Medicare’s Pre-Claim Review Demonstration Project


Imagine if every one of your Face-to-Face documents and plans of care were scrutinized prior to payment.  Would 90 percent of them be found compliant with existent rules?  If a non-clinical person determined that your documentation did not meet Medicare coverage guidelines, would you take their word over your nurses’?  How would you feel about submitting a perfectly valid claim for eligible services and being paid 25% less than your peers?

Agencies in Illinois do not have to use their imagination.  It is already happening through the Pre-Claim Review process.  This process involves submitting plans of care, face to face documents, physician and hospital notes and sometimes more to Palmetto prior to dropping a claim for ‘affirmation’.  Once affirmed, a secret code is given to the agency which is placed on the claim. Without the code, final claims are reduced by 25 percent.

And while Medicare is reporting a 90 percent ‘affirmation’ rate, it does not report that there were over 80,000 RAPs submitted compared to 23,000 final claims.  Agencies are apparently reluctant to submit their pre-claim review documentation.

Because a RaP will be taken back after 120 days if not answered by a final claim, I expect that many agencies are going to drop an enormous number of claims in the coming weeks which means the number of pre-claim reviews will far exceed that ever imagined by Palmetto, GBA.  Maybe Palmetto really can process an additional 60k reviews without any interruption in services to the rest of us.  Maybe; but I doubt it.

In April, Florida will come on board.  Texas, Michigan and Massachusetts will follow at undetermined dates.

Agencies in states other than Illinois might not be impressed with all this stuff and nothing.  They are busy with the changes to the OASIS data set, the impending Conditions of Participation and perhaps their own audits or surveys.  Hopefully they will take pause and consider the magnitude of this demonstration project to understand the egregious nature of this intrusive and burdensome little project taken on by Medicare.

The new conditions of participation expected in July of this year explain that the prior Conditions focused on identifying agencies with poor performance.  The updated Conditions of Participation take a much-needed step away from this punitive approach.  As written in the new regulations:

Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.  

There is nothing about the Pre-Claim Review process that stimulates broad-based improvements in healthcare.   How could the Pre-Claim Review Project be so far removed from the intent of the home health Conditions of Participation?

Consider that the demonstration project is resulting in difficulty meeting the educational demands in Illinois and that resources have already been relocated from Florida to Illinois.  Do agencies in other states have the same access to education as the agencies under pre-pay review?

According to the Medicare Pre-Claim Review Q & A:

The demonstration establishes a pre-claim review process for home health services to assist in developing improved procedures for the investigation and prosecution of Medicare fraud occurring among Home Health Agencies providing services to Medicare beneficiaries.

Nobody can deny that a small number of agencies operate without any regard to Medicare rules and only a passing acquaintance with ethics.  This inconvenient acknowledgment of fraud amongst the ranks does not justify excessive scrutiny on 100 percent of providers.  Somehow it does not seem fair to involve home care agencies in a demonstration project designed to enhance their prosecution.

And yet, agencies who fail to submit documentation for a Pre-Claim Review are put on a 100 percent review – a level of scrutiny previously reserved for agencies operating far outside of Medicare rules for an extended period.

The documentation required for a pre-claim review is reviewed for clerical errors and dare I say, elements that cannot be established with limited documentation by reviewers who are not nurses.  The reason for denial given most often per Palmetto GBA is lack of medical necessity.  We see care plans daily that are very poorly crafted supported by excellent nursing and therapy notes.  Conversely, we see plans of care worthy of a Pulitzer prize supported by 9 visit notes at weekly intervals documenting that a skilled nurse taught meds – presumably meds ordered for the patient but who knows?  Nobody asked us if it was possible to determine Medical Necessity without a complete review of the chart.

In the same vein, we see homebound status documented on visit notes that is contradictory to plans of care.  In one recent chart, we found that a patient was shopping weekly.  On another, a therapist documented the patient was driving.  Sufficient documentation on a plan of care that a patient meets the homebound criteria does not make it so.

But, the reviewers are also quick to note when a signature is not dated or the date of encounter is omitted from the Face-to-Face encounter document.  I agree that dates are an important step towards compliance but lack of a date is often nothing more than an oversight; not a tell-tale sign of fraud on behalf of the agency, especially since it is the physician who responsible for the dates.  If this keeps up, the federal prisons will be filled with healthcare providers who forgot to date a couple of documents.

The burden to the agency is extensive.  On a recent CMS conference call, many agencies reported that the PCR process was costing them $25,000.00 per month.  Another agency stated it was taking them about an hour per claim.  Even if these estimates are overstated, they are still far above Medicare’s estimation that it would take minimal time and expense to get the pre-claim reviews submitted.

If Tom Price is confirmed as the new secretary of HHS, there may be some relief but the Georgia representative will oversee 13 different agencies including CMS, the CDC, the FDA, National Institutes of Health and more.  While he has been outspoken against the Pre-Claim Review Process as a senator it is hard to imagine that the Pre-Claim Review process will find its way to the top of his priority list upon confirmation.

So, who benefits from this circus?  Is Palmetto being honest when they say the project is going well?  Are our patients happier and healthier because of frantic efforts to assemble and transmit paperwork?  Could the resources being consumed by The Pre-Claim Review project be put to better use?  What can you do?

I can only provide an answer for the last question.  The first thing you should do is to contact your elected officials in Washington.  After that, get your care plans and Face-to-Face documents in order because there is now an abundance of reviewers at Palmetto who are fluent at reviewing (and finding cause to deny) them.  If you are in Illinois and have claims that you believe are non-affirmed due to incompetent reviewers at Palmetto, contact NAHC.  Under no circumstances do we recommend ignoring the Pre-Claim Review Process because your state is not in the demonstration project.

Many Thanks to Tim Rowan, founder of the Home Care Technology Report. who has extensively and  investigated the Pre-Claim Review process and its effect on providers.  His articles are linked within the content of this post and you can find additional information on his website.

And of course we want your comments and questions.  You can leave a comment here or email us with questions.  We particularly want to hear from Illinois agencies (after you contact your elected officials).

Advertisements

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.

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.

Nina Pham


 

The CDC, among others, have suggested that perhaps more training is needed to ensure that direct health care workers are properly using protective equipment.   According to that line of thought, poor Nina Pham simply did not know what she was doing when she picked up a touch of Ebola from her patient.  If only she had more education on how to put on gloves and a gown, this whole disaster could have been avoided.

I think not.

I posted my dismay regarding re-educating nurses on FaceBook and was amazed at how smart my friends are.

One non-nurse, Michelle said that education was a way to protect the facility.  In other words, when a policy is violated, the hospital is able to assure any surveyor or lawyer that they did, indeed, provide the education and training and have therefore met their responsibility.  Sadly, a successful healthcare facility (and by successful, I mean isn’t closed down) must cover all bases to minimize damages.  I would probably waste time and resources re-teaching PPE, too if I had to make the decisions.

She also pointed out that maybe protocols are not strictly enforced when the risks are lower which could lead to bad habits.  I agree.  Ever notice how MRSA is already a problem when we start monitoring hand hygiene?  (I love that.  Hand hygiene – soon there will be an aisle in the supermarket for hand hygiene products instead of soap, antibacterial gel and hand lotion.)

Lisa Selman Holman pointed out how very miserable PPE is to wear.  She is right.  It is hot and sticky, nothing fits right and it is ugly in the most unforgiving way.  I have yet to figure out how looking like Big Bird assists in the infection control process. Healthcare workers, especially those with a fashion sense, can’t wait to take it off.

If ever there was a time to spend money, this would be it.  Athletic clothing manufacturers have done amazing things with sports gear.  It seems like a clothing manufacturer who exists because they make comfortable, functional clothes that can wick away perspiration, kill enough germs to smell good and keep a body warm in water might be able to help design something comfortable, disease proof, easily taken on and off  with the assistance of an infection control specialist.

Sara Kawaguchi came up with the idea of having two people involved – one present simply to observe.  I love this idea and it is cheap to do when considering the stakes.  Having never met Miss Pham, I can only assume that she didn’t tear a glove, look at it and say, ‘Oh darn,’ and carry on with restarting an infiltrated IV line.   If she breached protocol, it was likely unnoticed by her.

My cousin, Steve, is a physician and his response was simple.

1) we are human
2) we make mistakes
3 there is no room for a mistake here, in flight or in surgery

There’s a lot of truth in that but we can minimize mistakes.  Even the world famous Quality Assurance plan designed by Toyota, Six Sigma refers to only six errors in a million.  When it comes to Ebola, nobody wants to be one of the six.

The Checklist Manifesto by Atul Gawande is written by a surgeon who almost killed a patient because he forgot to do something very simple and standard prior to surgery – type and match blood.  After this near catastrophe that left his confidence shaken, he set about researching how to prevent errors.  It turned out that aviation history was marred by the crash of the first B17 in which several people died.  It almost took Boeing aircraft out of the game completely.  The solution included a checklist which enabled the (highly skilled and trained pilots) to fly 12 planes a total of 1.8M miles without incident.  It is now used universally.

Checklists are not designed to educate anyone.  If you have ever turned in visit notes only to find out that you forgot to write a narrative because you were interrupted, you are prone to human error.  If you have ever been called about a bill you know you paid only to find the stamped envelope in your purse, you could have used a checklist.  They are designed to let you pick up where you left off in the event something slips your mind, you are preoccupied or there is chaos all around you.  They ground and center the user.

There are undoubtedly numerous approaches to improving the safety of healthcare workers but re-educating the staff in a critical care unit on how to put on and take off PPE is an intervention for the hospital – not the nurses.  Don’t tell me that the staff in an intensive care unit requires more schoolin’ to put on gowns, masks and gloves.  Make them more comfortable so they aren’t urgently ripped off like they were on fire the minute you clear the room.  Have someone else watch.  Use a check list.  Doing more of what was done in the past because it didn’t work doesn’t quite make sense to me.

What the healthcare staff needs the most is a cure for Ebola.  When it comes to caring for a patient with Ebola, especially at the end of life, perhaps the most important changes will come about from the staff who were actually there doing the job.  If the blame game stops and the focus is directed to increased protection of healthcare workers, why not consult that handful of clinicians who are the only ones in the United States to have cared for Ebola patients in US hospitals?

I know that you join The Coders in wishing Godspeed to Nina Pham’s recovery.  She was able to be there for a patient isolated from his family and friends when he needed them the most.  People like Nina Pham do not put their own lives on the line for a paycheck.  She has a calling and I pray she will be back at work sooner than later.

Also,  let’s not forget that Nina Pham is not alone.  A few dozen other healthcare workers who took the same risk as Nina Pham and so far, have been free of symptoms.  These include the staff in Dallas as well as Nebraska and GA where two other Ebola patients have been treated.  They are no less heroic because they have not contracted Ebola; they just haven’t made the news and I hope they don’t any time soon.

Ebola? Here in the States?


 

It looks like we have company in the form of another virus.  Ebola has caused quite a stir in the US and the media is torn between reporting it as a benign little incident so insignificant as to not warrant our attention and predicting Armageddon.  With all new viral pathogens, it is difficult to predict.  A virus will do what it can to survive and most times that means reducing the severity of the illness so as not to kill its host and prolonging the incubation period.  Who knows what Ebola will do.

If 40,000 fatalities from Ebola were predicted this year, there would be mass panic.  If there was a preventative measure, who wouldn’t do what they could to get it  no matter what the cost? 

We are looking at close to 40,000 deaths from flu and pneumonia this year.  There are legitimate questions about these statistics such as why are flu and pneumonia lumped together as the 8th leading cause of death?  They are not the same disease.  To dispel the statistical arguments, lets pretend that only 20,000 deaths will result from the flu this year.  Tragically, most cases of the flu are preventable at no cost to most people.

Setting death aside for a minute (or hopefully many years), consider the experience of having the flu.  The first day or so, patients are afraid they are going to die.  As it reaches its peak, they are afraid they will not die.

We don’t want our patients to feel like that.   Many home health patients will end up in the hospital if they get the flu.  Hospice patients may be terminal but most have plans to die from something less miserable.  It is okay to get between the flu and your hospice patient. 

So, while we are panicking about Ebola, let’s keep in mind that there are thousands of lives we can save with a simple flu shot.  The CDC has a ton of free resources that you can use in your agency, patient homes, and community to promote vaccination.  Most have room for your company logo and the CDC is fine with you adding it.  Think about it.  When was the last time that the government provided you with professionally designed materials to be used in promoting your agency or hospice? 

When we figure out what we can do about Ebola, we’ll post it here.  Until then, get out there and stick as many old people with needles as you can.  Here are some codes you can include on your care plan if you know upon admission that you will be giving a flu vaccine.

  • V03.82 Vaccine for Streptococcus Pneumonia (PPV)
  • V04.81 Vaccine for Influenza Virus
  • V06.6 Streptococcus pneumoniae [pneumococcus] and influenza

Is anyone qualified to write or help us write a short blog on how to bill for the flu and pneumonia vaccines?  Let me know below or by emailing TheCoders@hhcoding.com.

This Just (snuck) In!


Hospice Providers, take note

To be quite honest, I have never seen a ‘no code’ list in hospice.  If anything, I would expect to see a ‘full code’ list as any code status besides DNR would be the exception.

And yet, there is a new list of codes that hospices may not use when determining the primary reason for hospice care.   A list of codes at the end of this document will be automatically returned to providers when used as a principle code for hospice for claims billed after October 1.

This information comes from CMS change request 8877 which also contains very important information about the Notice of Election.

Home Health Providers:

An updated Local Coverage Determination has been published by Palmetto GBA for Alzheimer’s Dementia.  Among the insightful gems included in this guidance is the following passage begging the question of, ‘does someone have too much time on their hands?’

Behavioral disturbances often complicate the medical management of beneficiaries with Alzheimer’s disease. At baseline many individuals with Alzheimer’s disease manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline – resulting in sub-optimal clinical outcomes.

Wow.  I’m glad we cleared that up.  Seriously, look how often the word, ‘baseline’ is used.  If you really want to get paid, consider using the FAST scale to stage Alzheimer’s on admission and recert.  There are also numerous documentation requirements.  Please review and document accordingly.

If you recall, numerous claims once denied for Face-to-Face documentation are now being denied for lack of both long and short term goals.  The reference to short and long term goals is listed as the Physical Therapy LCD.  I am quite certain that the Alzheimer’s documentation LCD will be used in the same way.

Both of these regulations will take place on October 1.  Be ready.

 

The Hospice No Code List

290.0 Senile Dementia Uncomplicated
290.10 Presenile Dementia Uncomplicated
290.11 Presenile Dementia With Delirium
290.12 Presenile Dementia With Delusional Features
290.12 Presenile Dementia With Delusional Features
290.13 Presenile Dementia With Depressive Features
290.20 Senile Dementia With Delusional Features
290.20 Senile Dementia With Delusional Features
290.21 Senile Dementia With Depressive Features
290.3 Senile Dementia With Delirium
290.3 Senile Dementia With Delirium
290.40 Vascular Dementia Uncomplicated
290.41 Vascular Dementia With Delirium
290.42 Vascular Dementia With Delusions
290.43 Vascular Dementia With Depressed Mood
290.8 Other Specified Senile Psychotic Conditions
290.9 Unspecified Senile Psychotic Condition
293.0 Delirium Due To Conditions Classified Elsewhere
293.1 Subacute Delirium
293.81 Psychotic Disorder With Delusions In
293.82 Psychotic Disorder With Hallucinations In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.89 Other Specified Transient Organic Mental Disorders Due To Conditions Classified Elsewhere
294.20 Dementia, Unspecified, Without Behavioral Disturbance
294.21 Dementia, Unspecified, With Behavioral Disturbance
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
310.0 Frontal Lobe Syndrome
310.1 Personality Change Due To Conditions Classified Elsewhere
310.2 Postconcussion Syndrome
310.89 Other Specified Nonpsychotic Mental Disorders Following Organic Brain Damage
310.9 Unspecified Nonpsychotic Mental Disorder Following Organic Brain Damage

Computer Charting


untitled-8_thumb.jpg

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….