Tag / Julianne Haydel. Jackie Benson

by Julianne Haydel

Welcome Back, Mr. SCIC


The SCIC is Back

Nurses who did not enter home health until this decade may be familiar with SCIC’s. Maybe they read about them or they were briefly reviewed in orientation. In the early years of PPS, a SCIC or other follow-up assessment changed the payment of an episode. Then it didn’t. Soon it will again. So the Significant Change in Condition; or other follow-up is a thing and it’s about to be a bigger thing.

The Quarterly OASIS Q and A from Medicare state:

When diagnosis codes change between one 30-day claim and the next, there is no requirement for the HHA to complete an RFA 5- Other follow-up assessment to ensure that diagnosis coding on the claim matches to the OASIS assessment. The CoP 484.55(d) does require an RFA 05 when there has been a major improvement or decline in a patient’s condition that was not envisioned in the original Plan of Care. CMS expects agencies to have and follow agency policies that determine the criteria for when the Other Follow-up assessment is to be completed.

The OASIS User Manual defines ‘RFA-5 other follow-up’ as:

… comprehensive assessment is conducted due to a major decline or improvement in patient’s health status occurring at a time other than during the last five days of the episode. This assessment is done to re-evaluate the patient’s condition, allowing revision to the patient’s care plan as appropriate.

With 30-day claim periods and 60-day OASIS intervals, there may be changes in your patient’s condition causing your patient to need more care that are not reflected in payment. If this occurs during the first claim period, the SCIC assessment is a way to increase payment for the second 30-day claim period. The claim period will only be adjusted if the date of assessment occurs prior to the 30th day.

So, in crafting or revising your SCIC policy, a good place to start would be with the OASIS questions that will affect your outcomes and payment – particularly hospitalizations. Currently, you must collect information on hospitalization risk and it will affect payment. Why not include factors that might increase the patient’s risk for hospitalization?

  • One or more falls
  • Unintentional weight loss of a total of X pounds (contingent upon base weight of patient.)
  • Any hospitalization, ER visit or MD visit that results in a change in orders.
  • Persistent decline in mental, emotional, or behavioral status.
  • Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) that is not corrected within two weeks with patient and caregiver education.
  • New medications that require teaching
  • Exhaustion that was not present on admission and does not result from exertion such as family outing or holiday.

All of these criteria have the potential to change the case mix weight. And remember that the Conditions of Participation state that risks for hospitalization should be on the care plan along with interventions on how to mitigate those risks.

Crafting a policy around two mandates already in effect will result in a policy that doesn’t require a lot of extra work to teach or monitor.

Should you have any questions or comments, please email us or leave a comment. If you have a different idea, we are open to hearing it.

by Julianne Haydel

Happy New Year!


Welcome 2019! If you have performed or reviewed any OASIS assessments since the beginning of the year, you may have been taken aback by the number of changes in the dataset. While its true that more than twice as many questions have been removed than have been added, the questions added have multiple parts and are quite different from the traditional OASIS C questions.

After being immersed in OASIS-D for a couple of weeks, I decided to rest my weary mind today and look at a chart created for a patient who broke her hip. She was admitted to the hospital where she had an ORIF followed by a rehab and then SNF stay. Guess what I found? All the OASIS questions that are new to Home Health Care. This proves to illustrate the ultimate goal of standardization across post acute care providers described in the IMPACT Act. Very simple math will let payor sources know which providers are making patients better. And of course, they already know how much providers are paid. This could be a true advantage to home health. If we can achieve results that are equal to or better than other providers, Medicare will favor home health as providers because we cost less.

The good news is that therapists should be easy to train. In fact, CMS invites a multidisciplinary approach to the OASIS-D assessment and therapists might be the key to getting it right the first time.

The new questions are not difficult but they will require time and thought in order to arrive at the correct answer. There’s a new type of fall to be counted; the intercepted fall where a patient is caught by another before they hit the ground. Witnessed and unwitnessed falls will be documented so like most good agencies, falls will be assessed on each visit. Hopefully, reports will be engineered by software vendors so that you can run reports from your software. OASIS data will tell you how many falls were experienced, what kind of falls they were, and if there was an associated injury. QA will be easy although it is possible that an initial uptick in the number of falls will be the result of constantly assessing. Be sure to count each fall only once.

Mobility has subsections A through S. That’s almost an entire alphabet. The questions are interrelated but each one needs an answer. Only one goal is needed.

The Coders has education available for your agency. Contact us and we will find a day we can spend with your staff educating them about the magical powers of OASIS-D.

To find out if you need additional training, take our OASIS-D Quiz.

And until you are confident that your agency is proficient in the OASIS-D updates, we are always available for OASIS review and/or coding.

Good luck. More later.

by Julianne Haydel

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.

by Julianne Haydel

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

 

by Julianne Haydel

Hospice Updates


I had the privilege of attending an educational session with Jamie Boudreaux with the Louisiana-Mississippi Hospice and Palliative Care Organization this week.  I highly recommend taking advantage of any opportunity that comes your way to attend any LMHPCO events.

During Jamie’s talk, he referenced numerous changes that were proposed for 2016 in Hospice.  After hearing so much about this exciting document, I couldn’t wait to read it.  You should read it, too and send your comments should you have any.

The highlights – or at least those points that we find interesting as coders and clinicians, are found below.  This is not an all inclusive account of the regulations and I strongly encourage you to read them for yourself.

Good News First

You are getting a raise.  It is projected that hospice payments will rise almost 2 percent.  But that’s not all.  Remember that talk about a U Shaped curve?  It isn’t exactly a ‘U’ but you now have a change in how you will be paid.

There are two factors that will increase your payment.  In the current system, due to the increased expenses in admitting a patient and establishing a care plan, a patient will be on service for approximately 21 days until the hospice breaks even.  As time goes by, the payment stays the same and hospice providers are collecting the same payment for long stretches of time when the patient has minimal needs.  This is traditionally when the hospice made money.  As death approaches, the costs usually increase again.

As such, two new provisions have been added.

During the first 60 days of hospice, payment will be at a rate (adjusted for your area) of $187.63

After day 60, per diem payment will fall to $145.21

Important:  An episode of hospice care is considered to be all episodes that are separated by no more than 60 days.  You cannot discharge and readmit a patient prior to 60 days and expect the higher rate.  Hospice providers who pick up patients from other hospices as in a transfer will be similarly unable to claim the higher rate.

But there’s more!

During the last seven days of care, hospices will be able to bill a Severity Intensity Add-on or SIA.  In addition to the hospice per diem rate, for Registered Nurse and Social Work visits during those last 7 days, an additional rate equivalent to the continuous care rate may be billed up to 4 hours.  That means that in addition to the daily rate, a hospice can receive almost $160.00 more.

There are conditions:

  • The additional rate is only available for Registered Nurse and Social Work visits.
  • The SIO is not available for patients in nursing homes.
  • The beneficiary is discharged due to death
  • The care occurs in the last seven days of life.

The reported reason for this change is to encourage providers to provide additional care when it is needed the most.  A full 20 percent of patients did not receive a visit on the day of death.

So that’s the good news.  Hospice providers will be receiving additional cash when expenses are the highest. Back to the beginning of the document where the news isn’t quite so exciting.

Background

Normally, we would not bore you with the background of any proposed regulations but in this case, the continual references to the 1983 hospice benefit rules probably indicate that some of the recent changes and proposed changes are an indication that hospices haven’t gotten it right, yet.

The tone of this document is well worth your time to read so you can heed the inherent warnings.

Attending Physician

The rule is one per patient.  The fact that over one third of patients have multiple physicians submitting claims indicating they are the attending physician results in Medicare paying the physicians when in fact, the hospice is the correct payor source.  Don’t get caught doing this.

A signed document is required when a patient chooses to change physicians.

The Joy of Scrutiny

Medicare is not mandating surveys to be conducted at least every three years as opposed to the every 6 year rule now.  Select hospices who have long lengths of stay can expect to find themselves on a private list where all claims for services past 180 days of admission are routinely reviewed.  Do not get on this naughty list.

Remember, the data exists for Medicare to look at the average length of stay in addition to the percentage of patients on service greater than 180 days.  That’s a really good number to keep handy, by the way.  You can have a lot of patients on service for a year or more offset by some short lived admissions so your average length of stay may be okay but you might still have far too many patients on service longer than would be considered reasonable and necessary.

Utilization

Obviously this is not a regulation but it is an indication of the overall ‘tone’ being set by document.

The number of Medicare beneficiaries receiving hospice services has grown from 513,000 in FY 2000 to over 1.3 million in FY 2013. Similarly, Medicare hospice expenditures have risen from $2.8 billion in FY 2000 to an estimated $15.3 billion in FY 2013

…..this increased spending is partly due to an increased average lifetime length of stay for beneficiaries, from 54 days in 2000 to 98.5 days in FY 2013, an increase of 82 percent.

Cost Savings?

image

This chart shows how many dollars per day were spent on patients in the 180 days prior to hospice admission and how many days spent in the care of a hospice.  As it turns out, both of these numbers are critical for determining potential savings to the Medicare trusts.

On the vertical column, you can see the grand total of days a patient spent in hospice.  The horizontal line shows what the average daily cost of the patient was prior to admission.

This is Medicare’s work.  We do not agree with this method of cost analysis.  However, any differences of opinions regarding the formulas used do not account for $158,000 per patient with a diagnosis of Alzheimer’s Dementia which is about what it works out to be over 120 days.

The Medicare Hospice Benefit is not reducing healthcare costs in terminally ill patients. This is a problem folks.

Live Discharges

The proposed regulations are very clear that nobody expects the live discharge rate to be zero.  Patients have the right at any time to revoke their election at any time.  Some patients start to get better especially after they have been taken off 25 medications designed to prolong their life.  They move and sometimes they just hate your hospice and revoke.

Based on the data within the proposed regulations, there can be no doubt that an above average live discharge rate strongly correlates with other undesirable characteristics of hospice provider.  The patients discharged alive are from providers that also have more long term, low maintenance patients.  Additionally, patients in these hospices cost Medicare more in terms of money spent for nonhospice care.

The proposed regulations reiterated the limited number of reasons that a provider can discharge a patient.  They are as follows:

    • death
    • revocation
    • transfer to another hospice
    • moving out of the hospice’s service area
    • discharge for cause,
    • patient no longer being considered terminally ill (that is, no longer qualifying for hospice services

When discharging for cause, ensure that all reasons are documented especially if a patient has been on service for a while.  When more than one neighborhood becomes unsafe on day 181 of a hospice episode of care, it makes for a pattern.

There are very few legitimate causes for discharge in hospice. and the regulations are clear that discharging patients due to cost is not approved by Medicare.

Comments from Providers

The data in the proposed regulations is stunning but the real damage comes from various and sundry anecdotes.  It is important for providers to understand what those who right the rules are thinking and how they are thinking.   Copied directly from the regs:

We have received anecdotal reports from non-hospice providers who have rendered care and services to hospice beneficiaries in which the non-hospice provider states that the care given was related to the terminal prognosis of the individual. These reports go on to say that they have contacted hospices to coordinate the care of the hospice beneficiary only to be told by those hospices that they disagreed with the non-hospice providers’ clinical judgment that the care was related to the terminal prognosis.

We have been told that hospices are refusing to reimburse the non-hospice provider for care related to the terminal prognosis.

non-hospice providers also informed us that the hospices told them to code the claim with a different diagnosis or to code condition code 07 (treatment of Non-terminal Condition for Hospice) or the modifier “GW” (service not related to the hospice patient’s terminal condition) on their claims to ensure that the non-hospice provider would consequently get paid through Medicare.

We have also received anecdotal reports from hospice beneficiaries and their families that they have been told by the hospice to revoke their hospice election to receive high-cost services that should be covered by the hospice, such as palliative chemotherapy and radiation.

In addition to publishing these comments, staff memos to employees of specific large hospices were included stating that their providers should go after the long term patients.

Terminal Prognosis

This is the last time that you should ever consider the words ‘terminal’ and ‘diagnosis’ together.  People do not have terminal conditions in isolation.  They have terminal prognoses.

All of the research and numbers that Medicare has presented all go to support their belief that hospices are not living up to their provider agreement which includes care for the diagnoses that is most likely to cause death and any and all other diagnoses that affect the patient’s comfort, are a result of the terminal prognosis or contribute to the severity of the prognosis.

Consider a patient who needs bypass surgery but because of diabetes, long term use of steroids for arthritis and a longstanding history of noncompliance due to a psychiatric illness, she is not a surgical candidate.  There is no one diagnosis that is terminal.  All of them play a role in his terminal prognosis and all must be addressed by the hospice.

Coding

You are making progress!  In the 2015 regulations it was noted that 72 percent of hospice claims had only a single diagnosis.  This year, for the 2016 update, the percentage of claims with only diagnosis is down to 49 percent.

In addition, because there has been confusion and discussion about the nature of the ‘terminal prognosis’, providers have been omitting diagnoses that are significant to the patient’s overall condition.

Since the inception of hospice, adherence to the International Classification of Diseases (ICD) has been mandated.  This means that the primary diagnosis and all diagnoses that affect the patient’s ability to respond to or participate in the plan of care are to be included.

Therefore, we are clarifying that hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual. This is in keeping with the requirements of determining whether an individual is terminally ill. This would also include the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.

I have heard of denials because patients were admitted to psychiatric facilities that billed Medicare because the patient’s ‘terminal diagnosis’ was not psychiatric in nature.  I suspect this has happened numerous times because psychiatric conditions are mentioned more than once in this document.

We will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.

Let the last sentence of the section on coding resonate loudly on your priority list.  We can and will code for you.  You can learn ICD-10 coding or you can outsource to another company.  Alternatively, we can help with appeals, Focused Medical Review, or ZPIC audits.  The choice is yours but if you’ve ever been through that kind of regulatory scrutiny before, you would not choose non-compliance.

There is more – so much more but try digesting this first and we’ll keep an eye on the final release and do our best to summarize it for you.