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.

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Nina Pham


 

The CDC, among others, have suggested that perhaps more training is needed to ensure that direct health care workers are properly using protective equipment.   According to that line of thought, poor Nina Pham simply did not know what she was doing when she picked up a touch of Ebola from her patient.  If only she had more education on how to put on gloves and a gown, this whole disaster could have been avoided.

I think not.

I posted my dismay regarding re-educating nurses on FaceBook and was amazed at how smart my friends are.

One non-nurse, Michelle said that education was a way to protect the facility.  In other words, when a policy is violated, the hospital is able to assure any surveyor or lawyer that they did, indeed, provide the education and training and have therefore met their responsibility.  Sadly, a successful healthcare facility (and by successful, I mean isn’t closed down) must cover all bases to minimize damages.  I would probably waste time and resources re-teaching PPE, too if I had to make the decisions.

She also pointed out that maybe protocols are not strictly enforced when the risks are lower which could lead to bad habits.  I agree.  Ever notice how MRSA is already a problem when we start monitoring hand hygiene?  (I love that.  Hand hygiene – soon there will be an aisle in the supermarket for hand hygiene products instead of soap, antibacterial gel and hand lotion.)

Lisa Selman Holman pointed out how very miserable PPE is to wear.  She is right.  It is hot and sticky, nothing fits right and it is ugly in the most unforgiving way.  I have yet to figure out how looking like Big Bird assists in the infection control process. Healthcare workers, especially those with a fashion sense, can’t wait to take it off.

If ever there was a time to spend money, this would be it.  Athletic clothing manufacturers have done amazing things with sports gear.  It seems like a clothing manufacturer who exists because they make comfortable, functional clothes that can wick away perspiration, kill enough germs to smell good and keep a body warm in water might be able to help design something comfortable, disease proof, easily taken on and off  with the assistance of an infection control specialist.

Sara Kawaguchi came up with the idea of having two people involved – one present simply to observe.  I love this idea and it is cheap to do when considering the stakes.  Having never met Miss Pham, I can only assume that she didn’t tear a glove, look at it and say, ‘Oh darn,’ and carry on with restarting an infiltrated IV line.   If she breached protocol, it was likely unnoticed by her.

My cousin, Steve, is a physician and his response was simple.

1) we are human
2) we make mistakes
3 there is no room for a mistake here, in flight or in surgery

There’s a lot of truth in that but we can minimize mistakes.  Even the world famous Quality Assurance plan designed by Toyota, Six Sigma refers to only six errors in a million.  When it comes to Ebola, nobody wants to be one of the six.

The Checklist Manifesto by Atul Gawande is written by a surgeon who almost killed a patient because he forgot to do something very simple and standard prior to surgery – type and match blood.  After this near catastrophe that left his confidence shaken, he set about researching how to prevent errors.  It turned out that aviation history was marred by the crash of the first B17 in which several people died.  It almost took Boeing aircraft out of the game completely.  The solution included a checklist which enabled the (highly skilled and trained pilots) to fly 12 planes a total of 1.8M miles without incident.  It is now used universally.

Checklists are not designed to educate anyone.  If you have ever turned in visit notes only to find out that you forgot to write a narrative because you were interrupted, you are prone to human error.  If you have ever been called about a bill you know you paid only to find the stamped envelope in your purse, you could have used a checklist.  They are designed to let you pick up where you left off in the event something slips your mind, you are preoccupied or there is chaos all around you.  They ground and center the user.

There are undoubtedly numerous approaches to improving the safety of healthcare workers but re-educating the staff in a critical care unit on how to put on and take off PPE is an intervention for the hospital – not the nurses.  Don’t tell me that the staff in an intensive care unit requires more schoolin’ to put on gowns, masks and gloves.  Make them more comfortable so they aren’t urgently ripped off like they were on fire the minute you clear the room.  Have someone else watch.  Use a check list.  Doing more of what was done in the past because it didn’t work doesn’t quite make sense to me.

What the healthcare staff needs the most is a cure for Ebola.  When it comes to caring for a patient with Ebola, especially at the end of life, perhaps the most important changes will come about from the staff who were actually there doing the job.  If the blame game stops and the focus is directed to increased protection of healthcare workers, why not consult that handful of clinicians who are the only ones in the United States to have cared for Ebola patients in US hospitals?

I know that you join The Coders in wishing Godspeed to Nina Pham’s recovery.  She was able to be there for a patient isolated from his family and friends when he needed them the most.  People like Nina Pham do not put their own lives on the line for a paycheck.  She has a calling and I pray she will be back at work sooner than later.

Also,  let’s not forget that Nina Pham is not alone.  A few dozen other healthcare workers who took the same risk as Nina Pham and so far, have been free of symptoms.  These include the staff in Dallas as well as Nebraska and GA where two other Ebola patients have been treated.  They are no less heroic because they have not contracted Ebola; they just haven’t made the news and I hope they don’t any time soon.

Elderly Abuse?


A colleague of mine got a couple of phone calls from patients terrified they were going to be admitted to a nursing home.  Two men had come by with a three page list of questions and started asking very personal questions about whether or not they can get in a car, if they can go out to eat and how often their nurse visits.

My colleague reports in his email to me:

“They are not leaving cards or anything. One savvy patient finally got all their information and called us with it.”

and

“One patient was not home when they stopped at his house so they talked with and asked his neighbor questions.”

The men in question were employed by Jackson Dunham Sato & Associates. If you glance through the bio’s on the left sidebar, you will see that essentially all of the managers, partners and associates mostly come from one of two federal governing bodies – the OIG, and CMS (Medicare).  In fact, if you go to the top bar and click on careers, you will find that they are not interested in you if you are not:

  • A current or former Office of Inspector General Auditor/Investigator with healthcare experience
  • A current or former CMS employee who has been involved in program compliance/integrity oversight

At least you don’t have to worry about them poaching your employees.

I realize and you probably do, too, that all of this information is second and third hand.  In order to be responsible, I emailed each of the three senior partners and have not received a response.  The questions asked of them were:

  1. Is this your usual policy regarding identification of your investigators on home visits?
  2. Would it be possible to have your folks dress down; perhaps wear scrubs?
  3. What explanation is given to the patients if they do not ask for identification?  Do the investigators allow them to make assumptions no matter how terrifying?
  4. Do you understand that a patient fearful of nursing home placement might exaggerate their functional abilities?
  5. Could you or do you leave some sort of documentation with the patients?  Patients are calling agencies who are unaware of your presence and cannot offer the patients any reassurance because they do not know who interrogated their patients.
  6. Do you ever send clinicians out to the home to verify medication use and evaluate gait and balance?
  7. Do you do a mental status exam on the patients?  Many patients with Alzheimer’s Dementia and other organic brain syndromes appear as right as rain the first couple of times you meet them.
  8. How do you choose the providers you will be investigating?   Are they assigned to you by Health Integrity?  Do you have access to databases that you can mine for data?
  9. How are you paid by Health Integrity?  Is your payment predicated in any way on recouped monies or arrests?

I have not gotten a response but Health Integrity, LLC confirms that Jackson Dunham, Sato and Associates are a ‘partner’ on their website.  Health Integrity, LLC is the Zone Program Integrity Contractor (ZPIC) for CMS Regions 2 and 4.  Combined, these two regions encompass  Alaska, Arizona, Colorado,  Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, New Mexico, Oklahoma,, North Dakota, Oregon, South Dakota, Texas, Utah, Washington, and Wyoming.

Regardless of an agency’s guilt or innocence, our elderly deserve to be treated with more respect than they have been shown by Jackson Dunham Sato and Associates.  I question the motives of a firm that resorts to intimidating elderly patients and possibly encouraging them to exaggerate their functional abilities in order to ‘prove’ that a patient is not homebound.  Are they genuinely concerned about the welfare of our elderly and protecting the trusts that fund Medicare or are they simply trying to satisfy a requirement for contract renewal, bonus pay or something else?

I can sit at my desk a thousand miles away from a patient and know whether or not their homebound status is questionable.  It is tedious to read every note, every MD clinic visit and OASIS assessment to look for discrepancies and the tell tale signs that the patient does not fit the description in the care plan and the visit notes.   It is not the most glamorous job in the world, I assure you but it can be done without instilling fear of unwanted nursing home placement in elderly people.  Even if a visit has to be made in order to make a final determination, it does not require rudeness or fear.  Even if the investigators are accompanied by a nurse from the agency, it is unlikely that a nurse would be able to influence the patient to lie.

The very best consultant and the very best lawyer cannot help you if you are determined to play outside of the conditions of participation and conditions for payment.  We’ll take you money and do our best. If it is a question of inadequate documentation versus fraud, we can generally help but there is not much we can do if you simply choose to sidestep the rules.

Nobody who works for Medicare or is contracted or subcontracted by Medicare seems to understand that good providers have even less tolerance for the fraudulent providers than they do.  If they would make just the tiniest effort to work with the majority of providers who are good, they might learn a thing or two and then it wouldn’t take years and hundreds of millions of Medicare dollars gone before they caught up with the truly bad players.  At that point, they could offer more frequent education to those providers who take compliance seriously.

If your patients have had visitors or if you have had experience with Jackson Dunham, Sato and Associates, please email me privately and let me know.  As always your comments are welcome below and if I get a response from Jackson Dunham, Sato and Associates, I will be sure to let you know.

One last thing….. if I ever hear of you intimidating a patient, watch out.  I am not nice when I hear of an elderly person treated with anything less than respect.

This Just (snuck) In!


Hospice Providers, take note

To be quite honest, I have never seen a ‘no code’ list in hospice.  If anything, I would expect to see a ‘full code’ list as any code status besides DNR would be the exception.

And yet, there is a new list of codes that hospices may not use when determining the primary reason for hospice care.   A list of codes at the end of this document will be automatically returned to providers when used as a principle code for hospice for claims billed after October 1.

This information comes from CMS change request 8877 which also contains very important information about the Notice of Election.

Home Health Providers:

An updated Local Coverage Determination has been published by Palmetto GBA for Alzheimer’s Dementia.  Among the insightful gems included in this guidance is the following passage begging the question of, ‘does someone have too much time on their hands?’

Behavioral disturbances often complicate the medical management of beneficiaries with Alzheimer’s disease. At baseline many individuals with Alzheimer’s disease manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline – resulting in sub-optimal clinical outcomes.

Wow.  I’m glad we cleared that up.  Seriously, look how often the word, ‘baseline’ is used.  If you really want to get paid, consider using the FAST scale to stage Alzheimer’s on admission and recert.  There are also numerous documentation requirements.  Please review and document accordingly.

If you recall, numerous claims once denied for Face-to-Face documentation are now being denied for lack of both long and short term goals.  The reference to short and long term goals is listed as the Physical Therapy LCD.  I am quite certain that the Alzheimer’s documentation LCD will be used in the same way.

Both of these regulations will take place on October 1.  Be ready.

 

The Hospice No Code List

290.0 Senile Dementia Uncomplicated
290.10 Presenile Dementia Uncomplicated
290.11 Presenile Dementia With Delirium
290.12 Presenile Dementia With Delusional Features
290.12 Presenile Dementia With Delusional Features
290.13 Presenile Dementia With Depressive Features
290.20 Senile Dementia With Delusional Features
290.20 Senile Dementia With Delusional Features
290.21 Senile Dementia With Depressive Features
290.3 Senile Dementia With Delirium
290.3 Senile Dementia With Delirium
290.40 Vascular Dementia Uncomplicated
290.41 Vascular Dementia With Delirium
290.42 Vascular Dementia With Delusions
290.43 Vascular Dementia With Depressed Mood
290.8 Other Specified Senile Psychotic Conditions
290.9 Unspecified Senile Psychotic Condition
293.0 Delirium Due To Conditions Classified Elsewhere
293.1 Subacute Delirium
293.81 Psychotic Disorder With Delusions In
293.82 Psychotic Disorder With Hallucinations In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.89 Other Specified Transient Organic Mental Disorders Due To Conditions Classified Elsewhere
294.20 Dementia, Unspecified, Without Behavioral Disturbance
294.21 Dementia, Unspecified, With Behavioral Disturbance
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
310.0 Frontal Lobe Syndrome
310.1 Personality Change Due To Conditions Classified Elsewhere
310.2 Postconcussion Syndrome
310.89 Other Specified Nonpsychotic Mental Disorders Following Organic Brain Damage
310.9 Unspecified Nonpsychotic Mental Disorder Following Organic Brain Damage

Hospice Coding


coding wordle 2

 

72 percent of hospice claims list only one diagnosis.  The diagnosis used most often is Debility. The third most frequently used diagnosis is adult failure to thrive. 

That means that upwards of 75 percent of hospices may have some real problems soon.  The requirement that hospices adhere to the ICD-9 coding guidelines is not new.  It is written into the original 1983 hospice guidelines and CMS is very much aware that hospices are not following the long established rules of coding.

Hospices have responded by building cheat sheets and lists of common hospice diagnoses.  It’s a great idea but it probably won’t work.  It didn’t work for hospitals in the 90’s or home health agencies after their prospective payment system was refined in 2008.  To this day agencies that depend on untrained nurses to code are losing money by insufficient coding or worse, getting denied because of invalid codes.

The biggest mistake that home health agencies made all those years ago after PPS was implemented was not taking coding seriously.  With four exceptions, the ICD-9 coding performed by an agency did not affect payment.  As such, diagnosis coding was not taken very seriously by home health. 

That turned out to be a mistake. Diagnoses that required significant resources to treat were not included in future updates to the payment system.  Incorrect, poorly specified diagnoses were included but when coded correctly, they did not add to the reimbursement.

I am not going to pretend that I am psychic and charge you for my insight into the future.  I can only say that I see this happening to the Hospice Industry in the not-so-distant future.

How could this stubborn insistence on following the rules be any worse, you ask?  It comes right as the rest of the world is transitioning into ICD-10 coding.  That’s right.  By the time you get the hang of ICD-9 Coding, the rules of the game will change.

It’s almost as though Medicare has taken up our cause as their own and has begun emphasizing the value of our coding services.  Thank you, Medicare for the plug.  Can we talk about the face-to-face requirement, now?

If you do not want to outsource coding, there are other options (but none as good as contracting with us or another reputable company).

  1. If your hospice has common ownership with a home health agency, remember that this is not new to them.  Make some kind of arrangement with them. 
  2. When you are recruiting nurses or billers, put coding on the top of the list of preferred skills.
  3. Go online and look for certified coders.  Remember, coders do not have to be nurses.
  4. If there is a school that offers RHIT certification in your area, offer a student internship.  You might end up with the employee of a lifetime or a dud.  It is worth the gamble because they are trained in coding, electronic health information, etc.   
  5. Outsource ICD-9 coding and focus on investing in ICD-10 coding preparation for your staff. 

Remember, people do not wake up one morning and try as hard as they can to thrive and fail.  If you cannot come up with a good underlying reason, expect denials.  Not being paid fairly could easily be the result of poor coding which might lead to a poor outcome for hospices that go the extra mile to ensure patients and their families are comfortable at the end of life.  It takes resources to provide the kind of care that matters.  Don’t cheat your hospice or your patients by failing to take this seriously.

As always, Delaine and Jackie can be reached via email or you can call 337-654-7934.