Ebola? Here in the States?


It looks like we have company in the form of another virus.  Ebola has caused quite a stir in the US and the media is torn between reporting it as a benign little incident so insignificant as to not warrant our attention and predicting Armageddon.  With all new viral pathogens, it is difficult to predict.  A virus will do what it can to survive and most times that means reducing the severity of the illness so as not to kill its host and prolonging the incubation period.  Who knows what Ebola will do.

If 40,000 fatalities from Ebola were predicted this year, there would be mass panic.  If there was a preventative measure, who wouldn’t do what they could to get it  no matter what the cost? 

We are looking at close to 40,000 deaths from flu and pneumonia this year.  There are legitimate questions about these statistics such as why are flu and pneumonia lumped together as the 8th leading cause of death?  They are not the same disease.  To dispel the statistical arguments, lets pretend that only 20,000 deaths will result from the flu this year.  Tragically, most cases of the flu are preventable at no cost to most people.

Setting death aside for a minute (or hopefully many years), consider the experience of having the flu.  The first day or so, patients are afraid they are going to die.  As it reaches its peak, they are afraid they will not die.

We don’t want our patients to feel like that.   Many home health patients will end up in the hospital if they get the flu.  Hospice patients may be terminal but most have plans to die from something less miserable.  It is okay to get between the flu and your hospice patient. 

So, while we are panicking about Ebola, let’s keep in mind that there are thousands of lives we can save with a simple flu shot.  The CDC has a ton of free resources that you can use in your agency, patient homes, and community to promote vaccination.  Most have room for your company logo and the CDC is fine with you adding it.  Think about it.  When was the last time that the government provided you with professionally designed materials to be used in promoting your agency or hospice? 

When we figure out what we can do about Ebola, we’ll post it here.  Until then, get out there and stick as many old people with needles as you can.  Here are some codes you can include on your care plan if you know upon admission that you will be giving a flu vaccine.

  • V03.82 Vaccine for Streptococcus Pneumonia (PPV)
  • V04.81 Vaccine for Influenza Virus
  • V06.6 Streptococcus pneumoniae [pneumococcus] and influenza

Is anyone qualified to write or help us write a short blog on how to bill for the flu and pneumonia vaccines?  Let me know below or by emailing TheCoders@hhcoding.com.

Hospice Medications – Who Pays for What?


Hospice Providers, it’s time to take your head out of the sand!  Medicare keeps writing long memos about who pays for what medications and I still keep hearing that the hospice only pays for pain medications.  The information below was taken from the Medicare Memo issued last week.

  1. You don’t get to exclude all meds and care not directly related to the terminal condition. Supposedly this has always been the case.
  2. You cannot exclude medications that are used for the comfort and palliation of symptoms no matter what.  If a patient is admitted for end stage heart failure and has arthritis, you must pay for arthritis medications as well.
  3. Prior authorizations for Medicare Part D will be required and they must include the reason why the medication is not covered under the hospice benefit.
  4. Medications that are paid for after the patient elects the hospice benefit but before the pharmacy has been notified will fall into some sort of limbo land and the pharmacy will have to collect from the hospice – or the patient.  Any UFC fans out there?
  5. If a patient wants a specific drug that is not one your formulary and the patient refuses to try medications that are on your formulary, you can refuse to provide them.  Alternatively, you can provide them and bill the patient if you have a signed advanced beneficiary notice.
  6. Patients have the right to appeal your decision.

If you want to survive this maze, the first thing you need to do is to approve a formulary.  This is a list of drugs you may potentially be required to provide over and above the standing orders for pain meds.  Personally, I would start with one of those $4.00 drug lists from a chain drug store.  They all have one.

Hospice nurses must have frank discussions with patients and caregivers at the time of admission.  In truth, there is no way to determine if a medication is for palliative relief of symptoms until the patient is assessed.  In talking with patients and caregivers, the emphasis should be on symptoms.  Some individuals with diabetes are very uncomfortable when their blood sugar goes up beyond a certain point.  Other people can sport a blood sugar of 550 without symptoms.  Blood pressure is usually asymptomatic but strokes are not.  If a patient has suffered a prior neurological insult, the safest thing to do would be to find a cheap drug and treat it for less than 10.00 per month.

Nice hospice providers will alert their contracted pharmacy to a hospice admission as soon as it is known for sure that a patient will be admitted.  This will prevent those limbo drugs where everyone is fighting over who pays.  This process is recommended but not mandated (I think…) in the new CMS guidelines published last week.

People are funny about their medications.  If a patient refuses to try Prilosec and opts for Dexilant at 20 times the cost, work with the patient.  Ask for samples and assist the patient in getting the best price for the medication of choice.

Maybe the most disturbing aspect of the new guidance from CMS is the involvement of the patient and families.  Part D pharmacies are advised to bill family members for medications that were inappropriately filled.  Hospices with limited (if any) formularies will attempt to pass the cost off to the patient.  Although the patient has the right to appeal the logistics of a hospice patient or family member appealing to Medicare strike me as utterly incongruent with the fundamental purpose of hospice which is to allow a patient to die at home in peace.

I have not seen as yet the proposed consequences to a provider who simply tells the patient Medicare won’t cover something without explaining all of the details, alternatives, etc. I think good hospices will put a blank appeal form in the home folder for the patient.  Bad hospices will go out of their way to avoid telling patients and family members that an appeal is possible.

Meanwhile adopt a comprehensive formulary and start today advising the patient what you will pay for, the reason it will given (comfort) and what you will not be giving.  It may cost you a few patients but I guarantee those that don’t put these processes into place will lose more than a patient or two.

Good luck with all this, you hear?

Don’t Cheat Yourself

One of the most frequent requests we have is for Cheat Sheets of commonly used codes and combinations of codes.  We do not have one to offer you and we have no plans to offer one.  They really do sound like a great idea – we admit it – but they result in very poor coding, reduced revenue, denials and payment take-backs.  If you can get past all of that, maybe they are a good idea.

The Cheat Sheet concept skips the most important step in the coding process – looking at your code book. We prefer Decision Health’s Coding Manual.  Other coders have their own preferences.  Regardless of the book that you use, a true coder never codes without one. 

There are still agencies who have field clinicians do their own coding.   In hospice, it is rare to find anyone but the field staff coding.  Very few are nurses have have the training to code appropriately. In order to code well, you have to have the education and experience.  Like most other skills, repetition builds competence.  If a field nurse is doing one to two re-certifications and an average of four admissions per week, it is probable that inaccurate codes are being placed on your claims.  For this reason most agencies hire full time coders, outsource their coding or design a combination of both. 

On August 1, home health agencies will begin dual coding with both ICD-9 and ICD-10 codes, All claims for hospice beginning October 1 will require ICD-10 codes.  When ICD-10 is implemented, it will be near impossible to develop a cheat sheet that could be of even minimal assistance.  The number of codes will multiply as the focus of each code is narrowed considerably so as to leave no question regarding how and where the patient is affected. 

This means that in order to be ready for the August or October implementation date, agencies, including hospice providers must have in place a system that results in accurate coding.  Our preference is that you call us.  More important to you is simply taking the time to think about it now. 

If you will be using in house coders, invest in the training they need.  This is not a simple ‘translation’ process where you find a new code to replace old codes. There are new rules and conventions and it is grossly unfair to any coder to ask them to perform post ICD-10 implementation if you haven’t devoted the resources for education and the time for practice. If you are outsourcing, keep in mind that even the best coding company must fully integrate with your processes and there will be a period of adjustment.  Do you want that period to begin concurrently with ICD-10 implementation?

We have contracts with home health agencies and hospice providers that have in house coding so they can offload coding as needed because of backlogs, vacations, illnesses, etc.  This keeps their billing current and the agency has a chance to compare their in-house coding with the coding of a professional coding company.

Regardless of who you use, there are some decisions that must be made now while you have the time to pick and choose.  That is a much better use of your time than trying to create a cheat sheet for coding because we flat out refuse.  We’re too busy getting ready for ICD-10.

Guilty as Sin


Does it surprise you to know that we are guilty as sin when it comes to limiting access to psychiatric care?  I don’t mean ‘we’ as in an industry but ‘we’ as in The Coders; the people who watch over your ICD-9 coding and OASIS assessments,

It is fairly common for one or more us to refer to someone who has made us angry as:

    • crazy
    • bonkers
    • nuts
    • nusto fruitso
    • psycho
    • shizo
    • nuttier than a fruitcake
    • unbalanced
    • a sicko
    • wigged out

There are more creative ways to call attention to someone’s state of mind that we use mostly in attempt to be humorous.

    • He just ain’t right.
    • Her driveway doesn’t go all the way to the road
    • He’s a little left of center
    • She’s knitting with one needle
    • She’s a sandwich short of a picnic
    • And my favorite as read in a clinical record written by a local physician held in very high esteem in the community, ‘her elevator doesn’t go all the way up to the top’.

We call addicts crackheads and junkies even though statistically speaking most people have a close friend or family member addicted to one or more drugs.  We recite the nursing school line that addiction is a disease but we treat those affected as though they are human waste.

So, what’s the big deal?  Consider that most people suffering serious mental illness have some connection to the real world.  They hear insult after insult thrown about in normal communication describing their symptoms.  The know that being nuttier than a fruitcake is not a common aspiration and that the elevator ideally reaches the top floor.  No young girl wants to grow up and be a crack whore and no young man dreams of possibly being able to hold a minimum wage if his meds are just right.

The average person with schizophrenia is diagnosed in his or her early 20’s.  They know that telling someone that the CIA is onto them will result in ridicule. They know that it is a source of embarrassment for them and their loved ones to be mentally ill.  The delusions of grandeur common in persons suffering bipolar disorder isolate them from those who really care about them because we do not recognize them for what they are.  Or maybe, we just don’t want to.

In all reality, it is seldom that a person with a disease that causes delusions and hallucination has enough insight to understand that they are symptoms of illness.  It’s rare but not unheard of at all.  Do we make it easy for them to go to someone for help?  Do we make it as painless as possible for parents to admit to themselves that their child may have a serious psychiatric illness?  The same parents who would run to the ER if their child had a high fever is willing to write off increased moodiness. a decline in grades and the absence of friends as a ‘phase’.  We all want to believe that ‘there’s nothing wrong with my child’.  That attitude is about effective with mental illness as it is with cancer.  Deny it long enough and very, very bad things will happen.

So, the next time somebody suggests something totally preposterous to me, I am going to call them a ‘hypertensive’ or worse, accuse them of incontinence.  In fact, I’ll code them in their entirety, add all the numbers together and refer to them a 2530.21.  That will show them. 

Back to coding after this.  Send us some of the more interesting patient scenarios you run across.  We like a challenge.

And please be mindful of the language you use so that you do not unintentionally get between someone who needs help and help.