Archive for March, 2012

March 28, 2012

Don’t reverse those pressure ulcers!

I don’t know why I’ve had people ask me lately if you can reverse pressure ulcer stages for Stage I and II ulcers, but you can’t, and CMS has clarified M1324  in a recent Q&A.

CMS also clarified an M1307 question dealing with a pressure ulcer that progressed from Stage I to Stage II during the episode:

Question: If the patient had a Stage I pressure ulcer at SOC that progressed to a Stage II, how do we answer M1307 at discharge?
CMS Answer: If a patient had a Stage I pressure ulcer at SOC/ROC and it advanced to a Stage II by discharge, Response “1-Was present at the most recent SOC/ROC assessment” would be appropriate due to the fact that the ulcer, caused by pressure, was present at the most recent SOC/ROC assessment, even though it was a Stage I at that time.

Looking for more CMS answers?

March 26, 2012

OIG finds $432 million+ in HHA claims issues

The HHS Office of the Inspector General conducted a study looking at home health claims from 2002-2008 and found that$432 million in Medicare monies were inappropriately paid either because medical necessity was not established or coding was inaccurate. Millions more dollars were lost to CMS or HHAs because of upcoding or downcoding.

The number of HHAs grew from 7,052 to 9,801, and increase of 39 percent. Medicare spending on home health increased 84 percent from $8.5 billion in 2000 to $15.7 billion in 2007. The sharp rise in payments created the push to investigate payments.

HHS reviewed the claims of almost 500 beneficiaries to see whether Medicare coverage requirements were met.

The office found that 22 percent of claims were in error because services were not medically necessary or claims were coded inaccurately, resulting in $432 million in improper Medicare payments. Also, HHAs upcoded about 10 percent ($278 million) of claims and downcoded about 10 percent ($184 million) of claims.

OIG believes it needs to investigate more to determine what services are met and what potential for fraud is involved.

Read the complete report.

March 20, 2012

How do you correct an OASIS error when a clinician is no longer with you?

From CMS Q&As …

Question: Our clinician reported an ostomy as a surgical wound in the OASIS M1340, Surgical Wound item. The clinician no longer works for the agency, so we cannot contact her about the error. Can this OASIS change be made by the DON without speaking to the clinician?
CMS Answer: You have described a situation where a true OASIS scoring error was discovered during the audit process. The assessment was complete. The patient had an ostomy, a clear, non-disputable fact based on the entire clinical record. The assessing clinician responsible for completing the assessment misunderstood, wasn’t aware, or made an error based on the OASIS scoring guidance, which states all ostomies are excluded as surgical wounds in M1340.
HHAs should have a policy and procedure for correcting errors that involves the assessing clinician. The policy should follow established clinical record professional practice standards and guidance found in relevant CMS regulations and guidance. Normally, if an error is identified through audit or review, the individual who made the original entry into the patient’s record would, whenever possible, make the necessary correction by following agency policy. A correction policy may allow the auditor who found the error to contact the clinician, discuss the discrepancy in the medical record and make the correction following your policy including information such as who discovered the error, and the date and time of communication with the assessing clinician who agrees that it was an error. Correction of an error will not impact the M0090, Date Assessment Completed.
In a case where, as you have described, the original documenter is not available, the clinical supervisor or quality staff may make the correction to the documentation following the correction policy. The supervisor must document why the original assessing clinician is not available to make the correction and how the error was identified and validated as a true error. When corrections are made to assessments submitted to state, you must determine the impact of the correction on the POC, HHRG, the Plan of Treatment, RAP and make corrections to those documents and billing, as applicable.
When the comprehensive assessment is corrected, the HHA must maintain the original as well as subsequent corrected assessments in the patient’s clinical record per requirements at 42 CFR 484.48.

CMS urges HHAs to make corrections and/or submit inactivations as quickly as possible after errors are identified so the state system will be as current and accurate as possible, as the data is used to generate OBQM, OBQI, PBQI, Patient-Related Characteristics Report and HHRG.
Follow the guidance found in CMS Survey & Cert Letter 01-12 New Outcome and Assessment Information Set (OASIS) Correction Policy for Home Health Agencies (HHAs)—ACTION and INFORMATION.

March 19, 2012

5010 enforcement moves to June 30

Sorry! I forgot to hit “publish” on this post from last week!

From CMS …

In an announcement, the Centers for Medicare & Medicaid Services’ (CMS) Office of E-Health Standards and Services (OESS) said it will not initiate enforcement action against any non-compliant entities for an additional three (3) months, through June 30, 2012, for updated HIPAA transaction standards (ASC X12 Version 5010, NCPDP Versions D.0 and 3.0).

Health plans, clearinghouses, providers and software vendors have been making steady progress: the Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format. Commercial plans are reporting similar numbers. State Medicaid agencies are showing progress as well, and some have made a full transition to Version 5010.

March 14, 2012

Lower-limb amputations declining in diabetes patients

From the Centers for Disease Control and Prevention …

The rate of leg and foot amputations among U.S. adults aged 40 years and older with diagnosed diabetes declined by 65% between 1996 and 2008, according to a new study by the Centers for Disease Control and Prevention (CDC).

The CDC attributes better blood glucose control, foot care, and diabetes management, along with a drop in heart disease, as likely reasons that the number of amputations has fallen. 

Diabetes is the leading cause of nontraumatic amputations of feet and legs among U.S. adults.

The age-adjusted rate of nontraumatic lower-limb amputations was 3.9 per 1,000 people with diagnosed diabetes in 2008 compared to 11.2 per 1,000 in 1996.

To learn more, go to the CDC site on diabetes.