Archive for December, 2016

December 29, 2016

We’d Like to Avoid PCR, Like the Plague, However…

We’re all hoping, of course, that it will not happen, but it looks like CMS has the intention of spreading the ‘plague’ called Pre-Claim Review (PCR) into other states, including Florida (slated for April 1) and Texas (date to be determined). This plague got its start in Illinois. Illinois providers, through a painful process of trial and error, have mostly survived by changing processes and improving their immunity.

It is time to ‘vaccinate’ against the new plague with training of all staff regarding the PCR process and getting back to the basics of Medicare Home Health eligibility and payment. Now, more than ever, nurses and other clinicians need to perfect their assessment skills and adequately complete the OASIS.  It is imperative that the staff responsible for obtaining face-to-face documentation and recertification statements, etc are up-to-date on the expectations. CMS will be sending letters out to physicians regarding the process, so you will probably need to provide further education as the education provided by CMS will have a cooling effect.

As CMS has explained, the PCR process is voluntary, however it is important to know that if you decide to bypass the PCR process your documentation will still be reviewed, and even if it is adequate, your episode payment will be reduced by 25%.  You cannot appeal this decision, nor may you pass on the cost to the patient!

If you participate in the PCR, you will receive a decision of ‘affirmed,’ ‘partially affirmed,’ or ‘non-affirmed.’ In the beginning, your charts will likely be either partially affirmed or non-affirmed. PalmettoGBA (or other MAC, depending on the agency’s location) will provide a complete list of the missing or inadequate documentation, so that the agency can mitigate the errors.

Download the Pre-Claim Review guide located on the CMS website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html

Don’t let your agency be unprepared for Pre-Claim Review.  This process is NOT just for billing people. You will need someone (or more than one someone) on your staff responsible for gathering the documentation and reviewing it for sufficiency, then responding to the MAC reviewer. That person needs to be the one who knows the home health rules and documentation standards the best.

So, maybe we avoid the plague of PCR…there are lesser diseases out there that can damage your agency, like ZPIC audits and Probe and Educate audits. Any improvements that can be made in your processes and documentation can improve your immunity.

Need assistance in the educational aspects or process development? Selman-Holman & Associates, LLC is the expertise you need to work through this plague and build your immunity. Contact us at 214.550.1477 or Diane@selmanholman.com or Cathy@selmanholman.com.

December 27, 2016

What is the most frequently asked question regarding the transition to OASIS-C2? You need this answer today!

The most frequently asked question regarding OASIS-C2 is…when do we start using it? The easy answer—January 1! But it’s not so easy. CMS has verified that the transition will take place according to the M0090 date. Selman-Holman has developed the tool to assist you in this transition. (Click here to access tool).

 

Just remember, if an assessment is started on the OASIS-C1 format, but it not completed until January 1 or later, the OASIS-C2 items will need to be completed.

 

Selman-Holman & Associates, LLC, CodePro University and CoDR—Coding Done Right wish you all a Happy, Healthy and Prosperous New Year!

 

December 16, 2016

Sequencing Conundrum

This type of question is common, so that we could help you out with this conundrum.

Question:

I have a general question.  Say you have a patient that has had an exacerbation of their HTN and both SN and therapy are going out.  Therapy is going out because the patient has some residuals from a CVA, and therapy is going out more than SN.  Should the residuals of the CVA be primary over HTN, because therapy is going out more than SN?   Should our primary diagnosis be driven by whatever discipline is going out the most?  I have also been told that this is upcoding, is that correct?

Answer:

The guidance for M1021 (primary diagnosis) states this should be the main reason for home care services and identify the focus of care for the home care episode, so don’t go by the number of visits by discipline as the ONLY criteria to choose primary diagnosis – look at the focus of the entire plan of care:

what is the most acute condition being treated by the home health plan of care?

what requires the most intensive services and visit frequency (one of several things to consider)?

what did the physician identify as the main reason for home care services on the face-to-face encounter documentation?

 

In your example, you state the patient had an exacerbation of their HTN and has residual deficits from a CVA – consider these points:

What is the blood pressure on the SOC assessment?  If it is outside the desired parameters (high or low) does the patient have symptoms?  Are there medication changes?  Does the patient need teaching on how to take the meds?  Has the patient had adverse effects to the medications and are they effective?   Is the patient at risk of further complications due to the HTN at the time of the SOC and anticipated through the episode of care? If these considerations point to HTN as the most important condition being treated, then make it the primary diagnosis in M1021 and put the CVA deficits in M1023.

Also look at the residual deficits from the CVA:  How long ago was the CVA?  Has the patient had therapy before or is this the first?  Are the deficits getting worse or better?  How much do the deficits affect the patient’s functional abilities?  If the blood pressure is responding well to treatment with no problems and you have both PT and OT ordered, it makes more sense to choose the CVA as primary diagnosis and list the HTN as secondary.

Finally look at the F2F documentation:  is the HTN the reason the physician referred the patient to home care and the therapy for deficits is an additional service the agency identified a need for on the SOC assessment?  After considering the above points, you might choose to make the HTN primary in M1021 and put the CVA deficits in M1023.

 

So it is impossible to give one general answer – you must consider the situation in each individual case.

 

As to your final question:  “upcoding” – choosing a diagnosis or sequencing diagnoses in order to get more case-mix points – should never be done:  consider the information listed above and always confirm the diagnoses on the plan of care with the physician.  And be prepared to justify your diagnoses and show they were verified by the physician.  Your plan of care should reflect interventions and goals that support the diagnoses listed and their order of importance.

 

 

Need coding, OASIS, 5 Star Rating education or other home health related education? Call Selman-Holman & Associates, LLC  214.550.1477

December 4, 2016

Sometimes OASIS doesn’t mean what it says…

I know it comes as a surprise to some of you, but the government isn’t always clear with its instructions [tongue in cheek]. Take M1060 for example:

Do you see that first line regarding the weight? It states “Base weight on most recent measure in last 30 days…” That seems great to a lot of folks who think that ‘we will not have to get that patient weighed after all,’ for example, that patient that was weighed via the scale on the Hoyer lift, or that patient who does not have a set of scales and you forgot to bring yours. Do you think you can just review that hospital or SNF record looking for a weight and enter that one?

Sometimes OASIS doesn’t mean what it says. That first line “Base weight on most recent measure in last 30 days…” doesn’t really mean a thing. See the guidance below. I’ve emphasized the important part.

Q62.9.M1060. For the new OASIS item M1060, can the agency gather the patient’s height and weight by patient/caregiver report? M1060a requests most recent height measure since SOC/ROC, but M1060b allows most recent weight measurement in last 30 days. So does that mean that height must be actually measured after the home health admission, but weight can be entered based on hospital discharge paperwork documented within the last 30 days? Can we ask the patient or caregiver the patient’s height and/or weight? [Q&A ADDED 10/16; Previously CMS Qtrly 10/16 Q&A 10]

A62.9. The assessing clinician should measure the patient’s height and weight in accordance with the agency’s policies and procedures, which should reflect current standards of practice (shoes off, etc.). The assessing clinician is expected to weigh and measure the patient as part of the comprehensive assessment. Data collection for M1060 by self-report or from paperwork from another provider setting is not acceptable. If a patient cannot be weighed/measured, enter the dash value (“-“) and document the rationale on the patient’s medical record. A dash (–) value indicates that no information is available and /or an item could not be assessed. CMS expects dash use to be a rare occurrence.

Q62.9.1.M1060. For the new OASIS item M1060, can the agency gather the patient’s height and weight by patient/caregiver report? M1060a requests most recent height measure since SOC/ROC, but M1060b allows most recent weight measurement in last 30 days. So does that mean that height must be actually measured after the home health admission, but weight can be entered based on hospital discharge paperwork documented within the last 30 days? Can we ask the patient or caregiver the patient’s height and/or weight? [Q&A ADDED 10/16; Previously CMS Qtrly 10/16 Q&A 11]

A62.9.1. The assessing clinician should measure the patient’s height and weight in accordance with the agency’s policies and procedures, which should reflect current standards of practice (shoes off, etc.). The assessing clinician is expected to weigh and measure the patient as part of the comprehensive assessment. Data collection for M1060 by self-report or from paperwork from another provider setting is not acceptable. If a patient cannot be weighed/measured, enter the dash value (“-“) and document the rationale on the patient’s medical record. A dash (–) value indicates that no information is available and /or an item could not be assessed. CMS expects dash use to be a rare occurrence.

 

For complete, comprehensive training on OASIS-C2, attend one of Selman-Holman on-site conferences (see www.selmanholman.com/seminars  or on-line training found at www.med-PASS.com.