Conditions of Participation… Professional Requirements


This week’s Condition of Participation involves Professional Services.  These are common practice and similar to what is in place in your agency anyway.   There are new requirements for the Administrator and a new position called ‘Clinical Manager’.  The requirements are linked in the post.  Adjust your job descriptions and a review of the Medicare Benefit Policy Manual, chapter 7 would be a good idea.

The Condition is pasted below followed by the standards that will be surveyed to verify compliance.

484.75 Condition of Participation: Skilled professional services.

Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician and medical social work services as specified in §409.45 of this chapter.

Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care.

This Condition is written as though you know all about subsections 409.44 and 409.45 but in case you do not, you can click the links.

Not to be confused with official guidance from Medicare, here’s an abbreviated summary of what you already know:

Skilled nursing services are those skills which can only be performed by a nurse.  Coverage is determined by the complexity of the skill as well as the condition of the patient.  If the skill could be performed by the average Joe, it would not be considered skilled.  The Medicare Benefit Policy Manual is our favorite source for researching skilled nursing services.

Physical Therapy skills must be of a nature that they can only be performed safely by a skilled therapist.  In determining if therapy is skilled, determine if the Jimmo ruling of 2013 applies.

Medical Social Workers provide services ordered by the physician to address emotional and social needs that may interfere with the patient’s ability to respond to the plan of care or the agency’s ability to carry out the plan of care.  According to the Interpretative Guidelines, they are furnished ‘on a short-term basis and it can be demonstrated that the service is necessary to resolve a clear and direct impediment to the effective treatment of the beneficiary’s medical condition or to his or her rate of recovery’.

The standards that demonstrate compliance should be familiar to you even if you did not know they were a part of the Conditions of Participations.

The first standard reads:

484.75(a) Standard: Provision of services by skilled professionals.

Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures.

The appropriate qualifications are in another section, so we made a quick cheat sheet.  The information is straight forward except for physical and occupational therapists.  Each of these therapists have provisions for states that do not have licensing laws.  A quick search of the web revealed that all states require licensing so if you stick with licensed therapists in your state, you should be okay.

There is also a provision in this condition that professional services are provided according to the agency’s policies and procedures.  This includes contracted therapists so be sure to share relevant policies with contractors and include them in compliance training.

484.75(b) Standard: Responsibilities of skilled professionals.

Skilled professionals must assume responsibility for, but not be restricted to, the following:

  1. Ongoing interdisciplinary assessment of the patient;

The interpretative guidelines define ‘interdisciplinary’ as an approach to healthcare that includes a range of health service workers, both professionals and non-professionals, with the majority being from professional groups. Ongoing interdisciplinary assessment is the continual involvement of all skilled professional staff involved in the plan of care from the initial assessment through discharge and periodic interactive, discussions regarding the status and recommendations for the plan of care. The interdisciplinary approach recognizes the contributions of the disciplines (MDs, RNs, LPN/LVN, PT, OT, SLP, MSW, HH aides) and their interactions with each other to meet the patient’s needs.

The Coders recommend weekly or bi-weekly case conferences where patients approaching the end of their episodes are discussed in a meaningful way by all involved disciplines.  Any patients who have significant changes in their condition or treatment plans can be added to the list.  It also means documentation of any casual discussions you may have with other agency employees or physicians.

  1. Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); 
  1. Providing services that are ordered by the physician as indicated in the plan of care; 
  1. Patient, caregiver, and family counseling; 
  1. Patient and caregiver education; 
  1. Preparing clinical notes;
  1. Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; 
  1. Participation in the HHA’s QAPI program; 
  1. Participation in HHA-sponsored in-service training 

Some of these criteria will be discussed in subsequent parts of the Conditions of Participation so don’t worry if one or more confuses you.

Supervision

Supervision is the focus of the next standard supporting the condition involving Skilled Services.  There are numerous references made to §484.115; our little cheat sheet referenced above with personnel qualifications. 

484.75(c) Standard: Supervision of skilled professional assistants

This is a generic supervision standard that applies to therapy assistants, LPN, etc.  As such, it does not include a time frame or the criteria for supervision.  Oversight is usually guided by the practice standards for each discipline.  Additionally, there must be written instructions for these assistants and you can expect that they will be surveyed.

484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k).

484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(e, f) or (g, h), respectively. 

Please note that therapists can only supervise assistants within their disciplines.  Occupational Therapy must supervise Occupational Therapy assistants, etc.

484.75(c)(3) Medical social services are provided under the supervision of a social worker that meets the requirements of §484.115(m).

Home Health Aide services, training and competency are soon to follow.  Meanwhile if you have any problems with the Professional Services information, feel free to drop us a line.

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CoP’s Continued…. Infection Control


Clean Hands Count

Historically, there have been very few studies concerning infection control and home Visits.  The work environment is the patient’s home and there is only so much we can do to control it.   We don’t have a housekeeping department to mop up our messes with industrial strength cleaning agents like hospital nurses.  We cannot fire other family members if they don’t wash their hands and what about those pets who jump on the bed after being outside?

One idea is to simply give up.  A better idea is to recognize that without a clean-up crew and a controlled environment, Infection Control is more important than ever.  And, since the new Conditions of Participation you must implement a program by mid January 2018,  the latter option might be best.

The condition is straight forward.  Here it is for reference.

The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases.

The reason Infection Control is getting an entire blog post to itself even though technically it is part of the QA Condition is because the Interpretive Guidelines list specific components that your surveyors will be assessing.  They include six components identified by the CDC as being relevant in the home.

  1. Hand Hygiene;
  2. Environmental Cleaning and Disinfection;
  3. Injection and Medication Safety;
  4. Appropriate Use of Personal Protective Equipment;
  5. Minimizing Potential Exposures; and
  6. Reprocessing of reusable medical equipment between each patient and when soiled.

Not only should your plan address all six of these issues, but they should be evident in practice.

Hand Hygiene

The Interpretive guidelines advise agencies that handwashing should occur:

  1. Before contact with a patient;
  2. Before performing an aseptic task (e.g., insertion of IV, preparing an injection, performing wound care);
  3. After contact with the patient or objects in the immediate vicinity of the patient;
  4. After contact with blood, body fluids or contaminated surfaces;
  5. Moving from a contaminated-body site to a clean body site during patient care; and
  6. After removal of personal protective equipment (PPE);

Alcohol based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers most of the time. Antiseptic soaps and detergents are the next most effective and non-antimicrobial soaps are the least effective.  Bars of soap are so retro that they really don’t deserve much attention except that you might still find them in patient homes.

When hands are not visibly dirty, alcohol based hand sanitizers are the preferred method for hand hygiene. The agency must ensure that supplies necessary for adherence to hand hygiene are provided.  However, be careful if you have a patient diagnosed with Clostridium Difficile as hand sanitizers are not effective.  Gloves must be worn.

Environmental Cleaning and Disinfecting

The interpretive guidelines recognize that you have little control over the tidiness and disinfection in another person’s home.  However, they do state that the home health personnel ‘must maintain their equipment and supplies clean, during the home visit, during transport of reusable patient care items in a carrying case in the staff vehicle and for use of the items in multiple patients’ homes.’  Thus, your primary focus is on your supplies and equipment.

Safe Injection Practices

Safe injection practices include:

  1. Use aseptic technique when preparing and administering medications;
  2. Do not reuse needles, lancets, or syringes for more than one use on one patient; Use single-dose vials for parenteral medications whenever possible;
  3. Do not administer medications from a single-dose vial or ampule to multiple patients;
  4. Use fluid infusion and administration sets (i.e intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use;
  5. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to patient’s intravenous infusion bag or administration set;
  6. Enter medication containers with a new needle and a new syringe even when obtaining additional doses for the same patient;
  7. Insulin pens must be dedicated for a single patient and never shared even if the needle is changed;
  8. Sharps disposal should be in compliance with applicable state and local laws and regulations.

Since none of you would dream of reusing or sharing equipment, your attention is needed at number 8.  Know your state and local laws and regulations about disposal of sharps.  Frankly, it is a little insulting that someone thought they had to tell home health nurses that they shouldn’t use insulin pens or IV sets on more than one patient.

Appropriate Use of PPE

This refers to the gear used as a barrier against infection.  The idea is that any contaminants thrown your way will hit your PPE and be disposed of as you leave the patient room.  Examples include gloves, gowns, masks, and eye protection depending on the nature of the potential threat.

Although it is not clearly spelled out, it is in inherent in any regulation about PPE that the staff understand how to use it.  It is not as easy as it looks and taking it off is even more difficult.  Do you remember the nurse, Nina Pham who contracted Ebola in a Dallas Hospital?   She might tell you to take every advantage to learn about PPE.

Minimizing Potential Exposures

This focuses on the protection of the family members, other caregivers and visitors and the transmission of pathogens while transporting specimens and medical waste such as sharps.  There isn’t much written on it in the interpretive guidelines or Conditions of Participation probably because each patient and family are in a different situation.  Nobody catches arthritis by breathing the same air as a patient but patients with contagious diseases need to be assessed and plan put into place that is specific to the nature of the patient’s contagious condition.

Reprocessing (cleaning and disinfecting) of Reusable Medical Equipment is essential.

Reusable medical equipment (e.g., glucose meters, INR machines and other devices such as, blood pressure cuffs, oximeter probes) must be cleaned/disinfected prior to use on another patient and when soiled. The HHA must ensure that staff are trained to:

  • Maintain separation between clean and soiled equipment to prevent cross contamination; and
  • To follow the manufacturer’s instructions for use and current standards of practice for patient care equipment transport, storage, and cleaning/disinfecting.

There must be documentation that the staff has been trained.  To minimize the resources spent on training, an agency might limit the purchase of machines such as INRs and blood glucose machines to one or two brands so the instructions don’t change.  If, like many agencies, you opt to use the patient’s equipment whenever possible, be sure that patients know how to use and maintain their equipment.

The next standard is:

The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include:

Surveillance

According the Interpretative guidelines, The HHA infection control program should ‘use observation and evaluation of services from all disciplines to identify sources or causative factors of infection, track patterns and trends of infections, establish a corrective plan, and monitor effectiveness of the corrective plan.’

In other words, you should task all disciplines with looking for infections, their underlying cause and any trends.  A plan should be established to address any trends or patterns and the agency will monitor effectiveness.

The Interpretative Guidelines suggest the following activities be used in your surveillance:

  • Clinical record review;
  • Staff reporting procedures;
  • Review of laboratory results;
  • Data analysis for physician and emergency room visits for symptoms of infection; and
  • Identification of root cause of infection through evaluation of HHA personnel technique and selfcare technique by patients or caregivers.

More specifically, we suggest:

  • New orders for antibiotics
  • Hospitalizations for suspected infection
  • Deteriorating wounds
  • Fever – most computer systems have a trendline for temperature over time. Look for spikes.

If you have any other suggestions, please share them.

Now that you know who has been infected, an analysis should occur.  The easiest way to do this is to enter your numbers on a spreadsheet and then make a graph out of them.  If you are not friends with MS Excel, you can do the same thing manually.  Depending on the type of graph, you may see spikes, clusters or other indicators that ‘one of these things is not like the other’.

Put a plan into place that will address any variations in data or infections that might have arisen from your care or have been prevented by your care.  Instead of asking what your agency did wrong, consider what could have been done better.

Write down the steps that are needed to address any areas that could be approved.  Assign them to appropriate staff.  The agency does not have to break new ground in the science of infection control.  The tools and knowledge are there.  Use them.

Monitoring results is the missing step in many infection control programs.  When you write your plan that includes specific activities, include the frequency and method of monitoring results.  This will allow the agency to rapidly respond to any increase in infections that occur despite your well executed plan.  This is not failure, by the way.  Recognizing that a plan isn’t working and calling an impromptu meeting to make changes before your regular meetings is how good Infection Control Programs are managed.

When positive results are noted, they should be shared.  You have asked your nurses to participate in your Infection Control Program.  Let them know when their hard work has netted results.

The last standard in Infection Control concerns training and education.

The HHA must provide infection control education to staff, patients, and caregiver(s).

The interpretive guidelines are clear on what is expected:

HHA staff education should include as a minimum:

  • Appropriate use, transport, storage, and cleaning methods of patient care equipment according to manufacturer’s guidelines and receive the following provide the following for staff education:
  • Job-specific, infection prevention education and training to all healthcare personnel for all of their respective tasks;
  • Processes to ensure that all healthcare personnel understand and are competent to adhere to infection prevention requirements as they perform their roles and responsibilities;
  • Written infection prevention policies and procedures that are widely available, current, and based on current standards of practice;
  • Training before individuals are allowed to perform their duties and periodic refresher training as designated by HHA policy;
  • Additional training in response to recognized lapses in adherence and to address newly recognized infection transmission threats (e.g., introduction of new equipment or procedures);
  • Provide in-service infection control education for staff at periodic intervals (minimally annually) consistent with accepted standards of practice, such as: at orientation, annually, and as needed to meet the staffs learning needs to provide adequate care, identify infection signs and symptoms, identify routes of infection transmission, appropriately disinfect/sanitize/transport equipment and devices used for the patient’s care, medical waste disposal, including instructions on how to implement current infection prevention/treatment practices in the home setting.

It might be that Medicare is serious about Infection Control.  What do you think?

There is a plethora of tools on the internet to help with Infection Control.  As time allows, we will post links to some of them.  Many agencies have Infection Control programs that are outdated or not implemented and some of them are frankly too confusing to follow.   Simplify instead of complicate what is in place.  Put your real efforts into preventing and monitoring infections and let your computer do the data collection.

One approach that has a 100 percent chance of failure is writing or buying a pretty binder and keeping on the shelf between surveys.  The plan should be available and have clear instructions for anyone with a question.  The number of pages your plan has irrelevant.  The effectiveness of the program is where you should focus your efforts.

If you need any help designing and implementing an infection control program or any or all of the Conditions of Participation, you know who to contact.  We’re ready and willing to help.

Two More New Conditions of Participation


Assessment and Plan of Care

The current Conditions of Participation are not specific about the scope of the assessment or the plan of care, but most agencies are already meeting the CoP’s due out in January.  In the current CoP’s, the scope of practice for each discipline is defined, followed by a section on clinical records.  It reads:

A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary. The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient’s medical and health status at discharge.

The new Conditions of Participation have details about what is expected to be in your assessment and plan of care.

Assessment:

The condition reads: Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment

The standards that fall under this condition are as follows as I understand them.  They are not verbatim.

  1. The RN must conduct an initial assessment to determine the immediate care and support needs of the patient and for Medicare patients, determine eligibility, including homebound status. This visit must occur within 48 hours of referral or return to the home or on the specific date ordered by the MD.
  2. When nursing isn’t ordered, Physical Therapy, Speech Therapy or Occupational Therapy can perform the initial assessment. This is later clarified to read that Occupational Therapy can perform the assessment if the need for OT services establishes the need for services.
  3. The initial assessment must be completed in a manner consistent with the immediate needs of the patient but no later than five days after the start of care.
  4. Content of the plan of care is expected to include:
    1. Patient strengths, goals and care preferences – including information that may be used to demonstrate patient progress to the patient’s goals and measurable outcomes identified by the agency.
    2. The patient’s continuing need for home care
    3. Medical, nursing, rehab, social and discharge planning needs
    4. Medication review of all drugs the patient is using to include
      1. Potentially adverse effects
      2. Drug reactions
  • Ineffective drug therapy
  1. Significant side effects
  2. Significant drug interactions
  3. Duplicate drug therapy
  4. Non-compliance with therapy
  1. The patient’s primary caregiver(s) and other support including their willingness and ability to provide care, their availability and schedules and the patient’s representatives, if any.
  2. Incorporation of the OASIS dataset into the comprehensive assessment.
  1. The assessment must be updated at least every 60 days and also at the time of a significant change in condition, beneficiary elected transfer, transfer and discharge to the same agency within the same 60-day period, within 48 hours of return to home after a hospitalization and discharge.

Surely you have realized by now that most of these criteria are already written into the OASIS regulations, prior Conditions of Participation and sound clinical principles.   Now they are Conditions of Participation and while similar to what we already do, note that Occupational Therapy can now perform OASIS assessments.  Also, it’s worth noting that whenever the comprehensive assessment is mentioned, it is followed by the assessment of Medicare eligibility for Medicare patients including homebound status.

Careplanning, Coordination of Care and Quality of Care

 This is a new condition and while many agencies already do most of this, there are some standards that some agency’s haven’t done in the past.

The actual condition is:

Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.

The standards that agency’s will follow to ensure and demonstrate compliance are as follows:

  1. Each patient must receive services that are written in a patient specific plan of care identifying patient goals and outcomes, established and reviewed periodically and signed by a doctor of medicine, osteopathy or podiatry acting within his or her scope of practice.
  2. If the physician refers a patient and the plan of care cannot be completed until after an evaluation visit, the physician is consulted to approve additional orders.

Contents of the Plan of Care

  1. The individualized plan of care must include the following:
  • All pertinent diagnoses;
  • (mental, psychosocial, and cognitive status;
  • The types of services, supplies, and equipment required;
  • The frequency and duration of visits to be made;
  • Prognosis;
  • Rehabilitation potential;
  • Functional limitations;
  • Activities permitted;
  • Nutritional requirements;
  • All medications and treatments;
  • Safety measures to protect against injury;
  • Risk assessment for emergency room visits and rehospitalizations and all necessary interventions to address the risk factors.
  • Patient and caregiver education and training to facilitate timely discharge;
  • Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
  • Information related to any advanced directives; and
  • Orders, including verbal orders
  1. Drugs, services and treatments are administered only as ordered by a physician
  2. Flu and pneumonia vaccines may be administered per agency policy developed in consultation with a physician and after the assessment of a patient to determine contraindications.
  3. Verbal orders must be accepted only in accordance with state laws pertaining to verbal orders. When a verbal order is obtained, services are to be carried out as ordered without waiting on the signed order. Verbal orders must include the signature, date and time that the order was received and be placed in the clinical record.  They are to be authenticated and dated by the physician who gave the orders in accordance with state laws and regulations as well as agency policies.

Review and Revision of the Plan of Care

  1. The plan of care is reviewed and revised by the physician who is responsible for the for the home health plan of care as often as indicated by the patient’s condition but at least every 60 days. The agency  must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  2. The revised plan of care must reflect current information from the patient’s updated comprehensive assessment and contain information concerning progress towards goals identified by the agency and patient in the plan of care.
  3. Any revisions to the pan of care due to a change in health status must be communicated to the patient, representative (if any) and all physicians writing orders for the patient.
  4. Any revisions to discharge plans must be communicated to the patient, representative (if any) and all physicians ordering care, the patient’s primary care practitioner or other health care professional who will provide care to the patient after discharge from the agency.

Ensuring Care Coordination involves:

  1. Communication with all physicians involved in the plan of care.
  2. Integration of orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
  3. Integration of services provided by the agency or under arrangement to assure the identification of patient needs and factors that affect patient safety and treatment and coordination of care.
  4. Involvement of the patient, representative (if any), and caregivers as appropriate in coordination of care activities.
  5. Ensure that education is provided by the agency to the patient and caregivers regarding care and services in the Plan of Care and to ensure a timely discharge.

The agency must provide written information to the patient that includes:

  1. Visit schedule of all agency and contracted personnel
  2. Patient Medications and instructions on how to take meds including medication name, dosage and frequency and which meds will be administered by the agency or contracted personnel.
  3. Al pertinent instructions related to the patient’s care and treatments that the agency will provide specific to the patient needs.
  4. The name and contact information of the agency’s clinical manager.

So that’s a lot.  Agencies who choose to wait will be working weekends and holidays to be in compliance by mid-January.  The first thing I might do is call my software vendor.  The plan of care requirements haven’t changed but the information that is required to be given to the patient has.  Could a patient friendly medication sheet containing frequency as well as the name and strength of the med be generated?  Depending on your patient population, there may be questions about whether or not you want to leave the entire plan of care in the home.  Will the computer generate a separate form?

Notice that teaching must be specific to the patient.  This may seem self-evident but I have seen nurses teach that Neurontin is for seizures when the patient never had a seizure in their life but was taking Neurontin for neuropathy.  Still, the patient verbalized understanding.

Care coordination and communication is an ongoing Condition and an ongoing problem.  I thought that software messaging would reduce the problem but sadly it has not.  The software accounts I have for clients have so many emails in the inboxes and the vast majority of them do not concern me. One of you has a better idea.  Care to share?

Look for more next week.  Meanwhile, get through these Conditions before moving on to the next.

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.

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.

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.

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