.  We do not agree with this method of cost analysis.  However, any differences of opinions regarding the formulas used do not account for $158,000 per patient with a diagnosis of Alzheimer’s Dementia which is about what it works out to be over 120 days.

The Medicare Hospice Benefit is not reducing healthcare costs in terminally ill patients. This is a problem folks.

Live Discharges

The proposed regulations are very clear that nobody expects the live discharge rate to be zero.  Patients have the right at any time to revoke their election at any time.  Some patients start to get better especially after they have been taken off 25 medications designed to prolong their life.  They move and sometimes they just hate your hospice and revoke.

Based on the data within the proposed regulations, there can be no doubt that an above average live discharge rate strongly correlates with other undesirable characteristics of hospice provider.  The patients discharged alive are from providers that also have more long term, low maintenance patients.  Additionally, patients in these hospices cost Medicare more in terms of money spent for nonhospice care.

The proposed regulations reiterated the limited number of reasons that a provider can discharge a patient.  They are as follows:

    • death
    • revocation
    • transfer to another hospice
    • moving out of the hospice’s service area
    • discharge for cause,
    • patient no longer being considered terminally ill (that is, no longer qualifying for hospice services

When discharging for cause, ensure that all reasons are documented especially if a patient has been on service for a while.  When more than one neighborhood becomes unsafe on day 181 of a hospice episode of care, it makes for a pattern.

There are very few legitimate causes for discharge in hospice. and the regulations are clear that discharging patients due to cost is not approved by Medicare.

Comments from Providers

The data in the proposed regulations is stunning but the real damage comes from various and sundry anecdotes.  It is important for providers to understand what those who right the rules are thinking and how they are thinking.   Copied directly from the regs:

We have received anecdotal reports from non-hospice providers who have rendered care and services to hospice beneficiaries in which the non-hospice provider states that the care given was related to the terminal prognosis of the individual. These reports go on to say that they have contacted hospices to coordinate the care of the hospice beneficiary only to be told by those hospices that they disagreed with the non-hospice providers’ clinical judgment that the care was related to the terminal prognosis.

We have been told that hospices are refusing to reimburse the non-hospice provider for care related to the terminal prognosis.

non-hospice providers also informed us that the hospices told them to code the claim with a different diagnosis or to code condition code 07 (treatment of Non-terminal Condition for Hospice) or the modifier “GW” (service not related to the hospice patient’s terminal condition) on their claims to ensure that the non-hospice provider would consequently get paid through Medicare.

We have also received anecdotal reports from hospice beneficiaries and their families that they have been told by the hospice to revoke their hospice election to receive high-cost services that should be covered by the hospice, such as palliative chemotherapy and radiation.

In addition to publishing these comments, staff memos to employees of specific large hospices were included stating that their providers should go after the long term patients.

Terminal Prognosis

This is the last time that you should ever consider the words ‘terminal’ and ‘diagnosis’ together.  People do not have terminal conditions in isolation.  They have terminal prognoses.

All of the research and numbers that Medicare has presented all go to support their belief that hospices are not living up to their provider agreement which includes care for the diagnoses that is most likely to cause death and any and all other diagnoses that affect the patient’s comfort, are a result of the terminal prognosis or contribute to the severity of the prognosis.

Consider a patient who needs bypass surgery but because of diabetes, long term use of steroids for arthritis and a longstanding history of noncompliance due to a psychiatric illness, she is not a surgical candidate.  There is no one diagnosis that is terminal.  All of them play a role in his terminal prognosis and all must be addressed by the hospice.

Coding

You are making progress!  In the 2015 regulations it was noted that 72 percent of hospice claims had only a single diagnosis.  This year, for the 2016 update, the percentage of claims with only diagnosis is down to 49 percent.

In addition, because there has been confusion and discussion about the nature of the ‘terminal prognosis’, providers have been omitting diagnoses that are significant to the patient’s overall condition.

Since the inception of hospice, adherence to the International Classification of Diseases (ICD) has been mandated.  This means that the primary diagnosis and all diagnoses that affect the patient’s ability to respond to or participate in the plan of care are to be included.

Therefore, we are clarifying that hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual. This is in keeping with the requirements of determining whether an individual is terminally ill. This would also include the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.

I have heard of denials because patients were admitted to psychiatric facilities that billed Medicare because the patient’s ‘terminal diagnosis’ was not psychiatric in nature.  I suspect this has happened numerous times because psychiatric conditions are mentioned more than once in this document.

We will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.

Let the last sentence of the section on coding resonate loudly on your priority list.  We can and will code for you.  You can learn ICD-10 coding or you can outsource to another company.  Alternatively, we can help with appeals, Focused Medical Review, or ZPIC audits.  The choice is yours but if you’ve ever been through that kind of regulatory scrutiny before, you would not choose non-compliance.

There is more – so much more but try digesting this first and we’ll keep an eye on the final release and do our best to summarize it for you.

by Julianne Haydel

5 Common (expensive) Errors


Sometimes we get discouraged because we seem to teach the same information over and over again. The fact is that many nurses in home health and hospice are new to the industry. Complicating matters is the fact that many of us have been around so long and are so familiar with OASIS and coding that certain that it is difficult to believe it is hard for the new kids on the block. If you are the new kid on the block, read carefully. If you aren’t the new kid on the block, read it and share. These five errors are common occurrences and there is no good reason for a good agency to leave this kind of money behind.

Low Vision:

It is easy to miss the mark here. We see low vision coded with no supporting code, supporting codes without a low vision code and no codes for vision even though the patient is on three drops for glaucoma. Consider that a patient with low vision is compromised. Even when low vision is not actively addressed in the care plan, the patient will be at higher risk for falls, require slower teaching because they may not be able to read your teaching guides and are prone to medication errors. Even when a diagnosis does not meet the criteria for low vision, be sure that the patient’s visual acuity, or lack thereof, is fully documented. Remember, low vision codes require a supporting diagnosis that is not corrected with lenses or surgery.

Omitted Diagnoses

The OASIS instructions for M1022 state that all diagnoses that affect the patient’s response or outcomes must be included in the secondary diagnosis list. Many clinicians are limiting their diagnoses to those that are actively being treated. Several denials have come across our desks where a reviewer actually includes the lack of orders and goals for a diagnosis as a reason for denial. Always refer to the OASIS Manual Chapter 3.

When determining which diagnoses should be included ask yourself if you think the treatment plan or the patient’s outcome would change if he or she did not have the diagnosis. Diabetes affects pretty much every system in the body and would always be included. GERD, maybe not so much. Low vision, Yes. Hypothyroidism, No. When the diagnosis really doesn’t affect the plan of care or the patient’s response to the plan of care, leave it off.

Too many diagnoses:

See above. There are some diagnoses for which an agency receives additional reimbursement that are put on care plans when they should not be. This puts the agency at high risk for denials. If a patient takes Nexium, it does not mean that they have GERD. If a patient is newly diagnosed and your care plan involves teaching diet and new meds, absolutely include it.

Symptom Codes

When a diagnosis is characterized by a symptom, don’t code the symptom. Arthritis is a condition that causes inflammation and pain of the joints. There is no reason to include pain. But, don’t forget to assess it, treat it and document pain in your notes of an arthritic patient.

Juggling Codes

A long time ago, someone told agencies that one reason they were being scrutinized is because the diagnosis codes never changed. That much is true. However, simply juggling the codes without any supporting documentation looks as though you rearranged codes to avoid having your patient look as though they were stable with no ongoing needs. If your patient doesn’t need you, discharge them. If your agency doesn’t like it, so be it. Move on. Do not be part of a culture that plays fast and loose with Medicare regulations.

Be sure to get with us if you have any questions or if you need any help with coding. We love questions.

 

 

by Julianne Haydel

Quarantining Kaci Hickox


When I went to nursing school, it was called isolation.  When HIV became better known, ‘universal’ precautions were implemented.  Every patient was treated as though they were HIV positive and they still are.  Now, there’s that pesky little Ebola bug and it is causing nothing if not widespread fear and panic.  It’s not blood borne and at this juncture, isolation precautions are being threatened. 

Unlike HIV, Hepatitis and other blood borne diseases, nobody is able to state with complete certainty that there is no risk of exposure from casual contact with an Ebola infected patient.  The odds are clearly in favor of no infection but someone wins the lottery against staggering odds every week or so.  A very low risk is not the same as no risk.

We are Americans and we want absolutes; unwavering positions, assurances and guarantees.  We want answers before we ask the questions and we do not sit well with not knowing.

Lacking absolutes, we conjure up every possibility in the universe.  Fear sells.  Anxiety is contagious.  If you want to sell a newspaper, write about something frightening. 

On the other hand, if you are a politician seeking reelection, preventing widespread panic and fear is the way to go.  The end result is that Americans get mixed messages and trust is eroded.

Where we stand now is between the press and the politicians with two very different agendas and neither of them is completely trustworthy.  It is for this reason that it’s reasonable to ask those people who have been in contact with Ebola patients to lay low for a couple of weeks until the period of incubation has expired.  The risk may be very low (as per the politicians) but the consequences are dire (according to the press).  It is in that measurement between risk and consequence that decisions are being made. 

Kaci Hickox, a nurse, is bound and determined to convince us all that mandatory quarantine is barbaric and illegal.  She knows that if she goes out in public, the fears of the community will escalate but strangely that is exactly what she wants to do.  She is basing her position on science but science has not revealed all there is to know about Ebola as yet.  She is forgetting that science is only half of the ingredients of a good nurse – the other half being compassion.  Where is her compassion for those individuals, perhaps thousands, who will lose sleep if she breaks quarantine?  Where is her compassion for her neighbors who will voluntarily isolate themselves out of fear? 

I gather Kaci Hickox, who took care of Ebola patients for 4 weeks in Sierra Leone, is so utterly confident in her own isolation techniques that she believes it to be impossible that she is sick with Ebola.  I have seen that kind of confidence before and it never ends well.    

In comparison, Nina Pham and Amber Vinson took care of an Ebola patient in a US Intensive Care Unit – a far cry from the facilities available in West Africa.  Maybe Kaci Hickox is a much better nurse than the Dallas crew or maybe she is just selfish. 

Her lawyers are falling back on a supreme court opinion that says that quarantine cannot be enforced based on fear alone.   One look at the number of cases in West Africa and the trend would scare the Supreme Justices, too.  Just for fun, check out this graphic from the Economist.

I wish I had all the answers.  This much I know….  If I had been in Sierra Leone taking care of Ebola patients and then flew home to the US, I would be tired.  Jet lag is a killer all by itself.  If someone offered to bring me food and told me to hang out at my house for a couple of weeks, I could live with that.  I could appreciate that even though the risk of spreading the virus is very low, the risk of frightening my neighbors is very high and I do have compassion for most of my neighbors. 

Maybe Kaci Hickox is fearless and brave but a new mother who ran into Ms. Hickox at the mall with her infant child might very well live in frank, abject fear for weeks when she is already tired and cranky.  A corner grocery store where people shop might suffer enormously if Kaci Hickox showed up there. 

None of this matters to Kaci Hickox.  I am not used to nurses being selfish. She is like a three year old who wants to go out and play and doesn’t quite get that none of the other children want to play with her.  I understand that the fear is out of proportion to the risk but fear is as ruthless as Kaci Hickox appears to be. 

A greater concern is the fact that she is forcing the hand of authorities to use a higher level of vigilance than would be necessary if she took a break from the ‘all about me’ attitude.  She is taking the attention away from where it needs to be which is on the virus and it’s prevention and cure and bringing it to herself and her own desires to wander around aimlessly regardless of how uncomfortable her presence makes others feel. 

If any of you are brave enough to go to Sierra Leone, have no fear.  You will have our undying support.  Blog readers everywhere will make you wish you were isolated even longer so you could bask in our undying admiration for you.  But, please do not go if you are not prepared to lay low and err on the side of safety when you return if you err at all.  We don’t want to hear about your ‘rights’ when the consequences are so great even though the risk is small. 

When science tell us there is zero chance of spreading the disease, we will come and hug you but until the guarantee is in place and supported by evidence, we’ll worship from afar. 

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. 

by Julianne Haydel

Coding Essentials


Most nurses in the field no longer code and yet they remain the most important source of information when it comes to assigning ICD-9 codes.  In the majority of cases, a good assessment will tell the coder everything they need to know but not always.  If the coder isn’t certain of how to code, there is a good chance the care plan and documentation that follows will be inadequate resulting in a denial should the claim ever be reviewed.

That’s where a good admission summary comes in handy.  A lot of agencies have let the summary go by the wayside as it is not technically required anymore.  I bet your next paycheck that agencies who write summaries are denied less often than those who do.

A summary can be a long and boring narrative put together from a template that reads exactly the same as all the other summaries in the agency or it can be as simple as answering a few simple questions.

You can find a summary worksheet here to use as a sample.  Most computer systems will allow you to create templates.  If not, a summary can still be created using these questions, modified for your agency’s use, if the responses are in complete sentences.

There is no right or wrong way to write a summary.  Nurses who do not like to write often find it difficult and time-consuming.  Using a tool to order thoughts and facts can be of enormous use.

Depending on the software you use, you may want to add vital sign ranges.  Some software will print lists or summaries of vital signs for you.  The med list should always be attached to recertification paperwork so questions about meds can be answered.  You would be amazed at how often medications change from one episode to the next without an interim order.  This worksheet along with a current med sheet will allow you to document what has gone on with the patient’s med regime so that the skilled care provided will be evident.

Most important, pretty much any coder can work from a sheet like this.  It does not matter if the skilled nurse knows that two codes are needed for a pressure ulcer if she documents a wound to the left heel.

Patient care has become increasingly ‘technical’ but historically good patient care has always been a combination of science and art.  By off loading the technical task of sequencing coding, the nursing staff is able to devote more time to the art of caring while coders solve the ICD-9 coding puzzle but only if the coder has all the puzzle pieces.