5 ADRs – Your Risks


Home health care agencies that bill Palmetto GBA are currently in the midst of receiving five ADRs each across the board.  As such, clinical record review has been ongoing at our office.   What we’re finding is almost typical but not identical to what we have been seeing in clinical records in the past.  Here are the top five risks for denial that we have identified.

  1. No physician statement of how long services will continue for second or later episodes. This is occurring even when the agency’s software has a blank for the information.  Remember, if your physician’s estimate is a little too optimistic, it is not mandated that you discharge or otherwise do away with the patient.  Help your physicians arrive at a reasonable time frame based on your combined experience.  If you have no experience, consult your DON.   If new needs arise, revise the end date on the following POC if any.
  1. Unsupported diagnosis codes. If a physician documents that a patient is forgetful and your assessment reveals that the patient is not oriented to person, place or time, you are likely both correct.  However, in a case like this, a code for dementia is not supported by the MD.   Another thing – it really is okay to let a diagnosis of hypertension stand-alone if the patient has hypertension.  It does not need to be dressed up with additional diagnoses such as hypertensive heart disease or heart failure.   It only ‘looks better’ at first glance until someone realizes that there is no MD support the code. When a physician’s documentation does not support your codes, it really is okay to ask.  Send a fax to the MD asking if your codes might be accurate.  There is always a chance that the doc’s documentation is not accurate and your question may be the catalyst to better overall care for the patient.
  1. Unmet needs for additional disciplines. When we look at ADRs, we ask for a copy of the packet that will be going to Palmetto or whomever.  In limiting our view to only what Palmetto reviewers see, we sometimes see glaring omissions that may not be obvious to clinicians up to speed on the patient.  We see patients with falls and no therapy and patients with difficulty with ADLs and no home health aide ordered.

Usually these services were provided in a previous episode or admission or refused by the patient but unless documented, it is impossible for a reviewer to see these omissions.  A lot of agencies have moved away from 486 summaries (against our better judgment).  If your agency does not write summaries as a rule, be sure to at least include that the patient is being ‘readmitted’ to indicate that there is more to the patient’s story.  When you see the word, ‘readmitted’ when preparing documents for an ADR, ensure that you mention prior disciplines and treatment modalities in a cover letter to accompany the ADR.

  1. Signature issues. It seems that most agencies understand the signature requirements imposed by Medicare but not all.  Ineligible signatures a ‘gimme’ for Palmetto GBA where the reviewers of clinical records deny entire episodes based upon one undated signature.

What’s curious about signature issues is that until an agency receives a denial, they don’t believe they have a signature issue.  They have strict policies about billing and have created a work environment where fraud is not tolerated.  When someone reminds them about signatures, they are confident in the high ethical bar the agency has set.  They don’t see the problems we do.

The truth is that without diligence, inadequate signatures slip through.  Stamped signatures, NP signatures and the signatures not matching the name on the plan of care are found occasionally and when those charts are reviewed by a payor source, a denial results.

There is no great clinical skill in checking signatures and agencies without signature problems encourage everyone who sees a signed 485 to verify the presence of a date and the correct name on the signature line.  If the problem is pervasive, pay a bounty for every ineligible signature.  Remember, it is far easier to convince a physician to sign an attestation when he or she clearly remembers when they signed a document.

  1. Lack of Communication. There are numerous instances when we believe an MD should have been notified that just sit there in the chart.  In the past couple of months, we have seen an established PEG tube that was leaking, blood pressures and blood sugars that are outside of the stated parameters and increased pain that is not reported to the physician.  New meds show up on recertifications and we can only assume a physician ordered them.   Nobody takes

Some clinicians feel as though they are ‘bothering’ the physician when they call for orders.  Others are confident that the physician does not want to be called.  Our all-time favorite is the statement, ‘MD Aware’ and better yet, ‘MD fully aware’.

These examples of lack of communication will almost certainly result in a survey deficiency.  They may also result in a denial if the episode has no new exacerbations, orders, meds, hospitalizations, etc.  The patient becomes ‘static’ or ‘chronic’ and it becomes unfair to say that the patient has an acute, intermittent need that can be met by home health.

Faxes are wonderful things.  So is secure email if you are lucky enough to have an MD who uses it.  You can write up your non-critical concerns and send to the doc at the end of the day with a phone call to verify receipt.  (Don’t trust the fax verification sheet because who knows what happens to faxes once they are received at the MD office.)  That will certainly take care of any deficiencies on state survey.

To make payment for claims more likely, ask for orders if none are forthcoming.  Not every high blood sugar or blood pressure requires a change in medications but when changes are warranted, it is usually because of a trend.  Ask the MD for an extra visit to ensure that the errant numbers fall back to within parameters.  Think of it this way.  If your assessment reveals numbers that are the start of a new problem requiring a change, would you want to wait a week or more to get a second reading?

Ask for lab if indicated.  A patient who is no longer responding to Lasix may have kidney disease.  You can ask if the MD wants a metabolic panel or for you to advise the patient to schedule an apt.

When a patient reports severe pain, ask for therapy orders or non-pharmalogical relief.  Do your homework by verifying pain meds are taken as ordered.  More than one patient has stayed in pain because they are afraid of getting ‘hooked’ on pain meds.   Work with the patient and the MD to find non-narcotic pain relief.

If the MD complains about your frequent communication, consider if you are overdoing it.  Review the information with peers.  If the communication was necessary for good care, ask the MD for suggestions on how to minimize it.  If none or forthcoming, it may be time to accept the fact that he will be referring to another agency in the future – at least until a patient is hospitalized because the MD was not notified of a serious problem with his patient.

So far, all we have done is review the ADRs.  No results have been forthcoming.  We would be interested to know what you are finding as you review your charts and/or hear from Palmetto about your ADRs.

 

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Targeted for ADRs


Every so often, Palmetto posts a list of the claims that will be of interest to them on their website. This is the list that was published on August 4.

Note the last letter of the HIPPS code. The letter ‘L’ indicates 16 – 17 therapy visits and the dreaded ‘K’ means that 20 or more therapy visits are scheduled. Only one of the edits is for therapy below 14 visits. In that edit, Palmetto GBA is looking for the lowest clinical and functional scores together with therapy.

Palmetto is asking why a patient who appears to be clinically stable and can walk, talk, bathe, transfer and dress themselves needs any therapy. It’s a good question. There could be a perfectly legitimate explanation but if it is not documented well, you are looking at a denial.

Pretty much all episodes with 20 or more therapy visits are being scrutinized. These are the expensive claims and people who are ‘gaming’ the system will often use high utilization as a method to do so. This does NOT mean that a patient should not receive 20 therapy visits if needed. For most agencies, these episodes will be few and far between.

16 and 17 visits are very profitable as well even if the dollar amount is not the same. The profit starts to drop off at 18 and 19 visits until 20 visits are made.

All clinical documentation should support the services billed but in an agency where staff is limited or compromised at time of billing, claims with these HIPPS codes might be prioritized for review prior to dropping claims.

1BGP* 0 – 13 Visits, Lowest Scores in the Clinical and Functional Domains and Maximum Score in the Service Domain
2BGL* 16-17 Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
2CGL* 16-17 Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
2CHL* 16-17 Therapy Visits, High Score on Clinical Domain, High Score on Functional Domain
5AFK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Low Score on the Functional Domain
5AGK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Moderate Score on the Functional Domain
5AHK* 20 or More Therapy Visits, Low Score on the Clinical Domain and High Score on the Functional Domain
5BFK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Low Score on the Functional Domain
5BGK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
5CGK* 20 or More Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
5CHK* 20 or More Therapy Visits, High Score on the Clinical Domain and High Score on the Functional Domain
All Aggregate Length of Stay and Disbursement/Beneficiary
All Home Health Services

 

More than Half!


More than half of the dollar amount of claims reviewed by one intermediary were denied in the last quarter of 2014. Multiple results were published this past week. Most were for smaller amounts but the denial rates were similar. The results posted below are the results for an edit of claims with a HIPPS code of 1BGP*. These are patients who were in an early episode, a clinical severity of 2 and a functional level of two, and a service level of 5. This represents a very high paying patient who is receiving therapy but otherwise isn’t all that sick.

Over half of the dollars that were billed for these claims were taken back or not paid because of a focused medical review.

For now, this is where we stand. As unfair as it may seem, there is no other option than to address these numbers until your claims make their way through the appeals process. Please do not think you are being told to grin and bear it because we are angry, too.

Region Midwest Southeast
Total dollars reviewed 6,074,393.71 5,588,813.76
Total Dollars denied 3,498,994.66 3,285,618.64
Denial Rate 57.6 58.8

The good news is that most of the claims were denied for Face-to-Face encounter documentation and we can obviously expect fewer denials in the future but not for several months. The claims that will be scrutinized for the next several months will all have required Face-to-Face documentation.

The bad news is that many of these claims were denied for multiple reasons. For instance, in the Southeast Region, there were a total of 1817 claims reviewed producing 1562 denials. There were 865 claims that were denied because ‘MR HIPPS Code Change  – Documentation Contradicts OASIS MO Item(s)’ Look for this denial related to diagnosis coding and therapy. The functional and clinical domain (except for diagnosis) can change but the diagnosis coding should be fairly static throughout an episode unless there has been change.

What can you do?

Agencies need to fight fire with fire. If it’s details they want, give them every detail you have. Deprive them of the opportunity to take your money back.

  1. Admit all patients with a goal of one episode at most. Any further episode must be approved by someone who has reviewed the chart.
  2. Involve the entire staff in educating each other about documentation.
  3. Constantly remind nurses who already document well that the increased focus is not about them but getting paid.
  4. Documentation takes time and should be included as part of the visit rate. If nurses are running the roads all day and producing sloppy documentation at night when they are tired, visits need to be backed down until all work can get done.

The best solutions will come from within your agency. Take advantage of each individuals talents and get everyone involved. Post excellent notes where everyone can see them.

If you think you cannot afford this level of attention to detail, you might rethink that position if you are hit with an edit.

We can help prevent that with our fabulous coders who will ensure proper coding so the careplan can be written within a couple of days and followed to a T.   Call us or connect by email.