Category / The Coders

by Julianne Haydel

Welcome Back, Mr. SCIC


The SCIC is Back

Nurses who did not enter home health until this decade may be familiar with SCIC’s. Maybe they read about them or they were briefly reviewed in orientation. In the early years of PPS, a SCIC or other follow-up assessment changed the payment of an episode. Then it didn’t. Soon it will again. So the Significant Change in Condition; or other follow-up is a thing and it’s about to be a bigger thing.

The Quarterly OASIS Q and A from Medicare state:

When diagnosis codes change between one 30-day claim and the next, there is no requirement for the HHA to complete an RFA 5- Other follow-up assessment to ensure that diagnosis coding on the claim matches to the OASIS assessment. The CoP 484.55(d) does require an RFA 05 when there has been a major improvement or decline in a patient’s condition that was not envisioned in the original Plan of Care. CMS expects agencies to have and follow agency policies that determine the criteria for when the Other Follow-up assessment is to be completed.

The OASIS User Manual defines ‘RFA-5 other follow-up’ as:

… comprehensive assessment is conducted due to a major decline or improvement in patient’s health status occurring at a time other than during the last five days of the episode. This assessment is done to re-evaluate the patient’s condition, allowing revision to the patient’s care plan as appropriate.

With 30-day claim periods and 60-day OASIS intervals, there may be changes in your patient’s condition causing your patient to need more care that are not reflected in payment. If this occurs during the first claim period, the SCIC assessment is a way to increase payment for the second 30-day claim period. The claim period will only be adjusted if the date of assessment occurs prior to the 30th day.

So, in crafting or revising your SCIC policy, a good place to start would be with the OASIS questions that will affect your outcomes and payment – particularly hospitalizations. Currently, you must collect information on hospitalization risk and it will affect payment. Why not include factors that might increase the patient’s risk for hospitalization?

  • One or more falls
  • Unintentional weight loss of a total of X pounds (contingent upon base weight of patient.)
  • Any hospitalization, ER visit or MD visit that results in a change in orders.
  • Persistent decline in mental, emotional, or behavioral status.
  • Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) that is not corrected within two weeks with patient and caregiver education.
  • New medications that require teaching
  • Exhaustion that was not present on admission and does not result from exertion such as family outing or holiday.

All of these criteria have the potential to change the case mix weight. And remember that the Conditions of Participation state that risks for hospitalization should be on the care plan along with interventions on how to mitigate those risks.

Crafting a policy around two mandates already in effect will result in a policy that doesn’t require a lot of extra work to teach or monitor.

Should you have any questions or comments, please email us or leave a comment. If you have a different idea, we are open to hearing it.

by Julianne Haydel

PDGM for Nurses


This brief overview is directed specifically to nurses and therapists who will be completing the OASIS assessments that will determine payment. This is not a complete guide to PDGM but it is important for the field clinicians.

You work hard. Get paid.

by Julianne Haydel

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).

by Julianne Haydel

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.

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.