Practical and Succinct Solutions to Coding - Select Data, Inc

Practical and Succinct Solutions to Coding: Obstacles Facing

Home Health Coding and Reimbursement Accuracy

Presented by

Susan CarmichaelMS, RN, CHCQM, COS-C, ICM, FAIHQ

EVP, Chief Compliance OfficerSelect Data

ObjectivesDiscussing increasing numbers of Complexities in Home Health that challenge reimbursement and the financial and quality outcomes bottom line

Exploring Regulatory Issues and Agency Finances

Making Connections Between Coding, the POC, and Keeping Your Reimbursement

Looking at Potential Impending Audits and Queries and their Impact

ICD-10…Will you be ready or will you be one of the agencies expected to have significant delays in payment?

The Forces are coming together and They are Driving Finances

Changes in Case Mix Dollar Payment

Coding Changes and Survey Sanctions

Increased Audits

Confusion re newer requirements ;i.e Face to Face, Therapy requirements

New Chronic Care Models

Affordable Care Act: EMR, Data Analytics

And Everything Starts with Solid Coding

Are you Keeping Up?

A lot is happening…Administrative Simplification Act (transition to 5010) FY 2010-2014

Meaningful Use EHRs 2011-2015

Health reform Initiatives i.e.

ACOs 1/2012 and advancing

Value-based purchasing 2013

Chronic Care Models: Guided Care

Patient Centered Medical Home

Transitions of Care

Readmission payment penalties 2013 Impact on Home Health

Rebasing

PECOS

ICD-10, OASIS-C1, HIS, Hospice Pharmacy requirements

LET’S START!There is much to do in one hour

The Coding team

The Coding Specialist is the one who can verify adequacy of initial documentation for the codes assigned, but more importantly, that means: verifies the reasons for the episode of care.

If your coder is not challenging documentation adequacy and specificity, raising questions for the clinician and the physician, and asking for H&Ps and other data, you may be at risk.

M1800Is your coding team looking at the functional scores of M1800?

Do your clinicians understand how to answer that question? Clinicians may mark “0” as default answer just because the patient lives alone or does not have a caregiver. “0” or “1” is to be used when the patient has a high level of functionality

Incorrect answers mean increased audit risk. This M question supports reimbursement and is a focus for audits

Proper Coding Sets the Scene for Quality Outcomes

Coding is not just assigning a code to a diagnosis. It is so much more!

The clinical assessment must be complete enough to drive and justify a plan of care for 60 days prospectively

Auditors look at OASIS answers

They look at the diagnoses code because those codes tell them about the patient and their needs

The frequency and duration must be in sync with the diagnoses assigned

BETWEEN CODING, THE OASIS, AND THE POC

Making the Connection

Documentation Accuracy

Diagnoses and the ICD-9 codes reported on each and every claim must match the diagnoses reported in M1022

The OASIS, POC, and the UB-04, must all match

Added to that is the primary reason the physician ordered home health care. Let’s discuss F2F.

The OASIS M1016M1016 refers to diagnoses requiring Medical or Treatment Regimen changes within the past 14 days prior to the SOC

The diagnoses of the past 14 days prior to the SOC must be listed

Are the coder s requiring completion of M1016 by the clinician? Surveyors can ask who is completing the OASIS questions. Remember the regulations, only one clinician completes the OASIS integrated assessment. This is NOT to be completed by a coder or clerk.

Coding GuidelinesM1020a/M1022b/M1024a-f

Must be cautious as to risk of up-coding and down-coding

Sequencing must be reflected by specific documentation

Record must reflect homebound status and medical necessity or it can not be coded. Is that verified first?

Has the coding specialist assessed that there has been a review of each medication?

The coding specialist must be certain substantive documentation exists to support each and every code assigned or the code must be omitted or documentation must be obtained.

Internal auditorDo you employ an internal auditor sampling coding monthly for accuracy? For instance, have you audited wounds and useage of the correct aftercare code? There is a significant number of codes This is an audit focus.

Frequently, audits reveal the coder was unaware that aftercare for traumatic fractures is excluded from V58.43 and should instead be reported with codes V54.10-V54.19 (Aftercare for healing traumatic fracture).

This is one of, at least 10 areas that should be audited.

The billing pre audit

There should be a review checklist for the OASIS, the POC, the UB-04,

Codes must match on all three documents

The documentation must substantiate the codes chosen

The codes can significantly impact reimbursement and result in under or up coding. Can you afford the Risk?

Therapy documentation is a focus

The coding specialist is seeking clarification of medical necessity, viewing clearly defined goals, and proper diagnostic codes

6/30/11 large HHA had to settle with DOJ:

Price $65 million dollars! Related to primarily therapy overutilization not justified by assessment or plan of care. That was expensive lack of documentation.

Therapy: Abnormality of GaitIf 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. Lack of documentation

specifics means the coding team must request more detail.Is the coder verifying the detail of the therapy documentation?

Therapy: Difficulty in WalkingIf 719.7- Difficulty in walking is coded, the therapist should be clear that this is due to e.g. degenerative and chronic joint disease. This code is used for e.g. gait deficiencies due to lower extremity joint stiffness or effusion. If this is not documented the visit is at risk as is the plan.

Is the coding team requesting documentation to

support the diagnosis?

Therapy: Muscle Weakness

If muscle weakness 728.87 is coded, there should be manual muscle strength 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.

Who is challenging therapy for the SPECIFIC

documentation needed?

Do you have Matrixes for M questions?

The Case for the Matrix

Having specific matrixes creates consistency in coding.

Matrixes provide guidelines to be certain supportive documentation is present.

Lack of documentation places reimbursement in jeopardy.

Establishing such matrixes requires hours of time invested, but is necessary.

RACs, MACs, Z-Pics: The Auditors are Unleashed

What are your agency case mix averages by admission: clinician: diagnosis?

Do you know your top five diagnostic patient profiles?

How do you set visit frequencies? Formula-based or what seems right?

Are you making visits that have no impact on patient outcomes?

Are you auditing for homebound status?


Are you making visits that have no impact on patient outcomes?

Are you auditing for medical necessity?

Does supply usage have adequate supportive documentation?

Do you know what coding, operational, or billing edits you are routinely triggering?


Are you auditing documentation for medical necessity?

What is your cost per visit by discipline?

What is your recertification percentage?

How are you applying the data collected to your business processes?


The RACs, MACs, MICs, and Z-PICs are now in place. The auditors are expected to perform. They have been chosen based upon performance.

Algorithms and Matrixes are in place using Predictive Analytics.

The NEW RAC is dedicated to home health, hospice, and DME


CMS is using predictive models to identify patterns found in transactional data gathered to identify risks and potential future behaviors. Auditors are looking at diagnoses in relation to visit frequencies and re-certifications.

They are looking at HIPPS scores compared to visit frequencies and durations. They should be looking at these.


They are looking at predictive models that capture relationships among many factors to allow assessment of risk or potential associated with a particular set of assessment/care frequency/payments expected. In other words, what are the guiding decision-making factors for agency transactions?


Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future. Poor coding performance places an agency in jeopardy.

That behavior is then compared to other agencies’ behavior in order to calculate risk then encompasses models that seek out subtle data patterns that answer questions about that agency’s overall performance.

These analytics quickly become fraud detection models.


Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future.

That behavior is then compared to other agencies’ behavior in order to calculate risk then encompasses models that seek out subtle data patterns that answer questions about that agency’s overall performance.

These analytics quickly become fraud detection models.


What happens if compliance measures are not employed?

Targeted Medical Reviews (TMRs)/(ADRs) Additional Documentation Requests will rise.

There will be claim denials and Medicare audits per the OIG as new fraud and abuse countermeasures are put into place.


Annually, CMS receives 1.2 billion claims.

That breaks down to 4.3 million claims per work day,

574,000 claims per hour, and

9,579 claims per minute.

Fraud and abuse are on the rise and the pressure is on. An increasing number of agencies are seeking outside expertise.

Audit Activity

MACs and PSC Contractors

MAC, Z-PIC, RAC, HEAT Activity

Increased activity and Enforcement

ADRs

Predictive Modeling

Comparative Billing


RACs- The contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, most due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, this auditor is expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only ,22 cents for every $1.00 recovered.


MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There are 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for over payment estimation of claims (current and prospective focus).

MACs have power and Congress is encouraging them to

use it.


CERTS - To better calculate the performance of the FIs and MACs, as well as to look at the reasons for their errors, CMS decided to look at a number of additional rates. The additional rates include

1) provider compliance error (how well providers prepared claims for submission)

2) paid claims error rates (measures how accurately FIs and MACs make coverage, coding, and other claims payment decisions). CERTs randomly select a sample of about a 100,000 claims each reporting period.


CERTs review the claims for proper Medicare coverage, coding, and billing rules, and if not in compliance, they assign an overall error rate.

CERTs also identify if providers received overpayment letters or notices of adjustments to be made for claims that were overpaid and underpaid. CERTs are considered the Quality Improvement specialists who track and trend the performance of fiscal intermediaries and Medicare Administrative Contractors.


Z-PICs- The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time. That power can cripple or financially devastate an agency. They have become very aggressive.


The HEAT is the technologically oriented auditing body using state of the art analytics to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector.

Retaining Your Dollars

Be certain a clinical documentation chart audit is available for all disciplines for clinical records, documentation must be consistent, complete, and defendable..

The following items should be included in every clinical note:

Homebound status: Identify what taxing effort was exerted if a patient left the house since the last clinical visit. Be certain all assistive devices are listed and/or the caregivers needed, the purpose for leaving the home, and if this was expected and/or a part of the careplan. Initially, this is reviewed by coding.


Identify what skilled the visit. If teaching was conducted, was it initial teaching, reinforcement teaching, or was it re-teaching? Identify in objective terminology measureable progress towards goals; ie for the psych nurse, what evidence toward cognitive structural behavior was identified? For physical therapy, how many feet were walked since the last visit and where does this relate to the plan? For the SN, did the patient identify at least two key side effects for their medications? Does the patient know what their medication is for and what it is expected to do for them? Do they know how to safely take their medications?

Retaining Your Dollars• Compare the Visits to the POC: Compare the

visit to the plan that is compared to the assessment. Have physician orders or notification for changes in condition. Note all change of condition clearly.

• SN should be reviewing the body systems noting VS and pain assessments


• When Teaching: Note if the teaching is New, Reinforced Teaching, or Re-teaching of the same subject to, perhaps, another caregiver. Note the caregivers willingness and capacity to learn and carry out the learning skills. Note the patient and caregiver’s learning in percentage; ie 70% or 80%.


• Specificity of wounds, skin conditions, falls risk, depression, and the focus of care are necessary. Auditors look for detail; for reasons that support skill. No skill can mean denial of visit payment. Recertification requires significant specific documentation

• Let’s discuss.


• Interdisciplinary communication: Comments to the physical therapist or the home health aide or other disciplines should be clearly noted. The visits should show the progress of the care in relation to the plan of care.

• This information is reviewed by the coder for recertification.

Survey Provisions go into Effect 7/1/2014

• Monetary sanctions between $8500-$10,000

for condition level deficiencies that place a patient in immediate jeopardy

Fines of $8500 for repeat deficiencies

Fines of $400 -$5000 per day for other deficiencies not placing a patient in jeopardy

Sanctions• Monetary sanctions are not the only sanctions that

CMS may impose. • Alternative or additional sanctions include

suspension of payments for new admissions and new episodes of care, temporary management of care, mandated directed inservices and training, as well as the temporary management of deficient agencies including making personnel changes and providing necessary interventions to assist the agency back into compliance.

Surveyor and Documentation• The rules place much more pressure on a home health

agency requiring excellent documentation of care following a careplan that is consistent with the needs identified in the patient clinical assessment.

• It will require coding to the highest level of specificity. • If outcomes are not achieved because needs were not

appropriately identified, visits were missed, or care was not appropriately delivered, an agency could face sanctions.

Survey Provisions

• The New Proposed Rules would place increased pressure on agencies for excellent documentation of care following the construction of a careplan consistent with the patient assessment.

• Does your Coding Team challenge the adequacy of the documentation to support each diagnosis?

Surveyors

• Care should be modified for Patient Response

• Decrease frequency as safety and learning is achieved

• Well established care, properly coded prompts outcomes

• Eliminate missed visits, poor compliance, patient and caregiver disconnect

Surveyors

• Looking for Responsible Reasonable Rehab services as well as general care delivery

• Contractors are the agency responsibility• Are orders and goals tracked and updated?• Does the Recertification process require a

review of the prior episode coding? Will your recertification reflect real Need?

ICD-10 Are you Preparing for ICD-10?

• “ICD-10 requires changes to almost all clinical and administrative systems. It requires changes to business processes.”CMS

• ICD-10 is one of the most significant events

planned for the industry.

It impacts all Home Health departments.

Training needs exist for Coding, Billing, Nurses,

Therapists, Office personnel, IT, and others.

Do not waste this year. Assist clinicians to document with more specificity.

Clinical Algorithms

• Increased specificity in data means more robust design of algorithms to predict outcomes and care

• Increased coding detail offers capability to find previously unrecognized relationships of diseases and variables

Coding Detail

• Increased specificity in data means more robust design of algorithms to predict outcomes and care

• Increased coding detail offers capability to find previously unrecognized relationships of diseases and variables

ICD -10

• ICD-9-CM codes will not be accepted for services provided on or after 10/1/2015

• ICD-10 codes will NOT be accepted for services prior to 10/1/2015

• Do not wait to improve on required documentation

• Get started NOW!

Increased number of digits and codes

CD-10 Codes provide greater detail in diagnoses and procedural description

Greater number also. 16,000 to more than 68,000 codes. Use of combination codes

ICD-10 codes have up to 7 digits and more alpha characters. The first digit is alpha. A code will be considered invalid if not coded to full number of characters (3,4,6,7)

Systems will be required to accommodate ICD-10 codes

Coding Changes

• Injuries are grouped by anatomical site rather than injury category

• Post operative complications have been moved to procedure in the specific body system chapter

Differences• ICD-9-CM Digits 2-5 are numeric• ICD-10-CM Digits 2 and 3 are numeric, digits 4-7 are

alpha or numeric

• ICD-9-CM Decimal point after 3rd digit• ICD-10-CM Decimal point after 3rd digit

• ICD-9-CM Dummy placeholder? NO• ICD-10-CM Dummy placeholder? YES

Increased Specificity• ICD-9-CM 17 Chapters and V/E code chapters• ICD-10-CM 21 Chapters- V/E codes in disease

chapters

• ICD-9-CM 13,000 disease plus V and E codes• ICD-10-CM 68,000 disease codes, including V

and E codes

Increased Specificity• ICD-9-CM Codes usually do not indicate timing

encounter• ICD-10-CM Codes specify initial and subsequent

encounters

• ICD-9-CM No differentiation between left/right• ICD-10-CM Differentiates between right and left

Increased specificity required

• Requires expertise in

anatomy,

physiology, and

diagnostics

The Coding specificity is far greater than ICD-9-CM and the need to better understand A&P and diagnostics is vital

Provider Impact

• Billing and Eligibility Transactions– New codes mean greater specificity– Means detailed documentation– CMS states there will be increased

rejections, denials, and pends as both plans and providers get accustomed to the new codes

Technology Impact

• Modifications to Field sizes• Alphanumeric Composition• Decimal Use• Redefining Code Values• Edit and Logic Changes• Table Structure Modifications• Forms• Interfaces

Business Ops and Clinical Impact

• Modifications to Field sizes• Alphanumeric Composition• Decimal Use• Redefining Code Values• Edit and Logic Changes• Table Structure Modifications• Forms Interface

Time to Make a Decision

• If You are Comfortable that your coding Team can be educated fully and completed in time and be trained economically- Start your Transition Plan NOW!!

• Include Anatomy, Physiology, Pathophysiology, Diagnostics, Pharmacology training for Coders and Clinicians. Accent the specificity needed.

Third Party Expertise Option• If you are already concerned about

reimbursement and cannot afford to not only send your coding team for the over 50 training hours experts say are necessary but must also incur the cost of a replacement team to code and incur the costs of parallel coding (ICD-9 and ICD-10 simultaneously month prior to October 1, 2015, then you should consider third party expertise.

If We Can Assist you in this Decision

• Assisting Home Health and Hospice Agencies for over two decades…..Contact:

• Susan Carmichael• MS, RN, CHCQM, COS-C, ICM, FAIHQ• Executive Vice President, Chief Compliance Officer• 4155 E. La Palma Ave Suite 250• Anaheim, CA 92807• 714.524.2500 x235• 949.584.6296 Cell

Healthcare

Practical and Succinct Solutions to Coding - Select Data, Inc