Documentation for Compliant Billing

Documentation for Compliant Billing

Select Data Susan Carmichael MS, RN, CHCQM, COS- C, FAIHQ Chief Compliance Officer

Sources:The Conditions of Participation Medicare Benefits Manual, essentially Chapters 7, 10, and 30 Section I Auditors Unleashed Home Health Eligibility Criteria Homebound Status Section II Skilled Nursing Visits and Medical Necessity Common Documentation Deficiency Areas Skilled Need: Teaching Skilled Nursing and Skilled Need

Section III ADRS Late Entries Wound Care Psychiatric Care Section IV Therapy Care and ICD- 9 Coding Supportive Services: MSS Supportive Services and Home Aide Daily Visits M1020, M1022, M1024 and Coding Points The Wisdom of the Home Health Clinician Summary

Certification and Accreditation Surveyors- ensuring compliance with State licensure laws and CMS CoPs Recovery Audit Contractors RACs- contingency motivated recovery audit contractors (retrospective focus) Medicare Administrative Contractors MACs- can impose severe administrative action such as up to 100% prepayment review, payment suspension, and use of statistical sampling for overpayment estimation of claims (current and prospective focus) Comprehensive Error Rate Testing CERTs- described as the QI for MACs looking at claims payment accuracy Medicaid Integrity Contractors MICs- described as the RACs of Medicaid

Program Safeguard Contractors PSCs Conducts billing audits and chart reviews Zone Program Integrity Contractor Z-PICs- primary goal is to identify cases of fraud, develop the investigation, and refer to the OIG. Will replace PSC HEAT- The more aggressive investigator of essentially DME and Home Health. Using state of the art technology to expand the CMS Medicaid provider audit program Expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay NOTE: Fiscal Intermediaries reviewing denials May 28, 2008- October 31, 2009 identified lack of medical necessity and homebound status unsupported in the medical record.

ADRs are on the rise

Goals include: More consistency in surveys with Focus on standards that are the most closely associated with providing a high quality of care Now, more than ever, the focus is the assessment and the Plan of Care with visits reflecting skill and purpose directly tied to that plan of care.

All Medicare certified providers are paid on a prospective payment system (PPS) based on a case mix score That score (based upon the clinician OASIS integrated assessment) must have an appropriate skilled discipline specific care plan that is a part of the overall Plan of Care Supported by Visit notes that clearly reflect purpose specific to the goal expectations of the POC

Provide evidence that the care given meets clinical standards Justify reimbursement for the payor Provide protection from liability Means of communication among individuals providing services Provide accurate data regarding care for specific patient and diagnostic populations.

Record must be accurate in all respects Content of the record should contain measurable and objective data Interventions must be specifically documented and be relational to the POC Document what was taught and to whom Document what was learned and by whom Legal signature includes: Full Name, Full credentials and be legible

Homebound Status Under the Care of MD, DO, DPM Medical Necessity and Skilled Need

CMS expects that the patient s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home. NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1

Dependent on the limitations of the patient Dependent on the patient s illnesses Can be acceptable for patient to attend partial hospitalization Can be acceptable for the patient to attend medical appointments NOTE: For a patient to be eligible to receive home health services, the regulation requires a physician to certify that the patient is confined to his/her home.

If the patient has a diagnosis involving upper extremities only, how are they homebound? Documentation would need to demonstrate the patient s loss of upper extremity use and thus, example, the patient could not open doors or use handrails on stairways or required assistance by another individual. Then describe the considerable and taxing effort to leave the home.

Patient just recently had surgery. What kind of surgery? Is there weakness? Is there pain? Are their ADLs restricted? What is the plan? Does frequency and duration match the POC and the diagnoses? Without adequate documentation, the visit, visits, or episode may be at risk.

You answered M1860 as patient able to ambulate with a cane but you document homebound status because, the patient is unable to leave the home without assistance. Incongruencies can trigger alerts.

Clear documentation that it is with considerable and taxing effort for the beneficiary to leave home. (74% of ADRs 2009 reviewed, for lack of homebound status, were denied). NOTE: Documentation of short of breath does not justify homebound status. Acceptable documentation would include short of breath after ambulating 10 feet and requires rest period.

The patient s residence is where the patient makes their home: Their personal dwelling Residing with a family member or friend In an assisted living facility The patient s zip code is used for Home Health Compare to determine places where your agency provided service Chapter 3, OASIS Guidance Manual,M0060.

A medical treatment plan of care or the optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments See 42 CFR Part484, Conditions of Participation, Subpart A General Provisions and 484.18 Plan of Care.

CMS accepted no stamped signatures effective 2007 The physician s signature on the Plan of Care must be obtained as soon as possible and must be obtained prior to billing Medicare for reimbursement Does your billing system have built in compliance rules so no claim is submitted to CMS without signed physician orders?

Section II

To meet the requirement for intermittent skilled nursing care, a beneficiary must have a medically predictable recurring need for skilled nursing services at least one every 60 days. Medicare Benefits Manual, Chapter 7

Skilled services are those services that are medically reasonable and necessary to the treatment of a patient s illness or injury It must be clearly documented that the services provided required the skills of the professional clinician AND that the patient condition/illness/injury warranted those services.

Services can be performed by: - Nurse; Registered or supervised LVN/LPN - Physical Therapist, Speech/Language Pathologist (referred to in CMS home health operational and billing manuals as Speech Therapist), and - Occupational Therapist (OT may not perform RFA1 OASIS assessment certification but may perform a recertification.

Documentation must identify why the skills of a SN or PT, OT, MSW are required: Inherent complexity of care Condition of the Patient Accepted standards of practice Identify reasonable potential for complications if no skilled intervention Identify the pt/cg inability to perform a procedure and/or lack of skill

Remember the records: MUST have a specific order for EVERYTHING the clinician does The clinician: MUST do EVERYTHING that has a physician order and MUST document EVERYTHING done thoroughly.

Repetitive clinical notes are frequently seen stating the same things over and over with no patient progress identified; how is it that the clinician is unable to teach a new med successfully within a visit or two? Notes from different disciplines reflect lack of plan coordination Visit notes do not substantiate orders and goals on Plan of Care/485 Clinical interventions without orders are non billable

Three Types of Teaching: Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis 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 has had prior instruction

The appropriate care must be coordinated with all clinicians and the patient Each documented visit must be able to stand alone and clearly reflect homebound status on EACH and EVERY visit, clearly supports skilled need, and identifies status of the patient progress with each note reflecting support of the physician s ordered plan of care.

Per the Medicare Benefits Policy Manual chapter 7, skilled nursing: Requires the skills of a registered nurse to oversee the nursing care Skills performed by a skilled nurse do not necessarily skill the care Care delivered by the skilled nurse must be reasonable and necessary

Agencies should be aware that 1 Visit RN visits are being reviewed as to intermittent need. Why is the RN performing only one visit? An order for 1 visit does not meet the requirement for intermittent care.

If SN has 1 visit and therapy is the primary service, nursing requires an order for at least two visits (and a skilled need) and a well documented assessment unless SN is conducting the OASIS assessment only. (If the latter is the case, the therapist must skill the case first and the RN must visit AFTER therapy, on the same day or within the 5 day window to complete the OASIS C ).

If a chronic diagnosis is the primary reason for ongoing care, the skilled nurse should be VERY VERY clear as to why (s)he is still making visits. If visit notes do not EACH stand alone and link to the care plan, the nurses visits are at risk. The casemix co- morbidities; such as CHF, CAD, COPD, DM, Parkinson s disease should be included in the diagnoses list. If they are standing alone, the nurse should carefully justify the skilled need because of the chronic disease.

In justifying observation and assessment, note if: There is significant change in meds, treatments, or conditions There is teaching and training needed The condition or disease symptomatology has exacerbated or changed in another way NOTE: the SN care must tie to the POC and the discipline specific care plan as well as the ultimate outcomes.

Teaching on new medications must include instruction or intervention on the related diagnosis. The clinician providing injections such as insulin, require specific documentation to support the need; specifically why the patient cannot self inject the med such as tremors, impaired cognitive function, and no willing and capable caregiver. Just that final statement is insufficient. Consider a SW verifying with family (patient approval of course, under HIPAA) that no family member can perform the care. Do this function each episode to verify the situation has not changed.

Be certain the skilled nursing visit supports the diagnosis and the reasons for the SN visit. If the primary diagnosis is DM but the majority of the visits are directed toward CAD, the SN should be alerted as it appears there is an incorrect primary diagnosis. Note: Of ADRs selected, those with 1 SN and 4 therapy visits had a denial rate of 73%

Section III

Per CMS, In 2008, the 5 reasons for ADR denial included: 1. Downcoding due to inaccurate primary diagnosis 2. Therapy visits not medically necessary thus disallowed 3. None or poor documentation for medical necessity 4. Skilled observation initial identified need then no progress documented 5. Timeliness with ADR response (Agencies should check weekly for ADRs on the FISS system)

Physicians are being interviewed re POCs and patient homebound status. Denials for no physician orders, lack of homebound status, and untimely orders are on the rise. NOTE: Recertifications require a verbal or signed written order prior to ongoing visits into that episode. Receiving a signed POC within 30 days (with no VO) of the episode, would disallow all visits within that period.

Treating a missing order as a late entry is not allowed. Backdating an order is illegal and considered a fraudulent practice. If an agency has missing orders, they should discuss the issue with the physician and obtain the appropriate order but note the CORRECT date, it was obtained. NOTE: Auditors are seeking trends. An oversite, properly corrected and documented reflects intent to correct an omission not perpetuate a fraud. Take action to instill processes so this issue does not reoccur.

For over a decade, effective February 5, 1998, drawing blood for laboratory tests is not considered a qualifying skilled service under Medicare Part A home health benefit. If a patient qualifies for home health service based on another skilled service and requires venipuncture then the services may be considered for coverage. (Balanced Budget Act of 1997) NOTE: Having a primary documentation of long term anticoagulant therapy (V58.61) should reflect teaching and assessment on the disease process, as well monitoring of other objective data such as lab results.

Wound Care Coverage must have specific physician orders for one or all of the following: Instruction/teaching on the wound care Performance of the specific wound care Assessment as to wound site progress/ complications NOTE: Documentation must include type of wound with size, depth, drainage, odor, color, skin condition, with specific interventions provided as ordered by the physician.

A stasis ulcer with a status of early/partial granulation adds two points to the Home Health Resource Group (HHRG). A not healing status adds 11 points. Auditors will look for the specific documentation to support each. In addition, an early/partial granulation adds 25 supply points and not healing adds 36 points. (CMS Regulation number 1560- F) Note: Inadequate venous circulation to the affected area should be clearly documented.

Homebound status can be applied in these cases if the patient refuses to leave the home because of manifestation of the disease or condition process or The patient is unsafe leaving the home because of behavior issues outside the home. NOTE: Is OT involved with the psych care? While nursing tends to use words, OT may assist to e.g. displace internalized anger through specific activities, which can also identify an objective sense of outcome achievement.

Evaluate the Patient Teach regarding the disease process Discuss ways to cognitively restructure how the patient can approach ADL s Psychotherapeutic interventions using techniques, such as cognitive restructuring therapy Assisting the client to achieve optimal independence

For the disease combination Alzheimer s and Parkinson s Disease, there is a 75% denial rate for SN. Frequently, there are full denials because SN visits are not medically necessary. Should the psych nurse visit and assist with routine establishment and cueing education for the caregiver. NOTE: If there are no changes SN is not considered medically necessary.

Section IV

The therapy treatment plan must: Relate to the exact diagnosis that has required therapy intervention Identify visit frequency and duration Identify the present and prior functional level State specifically the procedures, treatments, and/or exercises to be performed Clearly list the reasonable goals to be achieved Specify the rehab potential Specify the discharge plan

In 2008, claims chosen with 10-11 therapy visits and discharge in episode two had a 74% rate of denial essentially due to poor or insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment. NOTE: Do not use V57.1 Physical Therapy if SN is also involved with the care. (CMS OFFICIAL CODING GUIDELINES 2009)

If 781.2 Abnormality of Gait is used to justify PT care, PT needs specific documentation to support gait and balance and strength e.g. TUG or Tinetti Test Tools. Gait training should be specific with objective measurement progress. The gait should be described specifically and graphically; ataxic, spastic, staggers with increase in ambulation of feet this day.

If 719.7- Difficulty in walking is coded, the therapist should be clear that this is due to e.g. degenerative and chronic joint disease. Use for e.g. gait deficiencies due to lower extremity joint stiffness or effusion.

If muscle weakness 728.87 is coded, there should be manual muscle tests indicating weakness. The therapeutic plan should have specific exercises and goals related to the weakness. NOTE: Absence of a specific exercise plan can jeopardize visit payments.

The OT evaluation and documentation should reflect prior and present level with realistic goals. If PT is also involved with care the OT should clearly delineate a plan that justifies the OT intervention. NOTE: Have objective tests with clearly defined short and long term goals that are measureable and can be achieved within a realistic time point with direct relationship to the specified diagnoses.

Medical necessity must be evidenced EVERY visit. Document progress towards goals every visit. NOTE: High incidence of visit denials when both PT and OT are providing care. Of the ADRs selected, 1 SN and 4 OT visits have a denial rate of 71% essentially, because OT is not an initial qualifying skilled service.

Medical Social Services can be added when skilled services are in place. Covered services include: Assessment of financial situation, community services available, personal/family social factors, and the potential for counseling Patient risk areas identified NOTE: If a patient has a LUPA, 5 visits or less, and 1 visit is an MSW, the denial rate, as of 2008 data, was 67%.

Medical Social Services have non covered services that, if required, may be performed along with a covered service. Non- covered services include: Assistance with Living Wills and Advance Directives Assistance with Medicaid Applications and Meals on Wheels MSS is a service requiring a physician s approval.

Home Health Aide Services are supportive and under the supervision of an RN, if multidiscipline case. If therapy only, the therapist may supervise the home health aide. Supervision must be in the patient s residence but the hha need not be present.

When skilled nursing visits are ordered daily, there must be a, finite and predictable endpoint to daily skilled nursing visits. It can be listed in days, weeks, months, or have a specific date. The visit documentation must substantiate the skill and substantiate the endpoint. The Medicare Home Health Benefit was not established to provide daily skilled visits but rather, to provide intermittent skilled nursing services.

The one and only exception to this rule is a patient who requires and qualifies for skilled nursing services to perform daily insulin injections

The Plan of Care must be signed PRIOR to submission of the claim A date stamp in Box #25 should be present when the Plan of Care is received The POC must be supported by the clinician visits with a congruent final claim. There must be congruence between the OASIS 6 coding spaces: POC/485: 9 spaces+ E code on the UB- 04 claim

Field 11,12,13 Diagnosis Coding M1016, changes in past 14 days M1018- Prior conditions M1242- Pain M1300-1350- Integumentary status M1410-1510- Respiratory M1610-1630- Elimination M1700- M1750- Neuro/psych M1800-1890- Functional deficits M2100 Equipment needs M2200- Therapy needs

Field 10 Meds Meds vs diagnoses Have ordered use been listed for PRN meds Are OTCs listed? Are they New or Changed? Field 14 DME and Supplies o Complete documentation of wound, outcome, ostomies, catheters o Congruence with M1300- M1350 Integumentary o Congruence with M1410- M1510 Respiratory and Elimination systems

Field 16- Be certain the nutritional requirements are well documented and congruent with M1800- M1890 Field 18A/B Functional activities and Limitations M2100e- Equipment needs Field 21 Orders for disciplines and treatments: Document interventions which support diagnoses

Field 21 Orders for disciplines and treatments M2200 therapy need should be congruent with care Include descriptive terms on each visit such as assessing, teaching initially or reteaching Avoid words such as reinforce and encourage

Field 21 Therapy example: Pt w CVA and residual weakness having PT and OT F/U: _#Therapy to provide therapeutic ex bilat UEs to include ROM and strengthening; Self- care ADLs to include teaching dressing UE/LE with adaptive equipment, grooming while standing, transfer training- toilet, transfer and balance activities. Frequency and Duration: Therapy 3xwkx2 then 2xwk2, then 1xwk2 M2200 = 12 visits

What will be done? (Action Steps) Who will Do it? How frequently will it be done? How will the care be evaluated? (Measurements and Documentation)

In place of instruct low NA diet, consider writing SN to instruct patient/cg on low NA diet and effects on fluid retention. In place of SN to perform wound care consider writing SN to provide skilled observation and evaluation of surgical site, teach and reteach if necessary to insure tacit learning sterile dressing changes to pt/cg and perform sterile dressing changes. Washed wound with sterile saline and applied sterile 4x4 and cover w dressing. If pt/cg performed the task then note the specific observations. Do not forget to note the size and depth of the wound.. Stage if appropriate.

From the 6 lines of M1020 and M1022, CMS makes a payment decision. Agencies should review progress notes and case management coordination to the SPOC Documentation should support the codes which are sequenced on the OASIS and POC. NOTE: Clinicians should learn to establish an audit trail on the way toward expected patient outcomes.

Official Coding Sources: - The annually published CMS ICD- 9- CM Coding Guidelines - The Coding Clinic Allowable Coding Sources: - OASIS Chapter 3 - Appendix D to Chapter 3 - OASIS Q&As published quarterly by CMS

Promoting accurate coding selection in M1020, M1022, and M1024. Comply with provisions of HIPAA, Title II. Comply with refinements to the PPS Grouper effective January, 2008. Comply with Section 1862 (a)(1)(a) of the Social Security Act to ensure payment is reasonable and necessary.

Diagnoses must comply with specific criteria to qualify as a primary or secondary diagnosis: - Code by adhering to ICD- 9- CM coding Guidelines http://www.cdc.gov/nchs/icd.htm - Code only relevant medical diagnoses - Code only diagnoses supported by OASIS, POC, and clinician documentation

List diagnoses in the order that best reflects the seriousness of each condition and supports the disciplines and services provided. SOURCE: Official CMS I- CD- 9- CM Coding Guidelines 2011

Assess degree of symptom control in relation to identified signs and symptoms, medication profile review, frequency and duration, care plan and treatments. Clarify which diagnoses and symptoms have been controlled in the past, both poorly and well. The primary diagnosis should be the key reason for the POC and be the most intensive service.

These diagnoses coexist at the time the POC was established. Approved co- morbid diagnoses that could affect the plan of care even if that diagnosis is not a focus of care: CAD, CHF, COPD, Diabetes, Parkinson s Disease and HTN. In 2012, CMS will eliminate case mix for two hypertension codes: 401.1 Benign essential hypertension and 401.9 Unspecified essential hypertension

These codes require VERY specific plans of care to substantiate need as they are case mix diagnoses. Once named case mixes, these diagnoses were more frequently used and are now closely reviewed. They include: - Low Vision - GERD - Depression - HTN as a non SOC primary diagnosis - Alzheimer s (primary non SOC)

Acute care coding is retrospective. Home Health coding is prospective. The diagnoses on the OASIS must match the POC/485 and the UB04 Clinicians must be certain the POC (primary/secondary diagnoses) and the discipline specific care plan are substantiated by each visit and that each visit can withstand scrutiny on its own.

Documentation to substantiate coding and care have become critical to agency providers. Documentation has become the key communication tool for care. Documentation has become the first and last line of defense with the scrutiny of the industry auditors. Documentation provides the demonstration of the skills of the clinician and justifies the retention of the agency payment received.

A Prayer was said They were old and feeble Their heads were snow white They could hardly make it They were a sorry sight Saint Peter told an angel Go out and help them in They are old and so decrepit And no doubt full of sin But, put them in the gold room With others of their clan Set up the banquet table Bring in the angel band Stand by and feed them slowly But, feed them very well

On earth they worked with Medicare They have had their time in hell J

Contact Susan Carmichael at Select Data susanc@selectdata.com 714.524.2500 x235