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.

The OIG on Medical Director Payments

The Office of the Inspector General recently issued a fraud alert regarding physician relationships with providers.  In case you don’t know any criminals, the Office of the Inspector General (OIG) is that government agency which prosecutes Medicare fraud and abuse and a lot of other things.  They are the ones who dispatch the FBI and other investigative agencies to catch bad guys.  It is never a good idea to get on the bad side of the OIG.

Now that everyone understands that it is foolhardy and dangerous to mess with the OIG, perhaps the recent warning regarding physician relationships, found here, will be of interest to you.

The essence of the alert is that you can only pay medical directors ‘fair market value’ for work they actually do for your agency.  You cannot simply agree to pay a doctor a flat sum each month to be your medical director.  The physician must work for the money and payment must be reasonable for the work done.  Fair market value differs for each community and a healthcare accountant might be a good place to start when determining the fair market value for your area.   Hint:  Most doctors do not make $1,250.00 per hour and two hours of work over lunch does not satisfy a Medical Director’s contractual responsibilities towards the agency.

The alert goes on to say that an agreement may violate the anti-kickback statute if ‘even one purpose of the arrangement is to compensate a physician for his or her past or future referrals’.  That’s right, folks.  You heard it here, first.  Any and all medical director agreements are to be entered into regardless of where the physician sends his patients.   It does not prohibit a physician from sending patients to an agency where he or she serves as a Medical Director but no part of the agreement should be contingent upon referrals.

There’s more!  The OIG is very clear that they have recently reached settlements with 12 physicians who entered into questionable agreements.  This works for me.  We have had over a million phone calls from clients and other agencies complaining because their physicians just don’t get why they have to do things as medical directors.  These phone calls usually are an attempt to get us to contradict what their lawyers have told them about entrance fees for golf tournaments or the new hunting rifle given as a Christmas present.  We never do.

There have been recent cases where jury convictions have been based upon ‘sham’ agreements where the list of services listed in a contract for a Medical Director were never really performed nor did the provider expect them to be performed.  Employees have been placed on the stand and asked about the frequency in which the medical directors were seen at a nursing home.

The Executive Director of a home health agency in Lexington, KY agreed to pay $1,000,000.00 back to Medicare for an ongoing fraud case involving kickbacks.  Note that the Executive Director is paying back the money – the case against the agency is ongoing.

The kickbacks in the Kentucky case are not what you might imagine.  The agency was a corporate sponsor of Kentucky football and physicians were given tickets to Kentucky football games.  Some were given bottles of tequila, as well, and tickets to see Journey play in concert.  This is not the type of financial exchange that many of us associate with ‘bribes’ and ‘kickbacks’.    In the South, football tickets tend to be a currency of their own.

Now would be a good time to have all of your contracts reviewed by a healthcare lawyer.  We can certainly recite the contents of the OIG fraud alert and news articles but we are not qualified to answer questions regarding nuances of the law and your specific contracts.   There are varying degrees of cost in these gifts and the specific conditions upon which a gift was given matters.

If you are too cheap to get your contracts reviewed by a qualified lawyer who specializes in healthcare, a good rule of thumb is to give nothing at all.  We cannot support any exchange of cash or kind without a healthcare lawyer blessing your contracts.  We have worked with several and will be glad to give you a name upon request.

Please remember that your cash will be cut off before you actually go to jail or write 7 figure checks.  As such, your coders and consultants will not be paid.   That’s completely unacceptable.

Late to the Game

While we were attention to other things, the rules of the hospitalization game changed just slightly. Although penalizing hospitals for readmissions in not new, hospitals are finally paying attention when hit with their third year of fines and the potential for even greater fines in 2015.

Currently, the penalties are for Congestive Heart Failure and pneumonia. More measures have been added and the total penalty for re-hospitalizations next year will max out at 3 percent. That may not sound like a lot but consider that the median operating margin for hospitals with 200 beds was -7% and the average is increased by a few hospitals making an obscene profit. The ‘operating margin’ is the profit when only the payment and services are calculated. Other sources of income such as gifts, grants and investments are excluded. If a hospital that was average was to be hit with even a 0.5% penalty, it could be deadly. Furthermore, less than 1000 of the almost 5000 hospitals were not fined for 2013. If you are curious about the hospitals in your town, click here and look for the scrolling table in the middle of the page.

I know that numbers are boring. I appreciate that you suffered through this much of tonight’s post and hopefully you now have an idea of how your hospitalization rate has become less important than numbers you do not have. So, before you plan to attack the diagnoses that are troublesome to your referral sources, you should do just a little more math and find out your hospitalization rate for the following diagnoses.

  • Congestive Heart Failure
  • Pneumonia
  • COPD
  • MI
  • Elective Hip and Knee replacements (are they ever emergent?)

This should be easy but every coder sees the problem. Home Health agencies do not admit patients for pneumonia, MI or hip and knee replacements. There is no report that can be easily run. And yet these numbers are critical to your ability to demonstrate value to your best referral sources.

There are any number of ways this can be done. My preference is an old fashioned Excel spreadsheet. Another option would be for coders to add a suffix to Medical record numbers for each of the diagnosis categories to make it easy to run reports. Some computer systems have attributes that can be added. If your system allows it, you can query all OASIS data for the diagnoses the patient had treated in the hospital. Any or all of these options should be considered and at least one should be implemented.

After you have decided how to identify patients within the criteria, the next step is to regularly calculate the 30 day hospitalization rate for each subset of patients. Home Health hospitalization rates are calculated at 60 day intervals and the hospitals are interested in 30 days. Sadly, it is not enough to merely divide the 60 day number by two. I tried it. It does not work.  Patients go back to the hospital within 21 days for the most part.

Those of us who are mathematically challenged rely on simple rules. Count all the patients in a category and then count all of the ones who went to the hospital within 30 days (look for an OASIS transfer assessment). Then divide the big number into the little number. Example: 15 patients were admitted with Congestive Heart Failure. Two patients went to the hospital within thirty days of admission or Resumption. Divide the big number (15) into the small number (2). 2/15 = 13 percent.

For those of you who are not mathematically challenged, please rest assured that nobody is trying to insult you. This really is a big deal for some of us. If you are very gifted with calculating percentages, drop by the QA department and offer your services. Expect them all to say they know it already because many of us are embarrassed to admit we were daydreaming during 6th grade math. Still make a pretty graph or something for them. They will secretly love you.

After you establish the baseline, your agency can get an idea of how you are performing and what needs to happen to make your agency appealing to the referral sources. The answers are going to be different throughout communities and agencies but over the next few months, there will certainly be discussions on how to address each diagnosis code. In all instances, it will require constant monitoring. That much I promise.

Hopefully, once you get those numbers, you can next start planning to reduce them. We will be here doing as much as we can to help you. If you have any insight, please share it with us so we can enlighten the world.

Elizabeth Hogue Educates Us About Fingerprints

It seems as though some of you might be fingerprinted in the near future.   Elizabeth Hogue did such a good job of explaining it last week, we thought we would repost her email.  Elizabeth can be reached at:

(877) 871-4062

CMS Begins Fingerprinting “High Risk” Medicare Providers and Suppliers

The Centers for Medicare and Medicaid Services (CMS) issued MLN Matters Number SE1417 on April 11, 2014. This Special Edition MLN Matters is intended for providers and suppliers who submit claims to Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) and Home Health and Hospice MACs for services provided to Medicare beneficiaries. CMS makes it clear in this article that it will begin fingerprinting all owners of these types of providers with a 5% or greater ownership interest. The ultimate goal is to fingerprint all owners with a 5% or greater ownership interest in all providers or suppliers in the high risk category that receive reimbursements from the Medicare Program. According to CMS, the implementation of fingerprint-based background checks as part of enhanced enrollment screening of providers is based on Section 640 of the Affordable Care Act (ACA).

When fully implemented, the fingerprint-based background check will be required for all individuals with a 5% or greater ownership interest in a provider or supplier that falls under the high risk category. The high level of risk category applies to all providers and suppliers who are newly enrolling DME suppliers or home health agencies. This category will also apply to providers and suppliers who are elevated to the high risk category in accordance with enrollment screening regulations.

Fingerprint-based background checks will be implemented beginning in 2014. Providers and suppliers subject to fingerprinting will receive notification of the requirements from their MAC. The MACs will send notification letters to providers and suppliers that include a list of all owners with a 5% or greater ownership interest who are required to be fingerprinted. Letters will be mailed to providers’ or suppliers’ correspondence addresses and special payments addresses on file with Medicare. Individual fingerprinting will normally be required only once, but CMS reserves the right to request additional fingerprints, if needed. Owners will have thirty days from the date of notification letters to be fingerprinted. Providers and suppliers that find discrepancies in the list of owners sent to them by the MACs should communicate the discrepancies and take appropriate action to update enrollment records to reflect corrected ownership information.

Notification letters will include contact information for the Fingerprint-Based Background Check Contractor (FBBC). Individuals required to be fingerprinted are required to contact the FBBC prior to being fingerprinted to ensure that fingerprints are accurately submitted to the Federal Bureau of Investigation (FBI) and that the results are properly transmitted to CMS. Providers and suppliers subject to fingerprinting will be able to contact the FBBC by telephone or by accessing the FBBC’s website. Contact information for the FBBC will be included in notification letters sent by the MACs. The FBBC will provide at least three locations convenient to individuals’ locations where they can be fingerprinted. One of the locations must be a local, state, or federal law enforcement facility.

Individuals required to be fingerprinted must bear all expenses related to being fingerprinted.

CMS encourages providers and suppliers to provide fingerprints electronically, but CMS will accept the FD-258 card instead. FD-258 cards submitted will be converted to electronic submissions to the FBI by the FBBC.

Fingerprints will be sent to the FBI for processing. The FBI will compile background history based on fingerprints within twenty-four hours of receipt and will share the results with the FBBC. The FBBC will review each record and make recommendations to CMS regarding fitness. CMS will assess recommendations from FBBC and make final determinations. CMS may deny enrollment applications or revoke existing Medicare billing privileges based on its final determinations of the results of fingerprint background checks.

Providers and suppliers regularly face a number of hurdles in the enrollment process. The above addition to the process is bound to increase providers’ frustration. Meticulous compliance will be the name of the game!