The Countdown Begins


Here’s a rundown of the first section of the new Home Health Conditions of Participation.  Check back for additional information.  We’ll be adding more later.  Let us know if you have anything to add.

Patient Rights and Responsibilities

The Condition of Participation concerning patient rights and responsibilities will require that:

  1. The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.
  2. There must be a complaint log that documents the existence and resolution of complaints about care furnished made by the patient or their representative and family.
  3. The agency must let the patient know in advance of the disciplines that will furnish care, the plan of care, the anticipated outcomes of care and changes in the care to be furnished.
  4. The agency must advise the patient of agency policies regarding disclosure of patient records.
  5. The agency must advise the patient of any financial liability.
  6. The agency must advise the patient of the home health hotline number and explain its purpose, hours of operation.
  7. The names and telephone numbers of specified state and federally funded entities. (See Below)
  8. The right to access auxiliary aids and language services and how to access these services.

Specified numbers

  1. Agency on Aging
  2. Center for Independent Living
  3. Protection and Advocacy Agency
  4. Agency and disability resource center
  5. Quality Improvement Organization

These new and revised rights are in addition to other patient rights that are currently being used so you will have to edit your current forms before January 1.  We expect that most forms will patient rights 2 taken from the regulations and edited slightly for clarity.

We suggest that when the forms are replaced that old forms be removed from the office and archived on your computers so they are not accidentally used in 2018.

Complaints

Another thing you can do immediately is prepare your complaint binder for 2018.  Remember that the complaints that you must record and address are those having to do with patient care and mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the agency.

Anyone employed by the agency in any capacity who identifies, notices or recognizes anything suggestive of mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, MUST report the findings to the agency immediately and other appropriate authorities in accordance with state law.  Notice that it states the employee who identifies mistreatment must report it.  Be supportive of your staff but keep in mind that the person who suspects any neglect or abuse must report it.

Communication

Every agency who is Medicare Certified has completed a Section 504 packet for submission to the Office of Civil Rights.  The penalty for not doing so is having payment withheld so it’s a The Office of Civil Rights investigates claims of discrimination and assures that healthcare providers and others understand and attest to their non-discrimination policies.

Now the section on limited English proficiency has become a standard in the Conditions of Participation.

If your agency is very old, you may not be aware of what is in the packet but you can obtain sample policies and explanations on the Office of Civil Rights webpage.  If you scroll down to the third section  of the linked page, you can find the tools that The Office of Civil Rights has for Medicare Certified Healthcare Providers.

The available resources that you must plug in such as translators, etc. will vary according to your location.  Now is the time to task somebody with identifying these resources if you haven’t already.

So, here are three new requirements that your agency can address in a week.  Instead of being overwhelmed by all the changes, complete a few to the best of your ability and move on to the next.  Keep checking back for more advice on how to get in a position to be compliant by January and send to us any ideas that you have on how to best comply with the new Conditions of Participation.

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30-Day Episodes and More…


To be certain, I would have not written the 2018 proposed regulations in the manner in which they were posted earlier in the week.  The document which is technically not published because it hasn’t been certified, starts with the basic rate changes that are proposed beginning January 2018 and some important changes to the scoring system.  The most significant of these involves therapy.  Then it jumps into a couple of hundred pages (not including charts and attachments) describing a new system proposed for 2019.  By the time you finish reading about the 2019 changes and are wondering if you would look good in a Taco Bell uniform, the document once again returns to the changes for 2018.

There’s a lot of material to digest, folks.   Shall we begin?

2019 Payment System

Unlike Medicare, we are going to start with the 2019 payment system.  To call this an update or refinement is taking liberty with the concepts.  It barely stops short of introducing an entirely new payment system.  Even though the proposed implementation date isn’t until 2019, it is important that you become familiar with the payment system now so that your comments can be considered.

The document, posted here, gives the following contact information.  Whether you agree with our views or not, everyone’s voice should be heard if they have an opinion on the proposed regs.  The last day for comments is September 25, 2017.  Mark your calendars.   Here’s where comments should be submitted.

Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions under the “More Search Options” tab.

By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1672-P,
P.O. Box 8016,
Baltimore, MD 21244-8016.

There are additional addresses for overnight and in person delivery in the document.

Home Health Grouping Model

If all goes according to plan (doubtful but let’s pretend that it will), we will see the advent of Home Health Grouping Models.   Patients will fall into one of six groups depending on their primary diagnosis.  If there is a problem with an assessment falling into one these groups, the claim will likely be sent back to the provider who will have to produce coding with improved accuracy.

These groups are:

  1. MMTA                                            Medication Management and Teaching
  2. MS                                                  Musculoskeletal Rehabilitation
  3. Wound                                          Includes ulcers, surgical incisions, skin lesions, etc.
  4. Complex Nursing:                     Determined by diagnosis code
  5. Neuro, Stroke, Rehab              Self Explanatory
  6. Behavioral                                  Usually called psych

Therapy

Here’s a change that might interest you.  There will be no adjustment for therapy in this system.  The payment is built into the grouping models.   Please feel free to leave your comments below.  We want to know what you think.

Admission Source

Then there’s the Admission Source component of payment in 2019.   You will have four choices:

  1. Institutional Early
  2. Institutional Late
  3. Community Early
  4. Community Late

The rationale for these admission source criteria is that patients admitted from the hospital generally require more resources than those admitted from the community.

Comorbidities

There are 841 diagnoses that will bump up payment if they entered as a comorbid condition.   Here’s how you find them.  Go to https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html.

The first section is called, ‘Spotlights’.  There are three paragraphs followed by four links.  The link called, HHGM Grouping Tool has a nifty little spreadsheet where you can calculate payment according to the proposed rules.  Download it and extract all the files.  The very last extracted Excel file (above the Help file which I didn’t bother to read) is a ‘toy’ grouper.   That’s a very fun tool and I’m sure you’ll be using it a lot.  However, to find the significant comorbidities mentioned above, look at the tabs on the bottom of your screen.  One is called, ‘ICD-10 DXs’.  Click it.  There you will find almost 70,000 diagnosis codes.  Do not be alarmed.  Click Ctrl and the letter F at the same time.  A search box will appear on your screen.  Type ‘yes’ in the search box and ‘Find All’ at the bottom of the search box.  The comorbid conditions will be presented to you.

If anyone can tell me how to extract only those codes, feel free to let me know.

Functional Level

 This is the last step of the proposed payment system is similar to the current system with two notable additions.  M1033 –  Risk for Hospitalization and M1800 – Grooming have been added as contributors to the functional level.   The rest of the questions are the same:

  • M1810: Dressing Upper Body.
  • M1820: Dressing Lower Body.
  • M1830: Bathing.
  • M1840: Toileting.
  • M1850: Transferring.
  • M1860: Ambulation/Locomotion

Using the Medicare Grouper tool, you can enter data for your patients and see how they compare to your current case mix weights.  Alternatively, you can call us for assistance and for a very reasonable price, we will come up with a comparison of your case mix weights as they stand now to how they would fall out in 2019.  No dollar value has been assigned.

Questions

  1.  Medical Boards across the country are monitoring prescriptions of narcotics. According to the National Clearinghouse for Alcohol and Drug Information, as many as 17% of adults age 60 and over abuse prescription drugs. Narcotic pain killers, sleeping pills and tranquillizers are common medications of abuse.  An increase in the use of therapy, often ordered for pain management, can reduce the need for these meds.  Has anyone tried to determine with a large amount of data if this is the case?
  2. More to the point, does this payment system create an environment where agencies are given incentive to reduce therapy to the detriment of patient care?
  3. Billing for home health is a complex process. 30-day episodes will result in almost double the amount of work for the office staff increasing expenses without contributing to patient outcomes.  Will billing requirements be lessened?
  4. With 60-day episodes, there is occasionally a situation when an agency admits a patient who is a patient of another agency because the prior agency did not drop a RAP timely. The likelihood of this happening will greatly increase in a 30-day episode.  Will there be any protection for agencies who admit a patient of another agency unknowingly?
  5. In the early years of PPS, points were only awarded for the primary diagnosis resulting in widespread upcoding. Many nurses were upcoding in good faith because their supervisors had told them to put Ortho, Diabetes, Neuro or Trauma codes first.  Is the 6-clinical group method creating a similar situation?

 The current political environment casts doubt on whether any of this will be implemented and raises the chances that it will be postponed.  This does not cancel our obligation to make our opinions known because there are changes on the way.

Do not hesitate to contact us if you have any questions or comments.  The Coders will be submitting comments about the 2019 payment system and we hope that you do, too.

2018 Changes

Our Cliff Notes version of the 2018 payment updates is coming soon.  We promise.  We find it easier to understand one year at a time and think you will, too.  And because your deadline for comments is only a few weeks away for 2019 payment system, we tackled that first.  So, for today, that’s all, Folks.  Keep us posted with any news that you hear.

Star Light, Star Bright


Everyone wants more referrals but even the best marketer in the world is at a loss when the agency marketed is a two-star outfit.  Whether it’s Amazon or TripAdvisor, people are making purchasing decisions based upon Star Ratings.  The same holds true for insurance companies and hospitals.  They want the next provider of care for their patients to be five star agencies and yet, only three percent of agencies meet that criteria for quality of care issues.

Four stars are good, too and three stars is an indication that agency is trying.  One and two star agencies are often overlooked and discharge planners will try to find a patient an alternative if they choose one.   Remember, the hospitals are penalized for readmissions.  There’s no denying that star ratings are a powerful weapon in the fight for referrals in markets where competition is tough.

So, have you figured out that you need to improve or maintain your Star ratings?  Are you wondering where to begin?  Here’s your answer.

First, know what data factors into your star ratings.   There’s exactly nine of them.

Process Measures:

  1. Timely Initiation of Care
  2. Drug Education on all Medications Provided to Patient/Caregiver
  3. Influenza Immunization Received for Current Flu Season

Outcome measures:

  1.  Improvement in Ambulation
  2. Improvement in Bed Transferring
  3. Improvement in Bathing
  4. Improvement in Pain Interfering with Activity
  5. Improvement in Shortness of Breath
  6. Acute Care Hospitalization

Next, go to Medicare’s Home Health Compare page.  Find your agency and see which of these questions falls short of the national and state averages.  Begin with a plan to address the three worst and set it motion.  If you fall short in Drug Education, move it to the top of the list even if there are three more that are worse.  Poor compliance to medications will affect all the other outcomes.

Easy, right?  Your plan should look like a state survey plan of corrections with columns for the Star Factor, Interventions. Responsible Party and Follow-Up.  There should be one person who oversees the plan and that person should be a cheerleader and have the authority to call meetings.  He or she should be meticulous about follow-up and be respected by his or her peers.  If you don’t have a person like that, hire one because they will come in handy in a lot of different ways.

This is data taken from a random agency’s online published data.  It was easy to find because searches on the Home Health Compare site list all agencies that meet your criteria with their star ratings.  The last two columns are state averages and the National Average.

How often patients got better at walking or moving around 56.6% 69.6% 70.2%
How often patients got better at getting in and out of bed 51.6% 64.2% 67.1%
How often patients got better at bathing 71.5% 74.6% 73.6%
How often the home health team made sure that their patients have received a flu shot for the current flu season 22.3% 69.6% 74.4%

There are actually two types of outcomes reflected.  The first three all depend on two points in time.  The last one – flu shots – is defined by only the discharge or transfer OASIS.

People unfamiliar with OASIS may look at these outcomes and wonder what is wrong with the people running that agency.  Who could blame them?  I’m a little more cautious in judging this agency.  In fact, I am betting that the problem is OASIS data collection which hurts the agency more than the patient.

If this agency wanted to improve their star ratings, they might have an action plan that included some of the following interventions.

Education regarding the functional domain.

  • The importance of assessing rather than interviewing patient
  • The importance of reading physician or hospital notes on admission
  • Review of Medications to determine if any meds would render the patient unsafe to ambulate, transfer or bathe. If they are PRN meds, the nurse should review how often they are taken.  Remember to include antihypertensives, antihistamines, and other meds and the length of time the patient has been taking them.
  • A visit to the bathroom and bedroom to assess for structural barriers

Education of the OASIS conventions that affect the functional domain

  • Know what a ‘day’ is in OASIS land – the 24 hours prior to the visit and the visit itself.
  • Consider safety
  • Understand the ‘majority of tasks’ instructions in the conventions.

Discharge to Community Review

  • Determine if a discharge visit has been made. When a visit is not possible, the OASIS data must be taken from the last OASIS assessment.  Short lengths of stay will reflect a ‘static’ patient with no changes.
  • Determine if information on discharge conflicts with information on admission. Example:  The admit nurse noted the dates of pertinent immunizations and the discharge assessment states that vaccination status was not addressed indicating that a chart review was not performed.
  • Considering the course of care for the patient, was the admission assessment correct. All admission, resumption of care and recertification assessments resulting in a score of F1 in the HHRG should be reviewed for accuracy.  The very low score could indicate that the patient is not homebound or the clinician did not understand how to answer the questions.  Both possibilities need to be explored and explained.

Review of the OASIS data regarding flu shots.

If I could only choose one outcome to improve it would be the frequency that the agency assessed for flu shots.  It is easy and does not require a lot of agency resources to monitor and manage.

  • For this question, dates are critical. Any patient admitted after March 31 and discharged prior to April 1 should not be reflected in this question.  Ensure that the clinician answers ‘No” to:

(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu season?

  • The time frame under consideration is an episode of care.  An episode of care, often confused with a payment episode, begins upon admission and ends on transfer or discharge UNLESS the patient is hospitalized. If that happens, a new care episode will begin at Resumption of Care and continue to discharge or the next transfer.

Understanding these concepts will not only improve outcomes but they will also increase payment in some instances and the integrity of your data will be maintained or heightened.  Because payment system recommendations are made based on the data that agencies submit, everyone has the responsibility to submit accurate data.

Call us if you need help with understanding and monitoring your Star ratings.  It takes a while to wash out old data but sharing your data with your staff on a quarterly basis as it becomes available will go a long way motivating your staff to pay close attention to the OASIS data.  Better yet, your marketers will be armed with an explanation of why your agency pales in comparison to others and be able to tell prospective referral sources your plans for improvement.

Three Little Questions


Because the OASIS C database has become easier for you, Medicare has taken measures to ensure that 2017 offers some challenges in the way of OASIS C2.  In turn, we have taken measure to ensure that you understand at the very minimum the three new questions.  They come complete with their own conundrums, confusion and lots of reformatting and subtle shifts in definition.  It’s not as simple as it seems but it certainly isn’t out of your range of capabilities.

New Questions

Written by someone who is comforted by redundancy, MO1028 assesses (again) whether a patient has diabetes or peripheral vascular disease.

(M1028) Active Diagnoses– Comorbidities and Co-existing Conditions—Check all that apply

See the OASIS Guidance Manual or click here for a list of relevant ICD-10 codes.

  • Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
  • Diabetes Mellitus (DM)

Additional guidance is not much different from coding conventions.  The diagnoses must be documented in the medical records produced by the physician or NP.

Having the condition is not enough to win a checked box.  The C2 manual states that the diagnosis must be active and the manual infers that ‘active’ means that there are orders written or monitoring of the disease process ongoing.

So, that’s two criteria –

  1. Does the patient have the condition and
  2. Is anyone watching it or writing orders for it.

Worth noting, if only for a laugh, the OASIS Guidance manual for the C2 dataset provides the following rationale for this question.  We are not kidding.

Disease processes can have a significant adverse effect on an individual’s health status and quality of life.

Section GG

Another new question is (GG0170C) Mobility.  The question occupies an entire page in the manual and if you are like me, it may take you a while to understand what they are truly asking.  Look the column in the body of the table to the very most right where it says something about the patient moving from a completely supine position to sitting on the side of the bed, feet flat on the floor with no backrest.   Everything else on the page refers to that single activity.

The answer reflecting the greatest impairment is 01 and a patient who can complete the tasks independently gets a 06 score.  Note that this is a new opportunity to make a careless error as the level of severity for every other question is reversed with 00 being the least impaired and the last possible response being the worst level of severity.

But there’s more.  The dataset asks for a goal.  If your patient is able to do this task at admission, it is not a problem.  Your initial response and your goal will be the same.  However, if some improvement is expected by the grace of your carefully crafted careplan, there will be a second response describing your patient’s expected ability upon discharge.  Take your best shot and don’t fret about not being able to predict the future.  It is true that all kinds of things can happen between admit/resumption of care and discharge but it is not reasonable to downgrade your goal in the event of a zombie attack.  On the other hand, remember that you are not so good that you can take a person who is totally dependent following a cerebral vascular accident and have them independent at discharge.

Getting Personal

Medicare wants to know the patient’s height and weight in M1060.

(M1060) Height and Weight—While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up.

The Coders assume that you know how to round off numbers but Medicare does not and includes explicit instructions within the question.

Guidance for this question includes a helpful tip to measure your patient’s height and weight in accordance with the agency’s policies and procedures, which should reflect current standards of practice.  So, how many of you have a policy addressing how to measure the height and weight of a patient?

Assuming that such a policy exists in your agency, is it based upon sound clinical practice standards?  On your behalf, we have scoured the internet for practice standards for measuring height and weight and like the CDC Antropometry Procedures Manual.  Sadly, the manual refers to the Integrated Survey Information System anthropometry computer application (ISIS).   Do not be alarmed when you see this.

Also, when determining how height will be measured, plan on buying a stadiometer.  This is the apparatus seen in Physician offices that measures height.  Most of the affordable ones are wall mounted and we suggest that wall mounting is not recommended in your patient’s home environment.  Also, note that anything with brightly colored giraffes and ruler-like markings cheering on big boys and girls is not likely to be received well by adult patients or meet the practice standards. Call your medical supply company and plan to spend about $150.00 per portable stadiometer.

The Dash

There’s more – so much more but you have patients to see and notes to write.  We are going to leave you with information about The Dash.  This is not a simple dash as found in other places like a date or a social security number.  According to Medicare,

a dash (–) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged or dies before assessment of the item could be completed. CMS expects dash use to be a rare occurrence.

This definition is consistent throughout the manual.  When a dash value is an available option for questions, OASIS guidance generally indicates if the dash is a valid response.

For your convenience, we have uploaded some of these documents.  Hopefully, you will read them and then fill us in.  As always, we welcome your questions.  Maybe we’ll even answer a couple.

Changes to Palmetto’s Diabetes Guidance


Palmetto’s Local Coverage Determination regarding Diabetes has a significant update effective May 5, 2016.  From the LCD:

For other beneficiaries with stable glycemic control (defined as two consecutive HbA1c results meeting the treatment goals specified in the plan of care) performing the HbA1c test at least two times a year may be considered reasonable and necessary.

For other information on how these changes came about, check out ‘Care for the (whole) person with Diabetes‘ on the Haydel Consulting Webpage.

The entire text for the revised LCD can be found at the Medicare LCD database.  Remember these changes only apply to care provided after May 5.

 

Coding and Coverage for Hospice


It should be simple, right?  Choose from a list of codes that describe why your patient is receiving services and go on about your business…..  Piece of cake, right?

Somehow, that isn’t how it goes these days.

The first challenge is to determine what should be put in the diagnosis list.  The answer is quite simple at first glance.  Code every diagnosis that is related to the terminal condition of the patient.  At second glance, how does a diagnosis make the list?  Medicare says that pretty much any diagnosis in the zip code of the patient makes the list.  Old school providers say that only the terminal diagnosis makes the grade.  The real answer is somewhere in between.  Some questions to ask when determining which diagnoses makes the elite list:

  1. Is the diagnosis the reason the patient is terminal?

  2. Is the diagnosis one of the risk factors or underlying causes of the terminal diagnosis?

  3. Is the diagnosis a direct result of the terminal diagnosis?

  4. What happens if you don’t treat the diagnosis?

  5. Does the diagnosis affect the way that a patient responds to or participates in their plan of care?

Obviously, the terminal diagnosis will be included but on occasion, the terminal diagnosis is not clear.  A patient with end stage Alzheimer’s disease and NY Class IV heart failure doesn’t have a long future but it may be difficult to tell which of the diagnoses is terminal.  Use your judgment and if you are compliant in the rest of the coding process, neither the patient nor the hospice will suffer.

A patient who is terminal due to a stroke caused by long-standing hypertension would have Hypertension in the list.  The same patient may be confined to the bed in the final days of life and some skin breakdown towards the end of life is not unusual.  In these examples, the hypertension is an underlying cause of the stroke and the skin breakdown is a result of the stroke.  Both would be coded.

If pain, confusion or other discomfort is a result of not treating the diagnosis, it should be included.  Extremes in blood sugars may be encountered by a patient with a pre-existing diagnosis of diabetes.  Include it.

We see patients taking Statin medications which are generally used to lower cholesterol to prevent heart attacks in the future.  When the future is limited to a few weeks or so, it may not be important to treat the hypercholesteremia because nothing happens if it isn’t treated.

Patients with dementia are unable to respond to the plan of care as well as their clear headed counterparts.  Even when Alzheimer’s disease or other dementias are not the terminal diagnosis, they should be coded.

In the past, there have been hospice providers who have chosen the primary diagnosis based on the perceived cost of treating the diagnosis.  This has never been the correct approach to hospice care.  The hospice is tasked with covering essentially all care related to the terminal condition of the patient.  That does not mean that curative care should be offered for secondary and contributing diagnoses or even that the treatment prior to hospice admission must be followed.

Consider the following examples:

1.       A patient with a diagnosis of diabetes is admitted for services but her terminal diagnosis is heart failure.  Prior treatment was Lantus insulin.  In the interest of comfort, it may be reasonable to check blood sugars much less frequently and treat with a short acting insulin only when the patient is uncomfortable due to symptoms.  Because appetites and medications can interfere with blood sugar levels, longer acting insulins may not be appropriate.  Tight control of blood sugar is not going to help the patient in the long run.

2.       A patient with Alzheimer’s disease becomes severely agitated when his Namenda is withheld.  In order to provide the patient with the greatest level of comfort, the Namenda would continue.

Should a patient be reluctant to discontinue a medication, the family is free to purchase the medications.  However, it most likely will not be covered under the hospice benefit.   If the family has some of the medication from prior to admission, it can be continued while they are approached gently over time about the need for the medication vs the need to reduce the pill burden and potential for side effects.

Keeping these principles in mind, hospice patients can be accurately depicted in the diagnosis list and a care plan addressing the individual patient needs can be created.  It is not difficult but it will never be a reflexive and automatic process, either.  Until patients standardize dying, there will be no standard care plan.

Needless to say, we highly recommend certified ICD-10 coders to ensure that accurate coding is included on claims, changes in the patient condition are reflected in the coding list and you and your staff have time to spend with patients.