Don’t Talk to the Hand
December 28, 2008
I was reviewing clinical records recently for an excellent client. Well, most of the time they are excellent. But like every other client, past, present and future, they got a little careless when it came to coordination of care. A better name for care coordination I think might be simply talking to each other.
The particular chart I looked at was almost perfect. I was just getting ready to put it back on the shelf but had two questions. First, within the admission paperwork, there was mention of an area of redness on the heel of this patient. All subsequent notes noted that there was a wound on a finger. I thought it was sloppy charting. The second question concerned the patient being started on Lortab the week before discharge. Why?
So, before I called it quits for the day, I asked about the patient. As it turned out, the patient was scheduled for discharge and I had the opportunity to go with the nurse to see the patient. He was sitting up on arrival, fully dressed. I hated to inconvenience him but I asked if I could remove his sneakers and socks anyway. I managed to get the right foot exposed first and there was nothing to write home about. Just because I had come this far, I next turned to the left foot. With the help of an aide, I managed to take the snap shot below.
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Upon further investigation, I learned that the admitting nurse was only doing the visit as a favor to the agency. She documented the foot problem but didn’t report it. The aide saw the wound but assumed the nurse was aware. The LPN read about the wound on the finger but nothing written about the foot so she assumed it was a careless mistake like I did. The patient was cranky and frankly, didn’t like anyone removing his shoes and socks.
It would be easy if one person was to blame. But too many people knew about this wound. And everyone assumed that everyone else knew, too. It was a system failure with ominous results. However, this same failure to communicate exists in every client’s office at one time or another.
So could we all just please talk to each other?
Santa Baby
December 23, 2008
Dear Santa:
I hope you and the elves are doing well. I saw a few elves at dinner the other night. Frankly, they were tanked and I hope that doesn’t impede progress in the North Pole.
But, in case it does, I am humbly preparing a list that doesn’t require a bunch of drunken elves to deliver; not to mention an antiquated sleigh that apparently is not equipped with GPS. I refer to the time you brought the kitten I wanted to the neighbors and I got stuck with the Easy Bake Oven with a stupid light bulb instead of gas to provide heat.
But now, fat man in red, I am giving you the opportunity to make up for the lame Easy Bake Oven by bringing me a new set of coding guidelines for home health. I want a coding system with random assignment of codes. I want a coding procedure that doesn’t have manifestation codes, V-Codes, E-Codes or anything else of the sort. If you ever read the list of E-Codes, you would know how depressing it gets to read all the bad things that can happen to the human body. Such knowledge does not impart the Christmas Spirit you claimed to promote before the Easy Bake Oven fiasco.
And of course, the kitten you gave the neighbors got run over in front of my driveway. Did you forget that? Would you like to make it up?
How about a Home Health Assessment that isn’t so complicated it requires letters and numbers just to get the version straight? The term OASIS conjures up visions of palm trees and beaches and relaxation. It is a sick, sick joke perpetrated on nurses and is about as funny as the kitten being run over in my drive way.
My therapist seems to think I am making progress about the events surrounding your gift of a chemistry set to my brother. The scars are fading and I am once again able to smell sulphur without remembering all my Barbies perishing in the great fire that also took out my Barbie mansion, and the GI Joe tank Ken used for transportation. I still have nightmares about little melted pumps littering the floor of the play room.
I know it would help me with my resentment towards you if only you were able to bring to CMS some common sense about medical billing. Here’s how it should work. You take care of a patient. You see how much it costs to do so. You tack a modest amount on for a profit. You submit the claim. Medicare pays.
How hard is that? It should be easier than watching a little girl spend an entire weekend burying Barbie Dolls in her back yard cemetery that spans over an acre.
And if none of that is possible, then please just bless all of those I know with love and good fortune for the New Year. We will take care of the rest.
julianne
Vendor or Provider?
December 18, 2008
One of home care’s greatest advocates, Elizabeth Hogue, Esq. has been generous enough to share her thoughts with our readers regarding the treatment of post-acute care providers as providers. Many larger institutions guard information regarding their patients like the queen’s jewels. The worst case scenario is poor coordination of care resulting in suboptimal care at home following a hospitalization. Elizabeth’s legal expertise and analysis of the differences between Vendors and Post-Acute Providers can help you understand your rights as a provider in order for you to obtain the information you need to care for patients.
Post-Acute Providers Are Not Vendors
Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-Mail: ElizabethHogue@ElizabethHogue.net
Some hospitals and skilled nursing facilities (SNF’s) refer to post-acute providers as “vendors” and require them to follow the policies and procedures related to “vendors.” These may include, for example, a requirement for representatives of post-acute providers to sign in when they arrive at hospitals and SNF’s to coordinate services in hospitals’ Purchasing Departments.
On the contrary, post-acute providers; such as home health agencies, home medical equipment (HME) companies, hospices and private duty home care agencies; are not “vendors” and should not be treated like “vendors.” They are, instead, fellow providers. Vendors are manufacturers and distributors of supplies and equipment that are utilized by hospitals and SNF’s on the premises of institutions. Post-acute providers rarely sell equipment and supplies that are used by facilities on the premises. In fact, the users of post-acute providers are patients, not hospitals and SNF’s.
When hospitals and SNF’s lump post-acute providers in with equipment and supply vendors they are, at the least, being disrespectful of these types of providers. Such treatment may be demeaning to post-acute providers.
Some hospitals are asking post-acute providers who are categorized as vendors to pay fees to hospitals in order to appear on a vendor list. Such payments are likely to constitute illegal kickbacks in exchange for referrals and cannot be required.
In addition, restrictions that hospitals and SNF’s may appropriately put on the activities of vendors while on the premises are inapplicable to post-acute providers. Vendors may, for example, be prohibited from going to other areas of institutions besides purchasing departments unless they are accompanied by staff of facilities.
No such restrictions should be applied to post-acute providers. In fact, it is inappropriate to restrict the activities of post-acute providers who:
- Have received referrals of patients; or
- Cared for patients immediately prior to their admission to institutions
Under these circumstances, post acute providers should be permitted access to patients, their families, and information about them as part of the discharge planning process.
It is important to note that referrals for post-acute services do not have to come from physicians. They may come from patients, their families, physicians, case managers/discharge planners, or other sources. Referrals may also be received by post-acute providers, either verbally or in writing. When post-acute providers are acting on verbal referrals, they should, however, document the name of the person who made the referral and the date and time at which it was received.
Of course, patients have the right to freedom of choice of providers. This right to freedom of choice of providers includes the right to self-refer to any type of post-acute provider. There are a number of sources of this right, as follows:
1) All patients have a common law right, based upon court decisions, to control the care provided to them, including who renders it. Thus, when patients, regardless of payor source or type of care, voluntarily express preferences for providers, their choices must be honored.
2) Federal statutes of the Medicare and Medicaid programs guarantee Medicare beneficiaries and Medicaid recipients the right to freedom of choice of providers. (Medicaid recipients may have waived this right if they participate in a waiver program.) Consequently, when Medicare patients and non-waiver Medicaid patients voluntarily express a preference for a home health agency, these choices must be honored.
3) The Balanced Budget Act of 1997 (BBA) requires hospitals to develop a list of home health agencies that are:
a) Medicare certified;
b) Provide services in the geographic areas where patients reside, and;
c) Ask to be on the list.
In addition, if a hospital places the name of an agency on the list in which it has discloseable financial interests, the relationship between the hospital and the agency must be disclosed on the list.
This list must be presented to all patients who may benefit from home health services, regardless of payor source, so that they can choose the home health agency that they wish to provide services to them.
4) Hospital Conditions of Participation (COP’s) that became effective on October 1, 2004, include the basic requirements of the BBA described above.
5) Court decisions, such as the opinion in Assured Home Health, Inc. v. Providence Health System, also support patients’ right to freedom of choice of providers. In this case, Assured claimed that the hospitals in the System regularly violated patients’ right to freedom of choice and “steered” patients to agencies owned by the System. This case was settled when the System agreed to institute additional safeguards to protect patients’ rights, including monitoring of the hospital’s practices by outside third parties.
A patient who received services from a post-acute provider immediately prior to admission to an institutional setting may, of course, choose to receive services from a different provider upon discharge. If a patient does not choose another provider, his or her care should be continued by the same provider with which the patient is likely to have a continuing provider-patient relationship.
Likewise, patients who are referred to post-acute providers may, of course, choose different providers any time they wish to do so.
Patients greatly value the services that post-acute providers offer. Hospitals and SNF’s, therefore, should not treat them like “vendors.”
©Copyright, 2008. Elizabeth E. Hogue, Esq. All rights reserved. No portion of this material may be used in any form without the advance written permission of the author.
Home Health ICD-9 Coding Guidance
December 17, 2008
Our friends at CMS have issued new diagnosis coding guidelines for home health. A link to the document can be found to your left under Essential Links.
Essentially, this is a 27 page document that includes numerous charts for assistance is choosing primary and secondary diagnoses. On first review, there appears to be nothing earth shattering about the guidelines but the charts and explanations might serve as ideal teaching tools.
As always, Haydel Consulting Services LLC is recommending advanced ICD-9 coding training for as many clinicians in your agency as you can afford. The CMS document, in and by itself, will not produce competence in ICD-9 coding. But, as a reference tool, it appears to be quite useful.
Questions and comments are always welcome by clicking on the Comments section below or emailing to Haydelconsulting@bellsouth.net.
What are we Assessing in OASIS-C
December 8, 2008
The premise of OASIS is simple. Clinical data is collected across the board from patients at various time points. By using the patient data, outcomes can be calculated and payment can be aligned to costs. In the past, virtually all OASIS questions following demographics have been patient specific. Now, however, in reviewing the proposed changes (see yesterday’s post), many of the questions appear to be assessing the agency instead of the patient.
Furthermore, there are questions about the ‘current’ plan of care asked throughout. Does the patient have interventions for diabetic foot care? Is pain addressed? All of these questions are vitally important for the care of the patient and sound clinical practice dictates that they are addressed. But, being as old as I am, I remember (and prefer) a time when assessment preceded care planning. Except when dire emergencies demand immediate action (ventricular fibrillation comes to mind as an example), it is almost always better to gather as much pertinent information as possible before deciding on a course of care.
Consider the diabetic foot care question. Imagine how incompetent a nurse would look if she responded that there were no interventions for diabetic foot care in a patient at risk. But me? I would have to assess the patient first and then set priorities. For instance, a newly diagnosed diabetic might have a recent stroke, out of control blood sugars, an extremely long pro time because of Coumadin therapy and a poor caregiver situation. The nurse only has 60 days to get the situation under control. Actually, being that the patient will not last 60 days in that condition, he or she has less time than that. My priority wouldn’t be diabetic foot care. I might tell the patient to wear comfy shoes and thick socks and not to hack at their toenails with clippers but I am going to focus on all that is out of control first. The second episode seems to be a really good time to work on diabetic foot care.
Pain interventions and cardiac failure interventions are also assessed. The fact that we do not yet have instructions makes it difficult to know how ‘intervention’ is defined in these questions. Is an order for lasix an intervention? Or do they mean nursing interventions that are independent of medical orders such as daily weights and teaching a low salt diet?
Because these questions seem to ‘beg’ a particular answer, I also wonder about their validity in a dataset that is designed to measure specific clinical data and compare it across time. At this early stage, my preference would be to stick to patient assessment rather than agency assessment. After all, who cares if the care plan is the best in the world if the patient still has pain, diabetic foot ulcers and heart failure? Results tell the story!
