Home Health Insight

From Palmetto GBA:

Face to Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Non-physician Practitioners (NPPs)

Physicians play a key role in determining and documenting the medical necessity for home health care for Medicare beneficiaries. We encourage physicians who certify the need for home health care to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) to your patients regarding home health care.

Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:

The encounter was related to the primary reason for home care
How the patient’s condition supports the patient’s homebound status; or
How the patient’s condition supports the need for skilled services

Acceptable FTF documentation does not have to be lengthy or overly detailed. However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.

Below are examples of FTF documentation that, used alone, are considered insufficient documentation.
Homebound Status Need for Skilled Services
Functional decline Family is asking for help
Dementia or confusion Continues to have problems
Difficult to travel to doctor’s office List of tasks for nurse to do
Unable to leave home Patient unable to do wound care
Weak Diabetes
Unable to drive

Examples of appropriate documentation include:

Wound care completed to left great toe. No s/s of infection, but patient remains at risk due to diabetic status. Skilled nurse visits to perform wound care and assess wound status. Patient on bed to chair activities only.
Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema. Short of breath with talking and ambulation of 1-2 feet. Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status.

Who May Document the FTF Encounter?
The FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or qualified NPP working in conjunction with the certifying physician. An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility. That NPP can then report the FTF encounter to the certifying physician.

Medicare guidelines also contain specific documentation requirements:

The certifying physician must document that the FTF visit took place, regardless of who performed the encounter
If the FTF was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the FTF must communicate clinical findings of the FTF encounter to the certifying physician. NPPs performing the FTF encounter in an acute/post-acute facility must inform the physician they are collaborating with, or under the supervision of, so that the physician can inform the certifying physician of the clinical findings of the FTF
The certifying physician cannot merely co-sign the encounter documentation if performed by an NPP. He or she must complete/sign the form or a staff member from his or her office may complete the form from the physician’s encounter notes, which the certifying physician would then sign.
The FTF documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare.
The FTF documentation must include:
The date of the FTF encounter
Clinical findings to support that the encounter is related to the primary reason for home care, the patient is homebound, and in need of Medicare covered home health services

Finally, because the FTF is a requirement for payment, when the FTF requirements as outlined above are not met, the entire claim is denied. For cases in which the beneficiary’s condition otherwise warrants Medicare coverage of skilled home health services, but FTF documentation is insufficient, the beneficiary’s ability to receive this skilled care may be jeopardized.

References and Resources:

The CMS Medicare Benefit Policy Manual (Pub. 100-02, chapter 7, §30.5.1.1 (PDF, 416 KB)
CMS MLN Matters article, SE1219, ‘A Physician’s Guide to Medicare’s Home Health Certification, including the Face-to-Face Encounter’ (PDF, 128 KB)

We’ve been responding to a lot of ADRs and other such medical review requests here at Selman-Holman & Associates and when the documentation in the chart is decent we are usually successful. One item we’re especially concerned with is the lack of, or inadequacy of, Face to Face documentation. No matter how much you’ve improved your clinical documentation, and no matter how much your patient needs your services, if the Face to Face documentation is lacking, they’ll deny. In fact, if they can deny based on 3 simple things, they will not even look at the clinical documentation. What are those three things? 1} Face to Face; 2) Physician signature and date on the POC; and 3) SOC or Recertification OASIS has been transmitted to the state depository and the HIPPS code matches that on the bill. If any of those are not adequate, they can deny the entire episode without looking further. There is a 4th of course—homebound, but for that one they do have to look at the clinical documentation a little bit.

This from Palmetto this morning:
Medical Review Requirements for Home Health Face-to-Face Documentation
Palmetto GBA has noticed an increase in overpayments for Home Health Prospective Payment System (HH PPS) claims. The top reason for this increase is attributed to the requirement for a face-to-face encounter with the beneficiary.

Palmetto GBA evaluated its criteria for review of these types of claims. Effective immediately, we will begin a more comprehensive review using the regulations governing these types of claims. Palmetto GBA encourages all providers to review their internal processes to ensure that all of the criteria for coverage have been met and documented in the medical record.

As a condition for payment, the Affordable Care Act mandates that prior to certifying a patient’s eligibility for the home health benefit, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP), has had a face-to-face encounter with the patient.

According to the, CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.1, the face to face documentation must contain a brief narrative which ‘describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.’
Documentation must include details showing how specific clinical findings support homebound status.
Examples of inadequate documentation include the following:
• Diagnosis alone, such as osteoarthritis
• Recent procedures alone, such as total knee replacement
• Recent injuries alone, such as hip fracture
• Statement, ‘taxing effort to leave home’ without specific clinical findings to indicate what makes the beneficiary homebound
• ‘Gait abnormality’ without specific clinical findings
• ‘Weakness’ without specific clinical findings
The face-to-face documentation must also include clinical findings to support the need for skilled services, i.e. skilled nursing or therapy.

The Code of Federal Regulations, Title 42, Part 424, Subpart B, 424.22 states, ‘The documentation of the face-to-face patient encounter must be a separate and distinct section of, or an addendum to, the certification, and must be clearly titled and dated and the certification must be signed by the certifying physician.’

For more information, please refer to Medlearn Matters article SE1219 (PDF, 128 KB).

References:
• CMS Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.1
• Code of Federal Regulations, Title 42, Part 424, Subpart B, 424.22
• Medlearn Matters article SE1219
We’re here to help! 214-550-1477

Documentation…What’s all the Fuss?

I was talking with my good friend Thelma Bowen about documentation in home care. Not just the importance of coding and OASIS answers (and these are important), but also the importance of supporting that coding and OASIS with the day to day documentation. I think that despite all of the brouhaha about the importance of patient specific, individualized documentation to support the need for Medicare covered home health services, many HHAs struggle mightily from trying to take this concept from struggling to implement to making it happen. Agency leaders have asked me more than once: “How perfect do we need to be?” I always answer: “I don’t know? How much of your payments do you want to keep?” The fact of the matter is that the most important thing for HHA agency to do is to think in the long term rather than reacting to what they hear about what Medicare and their contractors are doing now. Sure, they need to keep up with and adapt to changes but if they have not laid a solid foundation of compliance with regulations they are already behind and at risk. We all know that recovery auditors can and do go back three years in their efforts to recover payments. It is important for them to stop assuming that the fact that they survive surveys with no problems means they are not at risk for payment denial on review. Survey status has little to nothing to do with their risk for payment denial when their claims are pulled for Medical Review. I think that the HHAs need to objectively assess their risk and make changes going forward to ensure that they are not just responding to the latest thing that Medicare has approved for review.

These are the biggest problems/needs that I am currently seeing: (in no particular order)

1. Failure of clinicians to adequately support in writing the homebound status of the patient. I compare and contrast narrative, OASIS items, referral information and F2F to what the clinician has selected. I think that the HHAs should remove all homebound checkboxes and require a brief specific statement specific to the patient that is supported by the documentation.
2. Failure of clinicians to adequately identify the impact of the underlying conditions on the patient ability to progress and to meet goals. I think that all HHAs should add at every part of the comprehensive assessment the following statement: “How do the cardio/circulatory (or respiratory, elimination, etc) conditions impact on the home health plan of care?” and “What knowledge deficits have been identified that require the skills of a nurse to instruct.” This is because therapists and nurses generally do not do a good job of doing this.
3. Failure of therapists to add comments throughout the comprehensive assessment to support the impact of underlying conditions on the treatment plan. The guidance to surveyors includes the following statement: “For therapy-only cases, the comprehensive assessment should incorporate OASIS data items as well as other assessment data items the HHA currently collects for therapy patients, as opposed to simply adding them at the beginning or end.”
4. Failure of clinicians to promptly contact the physician/physician designee to confirm diagnoses that are not physician confirmed on the referral and that impact on the poc.
5. Failure of clinicians to promptly submit OASIS documentation so that any needed QA can be done within the five day window. Many errors would be corrected if this occurred.

Learn more on documentation, denials, compliance, proper coding and the largest survey deficiencies with an upcoming seminar for Home Health and Hospice featuring some of the leading consultants in the industry May 16 and 17 in Birmingham, AL. Enter a special promo code NURSE in honor of Nurse’s week May 6-12 for your discount.

http://homehealthsolutionsllc.com/event/first-annual-alabama-home-health-hospice-summit/

Selman-Holman & Associates supports Home Health Solutions, LLC in its endeavors to educate homecare professionals in improving documentation. Contact us for more information on how to improve your documentation or click the link above to attend this comprehensive conference.

J’non Griffin, RN WCC, HCS-D, COS-C, BCHH-C, Guest Blogger

Coding Mysteries Exposed…

It seems that coding myths of all sorts have been running rampant lately among home health coders, both those related to the ICD-9-CM and ICD-10-CM code sets. Coders, don’t believe everything you hear, especially if it doesn’t make sense or seems to conflict with official coding guidelines. Even software scrubbers and edits can cause confusion within agencies when it comes to the assignment of codes, resulting in serious misunderstandings and potential claim errors.

Here is some clarity on a few of these myths and rumors:

#1)Hypertension coding- Since the change in case mix points to hypertension codes in January 2012, agencies and coders seem to be increasingly confused on how to use these codes. First of all, let’s clear the air on the rumor that “401.X codes are no longer valid codes.” They sure are! This rumor originates from the removal of case mix points for the 401.X codes, as well as the fact that many agencies have received ADRs after using these codes as primary diagnoses on their claims. Coders and other home health professionals need to know that these codes are still valid and need to be used appropriately. The cause for ADRs and other medical reviews on claims with these codes as primary relates to the use of hypertension as a primary diagnosis for multiple episodes. CMS is inquiring as to whether or not these patient’s are truly unstable, or if agencies are just monitoring blood pressures for multiple episodes. Second, coding for hypertensive heart disease (402.XX) does not presume a relationship between the hypertension and heart disease. In order to use this code, the physician absolutely must state that there is a causal relationship present between the heart disease and hypertension. Furthermore, take note that only certain cardiac conditions are classified under hypertensive heart disease (402.XX), and that this does not include many conditions such as coronary artery disease.

#2) Diabetes as a primary diagnosis- the popularity of many software edits and OASIS scrubber systems has created a whole new wave of challenges for agencies and caused coders to second guess their skills. Many software systems will report an edit that Diabetes (250.00) should not be coded as a primary, as (according to the incorrect software warning) the code indicates the diabetes is “stable”. However, this is a complete falsehood and terribly misleading guidance. 250.XX indicates the diagnosis of diabetes. The fourth digit “0” indicates the physician indicated no manifestations. The fifth digit “0” indicates that the physician did not diagnose the diabetes as uncontrolled or out of controlled. Under no circumstances does the code 250.00 indicate stable Diabetes. However, agencies and coders are being misled by poorly phrased software edits. While its important only to use Diabetes without mention of complications, and not stated as uncontrolled (250.00) as a primary diagnosis when the clinical record indicates it, there is no coding guidance or regulation preventing its use.

These two misunderstandings can cause serious problems for home health coders, not to mention creating claim errors for agencies as well. As we make the transition to the ICD-10-CM code set, coders are going to need to be even more cautious in keeping their eyes and ears open for these coding falsehoods. In order to help combat some of these perplexing untruths and keep coders on the right track, we will be frequently posting here on Home Health Insight some of the more commonly encountered coding myths. Please feel free to submit your coding myth, mystery, or question to us!

Brandi Whitemyer, Guest Blogger, Senior Associate, Selman-Holman & Associates, LLC and CoDR—Coding Done Right

Are you ready for ICD-10-CM? Those attending my classes feel more confident and ready for a smooth transition. Testing claims in ICD-10-CM began April 1. Please join me in Baton Rouge April 25, Mission May 23 or San Antonio on June 26.   Check
http://www.selmanholman.com/SHAweb_seminars.htm
for information. Lisa

Guest Blogger-Brandi Whitemyer, RN, HCS-D, HCS-O, COS-C, AHIMA Approved ICD-10-CM Trainer/Ambassador, Senior Associate

You can’t assess what you can’t see!

When assessing your patients, its important to remember that you can’t assess what isn’t there! For example, how often is it that you arrive to perform a start of care or resumption of care assessment and your patient has yet to pick up their medications from the pharmacy? Every home health clinician knows the line, “I have the scripts, I just don’t have all of them yet”, or, “I can’t afford those until Tuesday.” But how do you assess a patient’s ability to take all of their medications safely and reliably all of the time, when they only have some of their medications?

Well, CMS says you can’t! M2020, Management of Oral Medications, is an OASIS item frequently missed by clinicians due to a simple misunderstanding of OASIS-C guidance. Here is what CMS has to say (Q& A- January, 2011):

Question: If the patient does not have her prescribed medications in the home because she cannot afford them and she does not plan on getting them, what is the most appropriate response for M2020?

Answer: When completing M2020, Management of Oral Medications, you are reporting the patient’s ability to take all oral medications reliably and safely at all times on the day of the assessment. If the patient did not take her medications on the day of the assessment because they were not present in the home, you cannot make assumptions about a patient’s ability to take medications she doesn’t have. If the medications were not in the home, you would not be able to determine if she could take each medication at the correct time and dose. The patient’s status would be reported as “3-Unable to take medications unless administered by another person”.

So, if your patient does not have the ordered medications in the home, you as the assessing clinician, obviously cannot make any judgment as to how the patient is able to take his or her medications safely and reliably at all times and must respond “3.” Just keep in mind that patient compliance and willingness does not get taken into consideration. If your patient does not have his or her medications because he or she has no intention of taking them or refuses to pick them up because he or she does not ever take them, then you would not consider this in your response.

Similarly, when responding to OASIS items such as M1860 (Ambulation/Locomotion), if the patient is determined to only ambulate safely with the assistance of a device, but does not have any assistive device in the home (note: holding onto walls and furniture does not count as “assistive device” when assessing!), then you will need to respond “3” (“able to walk only with the supervision or assistance of another person at all times”) to M1860, Ambulation/Locomotion, (CMS Q& As Cat. 4b-Q155.1) Again, you cannot determine the patient’s safe ability to use a device that he or she does not have!

Selman-Holman & Associates, LLC and CoDR—Coding Done Right provides customized education for your agency on OASIS issues, as well as OASIS review. Call us at 214-550-1477 or send an email to QandA@selmanholman.com

Guest Blogger: Brandi Whitemyer, RN, HCS-D, HCS-O, COS-C, AHIMA Approved ICD-10-CM Trainer/Ambassador, Senior Associate

Guest Blogger-Brandi Whitemyer, RN, HCS-D, HCS-O, COS-C, AHIMA Approved ICD-10-CM Trainer/Ambassador, Senior Associate

Ready or Not-

Get ready! Believe it or not, ICD-10 is coming. It seems that many out there remain skeptics on this subject, but CMS has made it clear since the August 24, 2012 final rule announcement that the October 1^st, 2014 implementation date is set in stone. The Acting Administrator of CMS announced just last week that October 1, 2014 IS THE BIG DAY and there will be NO further delays! ICD-10 is tied to HIPAA regulation; so all providers will be required to comply with the transition. Fortunately, CMS has provided a timeline with suggested practices during the pre-implementation period to assist agencies in preparing for this looming deadline.

Here is what they have to say:

• Immediately- begin reviewing ICD-10 resources, making staff aware of the upcoming change, and identifying needs for process change within your agency. Design and develop your agency’s ICD-10 implementation plan and assign those responsible. Inquire with vendors and payers regarding their ICD-10 readiness.

• Spring 2013 through fall 2014- Begin the process of training at your agency. (Keep in mind that due to the extent of change involved you will need to train staff at all levels from field staff to billing to coding to administration.) At this time, staff responsible for coding should be assessed for readiness and trainability to transition to ICD-10. Staff directly involved in the coding process for your agency should begin training for the ICD-10 code set. Clinical and coding staff should all be involved in training to review specific areas that will impact performance on ICD-10, including documentation and anatomy & physiology.

• October 2013 through January, 2014-CMS is recommending that agencies begin submitting test claims for ICD-10 by October 2013. NGS has been contracted to assist in the submission of test claims for home health. The process of test claim submission can assist in early detection of problem areas, as well as assist agencies in identification of process improvement needs prior to the required October 1^st, 2014 implementation date.

• Spring 2014- Review your agency’s implementation plan for appropriateness and any needed changes. Review preparation of coding and clinical staff and assure the implementation of detailed training no later than 6-9 months prior to the October, 2014 implementation date (9 months recommended). Define vendor readiness and assure systems will be ready for implementation deadline. This is also the time period that we should have information from CMS about grouper changes.

• October 1st, 2014- full compliance deadline. All services on or before September 31^st, 2014 will be coded using the ICD-9 code set. All services initiated on or after October 1^st, 2014 will be coded using the ICD-10 code set.

The bottom line is that we are on the fast track to ICD-10 and there is no turning back now! Don’t let your agency fall behind with so much to do in the next 17 months. Selman-Holman & Associates, CoDR—Coding Done Right, and its team of AHIMA Approved ICD-10 Trainers/Ambassadors are ready to help your agency with creating the perfect, seamless ICD-10 transition plan for success!

Call 214-550-1477 or email Lisa@selmanholman.com for more information!

By  guest blogger-Brandi Whitemyer, BSN,RN, HCS-D,COS-C

Since its implementation in 2011, face-to-face encounter requirements have presented home health agencies with confusing and monumental challenges that impact payment, referral relationships, documentation, and agency workflow. As agencies rise to meet these challenges, it seems questions arise faster than answers in an industry pushed to fulfill yet another demand. Some of the toughest scenarios presented by face-to-face challenges can often only be solved with the assistance of an industry expert. Don’t let your agency be fooled and lose valuable revenue by assuming the answers to your face-to-face questions are easy.

Some of the most common and confounding issues involve late face-to-face encounters. While CMS has provided guidance on these scenarios, resolving them nevertheless involves attention to detail and patience to assure you don’t lose revenue. For example, does your agency know what to do in the following scenario? An encounter you thought occurred on day 28 never happened, only to find out the patient’s encounter occurred 70 days following the agency’s original start of care date. How should your agency act now?

According to CMS Q&As released as of April 2012, you will need to count back 30 days from the late encounter, identify the closest billable visit on or after that date (which will become your new SOC date), and create a new start of care OASIS using those M item response from the OASIS completed closest to that identified first billable visit date. Previous OASIS (including the SOC and any recertification completed) will need to be deleted per CMS guidance prior to the submission of any newly generated OASIS as well. In this process, you will need to assure that as you adjust your episode dates, you generate new plans of care to cover the corrected episode dates, and have these signed by the physician as well. Sounds simple enough right? Maybe, but too often it seems that one simple situation like this can create an avalanche of issues and questions.

For example:

Q: Why delete the OASIS rather than inactivate it?

A: CMS does not require nor want OASIS data on patient episodes that are considered non-covered. In this case, the original OASIS completed are representative of non-covered episodes.

Q: Where do I obtain the M item responses if the closest OASIS is a recertification or a discharge?

A: Use all available M item responses from the available OASIS first, then other M items may be obtained from the ROC or SOC OASIS, whichever was completed closest to the identified first billable visit date.

Q: What about the plan of care? How do I know what interventions and goals to include in which episodes now that the episodes have shifted?

A: As you may have varying interventions and goals from one episode to the next, you will need to review each original episode alongside the revised episode to assess what interventions and goals to include in each newly generated plan of care. Remember that the care you provided at any time must be supported by orders, either within the plan of care or supplemental.

These are just a few of the questions that can come up and, while CMS has issued a myriad of guidance on the issue, navigating a sticky face-to-face issue can still be confusing and time consuming. Unfortunately, the burden of the face-to-face falls on the home health agency, and handling any face-to-face scenario incorrectly can put your claims at risk and risk important revenue for your agency. Be sure to educate your agency staff to assure face-to-face compliance and reduce your risk. Selman-Holman & Associates can help your agency with any number of questions and issues related to face to face, including medical reviews and appeal of claim denials related to face-to-face issues. Don’t take a chance and risk your agency’s bottom line.

The Palmetto GBA Medical Review department will perform a service-specific prepay complex review on claims billed for selected Home Health HIPPS codes. Prepay complex review means Palmetto will not pay your claim until the review is done. The Medical Review department identified the top 20 Home Health HIPPS codes, ranked by provider disbursement. They determined that there is a high level of denial amongst some of the most frequently billed HIPPS and will be conducting medical review on two specific HIPPS codes with the highest claim count denial rate: 2CGK* and 1BGP* (last character of the HIPPS code doesn’t matter in this medical review).

My recommendations: 1) Design a report so that you know which episodes include the two HIPPS codes. 2) Review those charts carefully prior to sending the claim for documentation to support medically necessary care.  3) Call Selman-Holman & Associates, LLC if you’re not sure whether documentation is complete. Your HIPPS code may be incorrect, and if is not, you need to correct your OASIS (according to guidance provided by CMS), which means that you may also have to correct other items as well.

If you receive a request for the medical record, remember you have 30 days to submit the requested medical record information so time is of the essence (you’re not getting paid in the meantime). We can help you with that also.

When the claim is finalized, Palmetto will pay the claim in full or part, or deny. If you disagree with the decision, you may request a redetermination within 120 days of the determination (date on the remittance advice).

Completed review results will be posted to the Palmetto GBA website. Individual providers with significant denials may be contacted for one-on-one education.