Proactive Strategies for Home Health Care

Define Roles and Focus of Audit Groups

Identify key areas of Medicare Policy Benefit Manual, Chapter 7 essential to the home health clinician

Identify specific strategies to promote best practices and minimize interaction potential with RACs, Macs, and ZPics

4.5 million claims per work day

574,000 claims per hour

9,579 claims per minute

Is it any wonder there is concern regarding fraud and abuse?

“Accuracy of coding and claims for Medicare HHRGs:

We will review Medicare claims submitted by HHAs to determine the extent in which the HHRG billing codes that are used in determining payments of home health agencies are accurate and supported by documentation in the medical record. The Social Security Act 1895, governs the payment basis and reimbursement for claims submitted by HHAs including a case-mix adjustment using HHRGs. Medicare pays for home health episodes based on a PPS that categorizes beneficiaries into groups, referred to as HHRGs. Each HHRG has an assigned weight that affects the payment rate. We will assess the accuracy of HHRG assignment and identify patterns of coding by HHAs.

Remember that HHAs refers to home health agencies

2010-2015

The Auditors

Medicare Prescription Drug, Improvement, and

Modernization Act (MMA)

Tax Relief and Health Care Act of 2006 (TRHCA)

TRHCA section 306 gave CMS authority to make

recovery audit contractors (RACs) a permanent

nationwide program and the establishment of the

nationwide Program Safeguard Contractors (PSCs)

to fight fraud with data analysis

Focus on Hospitals and Physician Practices

In only six states, recovered over $1.6 Billion

Incorrectly coded: 35%

Medically unnecessary: 40%

Insufficient documentation: 10%

Per FI NGS, “The RACs detect and correct past improper payments so that CMS and carriers, fiscal intermediaries (FIs) and Medicare Administrative Contractors (MACs) can implement actions that will prevent future improper payments”

RACs can only review discharged records

Cannot review records already reviewed by other entities

Home Health, Hospice, and DME now have a RAC exclusive for them!

RACs are paid contingency fees from 9.9%-12%

Can reopen claims up to three years from date claim

was paid

Required to follow all CMS payment policies

Required to have a medical director on staff with

audits teams to include RNs, therapists, and coders

Annual accuracy rates are to be publically stated

Region A: Connecticut, Delaware, Maine, Maryland, Massachusetts, New York, New Jersey,

Pennsylvania, Rhode Island, and New York

Region B:

Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin

Region C:

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia

Region D:

Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming

Services are medically unnecessary or there is delayed

implementation (Focus: Therapy)

Patients are not Homebound

Services are incorrectly coded and sequenced

Failure to provide claim supportive

documentation

Duplicate claims submitted

Medicare secondary pay or improper payments

Lack of order centricity

Medicare Benefit Policy Manual- Home bound status

Homebound status may be an issue with certain records. CMS defines homebound status as:

Confined to the home – Describe why the patient is homebound. An individual is considered “confined to the home” if both of the following two criteria are met:

Criteria 1--The patient must either: Because of illness or injury, need supportive devices such as crutches, canes,

wheelchairs, and walkers; special transportation; or another person’s help to leave his or her residence, OR

Have a condition such that leaving his or her home is medically contraindicated

Criteria 2--There must exist: A normal inability to leave home; AND Exertion of a considerable and taxing effort needed to

leave the home. (Medicare Benefits Policy Manual Chapter 7 Home Health Services, MBPM

Chapter 7

Skilled Services-

Per CMS Medicare Benefit Policy Manual, Chapter 7:

“A service that is ordinarily considered nonskilled could be considered a skilled therapy service in cases in which there is clear documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform the service. However, the importance of a particular service to a patient or the frequency with which it must be performed does not, by itself, make a nonskilled service into a skilled service.”

If a chronic diagnosis is the primary reason for ongoing care, the skilled nurse or therapist should be VERY clear as to why (s)he is still making visits.

If visit notes do not EACH stand alone and justify care, the nurses or therapist’s visits are at risk.

Teaching-

MBPM Chapter 7 states:

Teaching & Training activities that require skilled nursing personnel to teach a patient, the patient’s family, or caregivers how to manage the treatment regimen would constitute skilled nursing services.

Where the teaching or training is reasonable and necessary to the treatment of the illness or injury, skilled nursing visits for teaching would be covered.

When is teaching & training no longer covered?

Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary.

The reason why the training was unsuccessful should be documented in the record.

There are essentially three types of teaching: Initial Teaching of a patient requires instruction on a new

order, new medication, new diagnosis. The specifics should be clearly stated,, if a med change or new med, what specifically was taught as to the administration of the med and how it impacts upon the disease process.

Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching.

Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient or caregiver has had prior instruction.

What was to be taught, how it would be taught, how the clinician knew there was learning does not appear to be clearly delineated within several of the records.

Congruency Congruency Congruency

Therapists use many tests to measure baseline and

progress. Be certain the same test is used to

demonstrate progress or regression.

Objective data/documentation supports findings

throughout the episode.

Protect your dollars…have objective supportive data

for findings.

Five denied visits out of 24 billed can mean a loss of

approximately $1200.00

Prior to 2008, the more than 50% of high therapy

cases ended with 10-13 visits

With the move to the tier model in 2010, this group

has declined and significant growth has occurred in:

6-9 visits

14-19 visits

20+ visits

Full or partial denial because the clinical

documentation:

Did not support the medical necessity of the skilled

services billed

Did not demonstrate a reasonable potential for

change (improvement) in the medical condition or

Sufficient time had been allowed for teaching or

observation of response to treatment in prior

episodes of care.

How many therapy visits are you averaging per

episode? Percentage of patients receiving therapy?

Of the patients who receive therapy, what is the

distribution (%) across the ranges?

How does your agency compare with your peers

regionally or nationally?

Do response levels on functional M items correlate

with therapy referrals? High-Low levels of

impairment?

Do therapy treatment plans and progress notes have:

Clear functional goal statements?

Document progress toward goals objectively?

How is care coordinated among therapists? Among all

disciplines?

How can you support “reasonableness and medical

necessity?”

What is the patient treatment: diagnoses? Restoration/maintenance of

function affected by illness? Frequency and duration of services

consistent with home care client’s: medical history, disease, prior to end

of episode level of function, and risk identification.

Is therapy consistent with the nature and severity

of the condition?

Therapy services must be provided, expecting that

the condition of the patient will improve in a

reasonable period of time.

Documentation of medical necessity should be

documented through evaluation, treatment plan, and

progress notes.

Has your agency identified high risk diagnosis,

number of visits, or number of episodes?

RACS are paid on a contingency fee basis

Focus: High dollar improper payments with highest return

for RACS (for dollars invested)

Belief is that Coding, Homebound status, Therapy use,

Wound Care, Co-Morbidities, and Medical necessity will

be scrutinized

RACS must pay back contingency fees if they lose appeals

RAC program to cost .22 cents for each dollar returned

to the trust funds (Based on RAC performance with

Hospitals)

Auditors

Medicare Administrative Contractors have replaced fiscal intermediaries.

January, 2009 CMS announced the awarding of the finalMAC contracts to a total of 15 companies. Each now has a jurisdiction.

California is in district 1 and New York is in jurisdiction 13.

MACs have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs) They can act with RACs.

Of the 15 MACS, 4 will service only DME claims

CMS has assigned agencies that provide Home Health AND Hospice to four “specialty” MACs (regions 1, 6,11,14,15)

Auditing claims and making coverage determinations more quickly is the ultimate goal and remains same in 2014

Full or partial denial because the clinical

documentation:

Did not support the medical necessity of the skilled

services billed

Did not demonstrate a reasonable potential for

change (improvement) in the medical condition or

Sufficient time had been allowed for teaching or

observation of response to treatment in prior

episodes of care.

While agencies worry about RACs, Remember, a MAC can place an agency on focused review for a year, if it identifies potential cause.

Answer ADRs promptly!

Let us not forget Medicaid

MICs Medicaid Integrity Contractors

MICs are expected to complete four program integrity activities:

1. Review provider actions

2. Audit claims

3. Identify overpayments

4. Educate providers, managed care providers, beneficiaries, and others with respect to payment integrity and quality of care

Program Integrity efforts target Medicare and Medicaid Individually as well as Medi-Medi

MICs have been labeled as the “RACs for Medicaid”

MICs are not paid by contingency fee but fee for service

Renewal of MIC contract is based on successful performance

Dollars identified or recovered are not tied to compensation of the MICs

MICs must comply with state-imposed requirements

Auditors

ZPICs will perform Medicare Program integrity

functions for CMS

Each MAC will interact with one ZPIC to handle

fraud and abuse issues within their jurisdictions

ZPICs are seen to consolidate work of present CMS

Program Safeguard Contractors (PSCs) and

Medicare Drug Integrity Contractors (MEDICs)

ZPICs are divided into 7 zones.

Bill Dombi, Chief Legal Representative for NAHC

stated (4/20/2010), “If an agency receives a Z-PIC

letter, they should just call their legal counsel”

The RACs act with the Department of Justice and

FBI as the investigators when fraud is very strongly

thought to have been found. When the ZPICs notify

an agency, they have already discerned an issue.

The HEAT

The more aggressive investigator of essentially DME and HH

Expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, McAllen, TX, and Tampa Bay

Using state of the art technology to expand the CMS Medicaid and Medicare provider audit program

This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector

“Providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and private sectors.” CMS

Consumer Assessment of Healthcare

Providers and Systems (CAHPS)

Readying for P4P

Looking at patient /beneficiary outcomes

Assessing beneficiary satisfaction

Why has CMS moved to CAHPS?

Measure patient perception of care- Are consumers happy with the home care they received?

Component of Home Health Quality Initiative (HHQI)

Place in public domain for beneficiary informed decision

Possible component of P4P

Similar in that they will rate providers

CAHPS asks patients to report experiences

Focus: Aspects of care patients find important

Aspects of care patients can report on

CAHPS reports are specific, actionable, objective

36 questions re patient experience and characteristics

of care

Everything starts with a solid assessment,congruent OASIS,

an individualized clinical careplan, coding to the highest level of specificity,

and correct sequencing to drive the Plan of Care:

the result is Proper payment

by Your Clinical Front

Line

Agencies must support services and care (NAHC,

2009, 2012)

This starts with the correct tools

This starts with excellent assessments and care

plans

This starts with expert ICD-9-CM Coding…more

than just a coder…..a process…a process designed to

target weaknesses and build on strength

With RACs, MACs, and ZPICs, increased scrutiny abounds.

Be certain visit documentation links to a documented diagnosis.

Are the OASIS answers congruent? How are you verifying congruency of answers?

Be certain there is coordination among the team.

Therapy and Nursing activity must be connected to specific functions, tests, and goals.

Patient responses to treatments and interventions should be clearly stated.

Measurements of progress toward goals should be clearly documented throughout the episode.

NEW NUMBERING SYSTEM NUMBERING BY SYSTEM

Tracking Items M0010-M0150

Clinical Record Items M0080-

M0110

Patient HX and Diagnoses

M1000s

Living Arrangements M1100

Sensory Status M1200s

Integumentary Status

M1300s

Respiratory Status M1400s

Cardiac Status M1500s

Elimination Status M1600s

Neuro/Emotional/

Behaviorial Status M1700s

ADLs/IADLs M1800s/M1900s

Medications M2000s

Care Management M2100s

Therapy Need/POC M2200

Emergent Care M2300

Data collected at

Transfer/DC M2400s

M0903 and M0906

Is your billing process/system order centric?

Be certain documentation is prompt, clear, concise

based upon realistic goals within realistic

timeframes…on each visit:

Does each note specifically identify wound care, IV

administration, and flushes?

Are education and patient teaching sessions clear

with patient responses and documentation of

progress or reevaluation need or completion?

Starts with a great tool, an experienced

well educated clinician and knowledge of

basics like…..

CMS is promoting evidence-based care practices

The conditions targeted by the new OASIS-C

process measures: diabetes, heart failure, pressure

ulcers

Prevention oriented situations: falls and depression

Implementation of best practices:

diabetic foot care

pain management

influenza and pneumococcal vaccinations

risk assessments for pressure ulcers

risk assessments for depression

risk assessments for falls

Care Processes mean the use of assessment tools

(included in a comprehensive assessment) or the

planning and delivery of specific clinical

interventions

Several evidenced-based screening tools can be

considered “best practices” in home health. OASIS-

C includes data items to measure these processes.

It is all about your processes

Measuring how customers (patients) view their experience

Inpatient and emergent care home health assessments

Functional status improvement

Clinical symptoms assessment and change

Pain assessment and intervention

Education of patients and caregivers

Patient care quality

25 Process Measures in Total

Represent 7 Domains: Timeliness of Care Assessment

Care Planning

Care Coordination

Care Plan Implementation

Education

Prevention

1.Timely

Care2. Assessment

3. Care Planning

4. Care Coordination

5. Care Plan Implementation

6. Education

7. Prevention

Date of referral and physician-ordered start of care (timeliness)

Patient-specific parameters for physician notification (care coordination)

see M0102 and M104 below

(NQF endorsed – will appear on Home Health Compare and

CASPER/OBQI)

Physician Notification Guidelines Established

Percentage of home health episodes of care in which the physician ordered plan of care establishes limits for notifying the physician of changes in patient status.

Looking at how many episodes of care had a specific date and how many started within 2 days of the referral date.

See the SOC/ROC M2250 Patient-specific parameters for notifying physician plan of care

Not NQF endorsed but will appear on CASPER Reporting/OBQI

Four Assessment measures

All NQF endorsed and will appear on Home Health Compare:

Depression Assessment

Multifactor Fall Risk Assessment

Pain Assessment

Pressure Ulcer Risk Assessment

Depression

Screening

M1730NQF Endorsed

If the answer is a 2 or a 3 or a 4?

Do you have an algorithm?

Do you have a psych nurse?

Having a current prescription for a hypnotic increases suicide risk by four times…..ABQAURP, 2012

CMS is looking at the percentage of home health episodes of care when patients were screened by a standardized depression tool at the SOC.

So you have a psych team?

Does your psych team include an OT?

Occupational Therapy is becoming a key

member on the team

So much of therapy for depression requires healthy displace of hostility.

The RN therapist frequently uses words and counseling.

The Occupational therapist frequently uses activities.

“sedative treatment was associated with nearly fourteen-fold increase of suicide risk…”

www.biomedcentral.com/1471-2318/9/20

OTs can assist with Stress Management and

Self Awareness

Anger and Conflict Management

Self Esteem Building

Basic Living Skills

Relaxation Techniques

Grief Counseling

The OT can assist, using various tools and activities

The trained OT can use the Mini Mental status exam and the

Geriatric Mood Assessment

Is the Geriatric Mood Assessment Tool one of your approved tools?

What other tools are you using or considering?

Must all tools used be approved by agency leadership?

Even therapy tools?

Multi-Factor

Falls Risk

Assessment

M1910

M1910- Multi-Factor Fall Risk Assessment

Falls history, multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards.

A good assessment is necessary as M2250 asks whether the physician-ordered POC includes fall prevention interventions. M2400 asks whether interventions to prevent falls were ordered in the plan of care and implemented.

Falls Risk assessment, planning and interventions (safety)

So, after the assessment, what is the algorithm?

The Pain Assessment

M1240NQF endorsed

M1242

Domain:

Formal pain assessment, pain interventions, and

pain management steps (effectiveness of care)

Look at your agency SOC/ROC M01240 and M1242

and note how integrated assessment information is

sought.

What information is collected ?

Measuring pain using a standardized tool

Measuring the patient’s acceptable pain level

Let’s discuss the advantages of having an

acceptable pain level measurement.

Pressure-Ulcer

Assessment

M1300 (NQF Endorsed) -

M1324

M1300, M1302 risk of developing pressure ulcers

The clinician/agency will determine if a risk assessment was performed and the patient has a risk

M1300 asks if the patient was assessed for risk of developing pressure ulcer. If the answer is “yes” then the clinician is asked if the assessment was based on an evaluation of mobility, incontinence, and nutrition or using a standardized tool.

Many agencies use the standardized Braden or Norton Scale.

Remember, the answer “yes” can only be chosen when the clinician completing the OASIS C assessment is also the person completing the pressure ulcer assessment. OASIS Contractor,

NAHC Conference, 10/2011

M1302 asks what was concluded about the patient’s pressure ulcer risk,

Influenza and pneumococcal vaccines (population health

and prevention) is only collected at transfer RFA 6/7 but,

should this information be collected at the SOC/ROC RFA1/3

or on the Agency Referral form so it is readily available?

The agency (You) will need a process to keep current on this

item. Perhaps, when recertifications are sent to the

physician, this question can be asked/clarified/verified?

Two items focused on medication safety:

M2002 Potential Medication Issues identified and

Timely Physician contact at SOC

M2004 Potential Medication issues identified and

timely physician contact during the episode

M2002 -

The Referral Form

Besides the present demographic and statistical data collected: Name, address, phone, next of kin, DOB, payor, recent hospitalizations, and medications…

Now, collect M0102 Date of Physician Order

M0104 Date of Referral

Status of Immunization

Previous Diagnoses and manifestations such as neuropathy, CKD/ESRD, PVD, Peripheral circulatory, and opthalmic conditions.

Procedure Codes

History of Pressure Ulcers

In OASIS-C, CMS wants to include a way to measure an agency’s use of evidence-based best practices…give good care after strong assessment, screening, and care planning for predictable outcomes.

Research shows that best practices assist to prevent exacerbation of serious conditions. Agencies that do not invest in an education EBP thinking may have significant difficulty with CMS and its many audit arms.

It is expected that processes of care implemented according to evidence-based guidelines will ultimately lead to better clinical outcomes.

What will be your process following the assessment?

Will the clinician alone determine the CP and POC?

Do you have algorithms in place?

When will you audit the care?

How will you look at clinician productivity? Individually? As part of a team?

Do you have a billing audit tool in place?

Do you have a RAC audit tool? Is there a difference?

Evidenced-Based decision making is based not only on available evidence but also on patient characteristics, situations, and preferences.

Buyssess and Wesley have identified that Evidenced Based Practices may be defined as “treatment choices based not only on outcome research but also on practice wisdom (the experience of the clinician) and on family values (the preference and assumptions of a client and his or her family or subculture).

We cannot lose site of the fact that good clinicians want to care for their patients as they attain, maintain, or recover optimal health.

Assisting the clinician with tools to bridge the span from assessment and SOC to Discharge and planned outcomes becomes the daunting task.

Quality care delivery and improvement processes are co-existent with a solid bottom line. It is establishing the proper process, for each domain, that is the leader’s challenge. But then, you are up to the task!

Contact Susan Carmichael at:

susanc@selectdata.com

or call: Select Data

714.524.2500 x235