Posts tagged ‘HHRG’

April 17, 2012

CMS has two new focuses for medical reviews

CMS to focus on 2 new areas for reviews

At the NAHC conference in Washington, DC, recently, Latesha Walker of CMS said that CMS will begin medical reviews in two new areas:

  • Episodes that barely exceed the low utilization payment adjustment (LUPA) threshold of five visits with document reviews.
  • Review situations where an agency billed a low HHRG code for a first episode, but a higher one later.

Just because there are two new additions doesn’t mean that the old reviews shouldn’t be paid attention to anymore!

A few other things discussed at the meeting:

  • CMS has already set a 1.32 percent cut for case-mix in 2013 because of case-mix creep. CMS is moving ahead with its PPS rebasing project.
  • Confused on assessments and billability of visits with therapy? You’re not the only one. NAHC is still asking for clarification on when an assessment visit is billable (ever?) what is billable if you don’t do the assessment at exactly 30 days or the 13th or 19th visit. What if it’s the 14th visit? When does a visit become billable?
  • New CoP? Really? We’ll believe it when we see it, but Pat Sevast said new Conditions of Participation are on CMS’s to-do list.

Thanks, again, to HCLA for its update in its News Alert!

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.

December 8, 2010

2011 OIG Work Plan focuses on payments

If you haven’t seen it yet, or you don’t know about it, the Office of the Inspector General is implementing its FY2011 Work Plan. The great thing about OIG is that the agency spells out exactly what  it will be focusing on in each care continuum.

Here’s a look at the HHA (Medicare Part B) focus:

Payments for HH Beneficiaries: The OIG will review Part B payments for services and medical supplies provided. The agency specifically mentions identifying payments to outside supplies to examine controls.

HHA Claims for Medicare HHRG: Coverage requirements (homebound, intermittent care, under care of MD, etc.) are a focus. OIG will also assess the accuracy of HHRGs submitted in 2008.

Oversight of OASIS: OIG will review CMS’s oversight of OASIS data. The focus is to review CMS’s process that should ensure that HHAs submit accurate, complete data.

HHPPS Controls: This includes reviews for billings at the appropriate service location. This focus will analyze HHA activities on items such as the number of claims submitted, number of visits provided, ownership information, and arrangements with other facilities.

HHA Profitability: This analysis items seeks to determine whether the payment methodology should be adjusted.

Medicare HHA Enrollment: This item really focuses on cross relationships with suppliers and ownership. OIG specifically mentions that previous work found that DME suppliers omitted or provided inaccurate information … and that these suppliers were often associated with HHAs through shared owners or managers.

See OIG’s focus across the health care spectrum.

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