Skip to content

Archive for

Jul 29

Thanks for the Visual

A friend of mine who practices health care law politely pointed out to me today that nowhere in CMS regs does it state that Physical Therapy must be rendered by therapists wearing clothes. Yet, try sending a nude therapist to a patient’s home and you will find yourself in regulatory hell. Thanks for the visual, Chris. I will have nightmares tonight.

My wise friend went on to say that at this point in time, the emphasis should be on over documentation as opposed to under documentation. Whether your concern du jour is RAC audits, payment, outcomes or state survey, your clinical records will determine your fate.

And of course attorneys and consultants have the luxury of really focusing on clinical records. We are not trying to schedule three resumptions on an afternoon when two nurses called out sick. We do not have to verify visits to ensure that our staff gets paid. When troubled clients call us we ask them to schedule an appointment. An agency nurse should have her ears boxed for taking that approach with a distraught family member. So when exactly do you look at clinical records?

A quarterly review is better than nothing but you are hard pressed to go back and draw lab that was ordered and missed two months ago. But, a quarterly review will give you the information you need for educating your staff.

Daily review of visit notes as they are submitted to the office will avoid a lot of problems but not all. A note can seem perfect outside of a chart and in the context of the entire record it is lacking important information.

But you have to bill every sixty days. There are requirements that the care provided during an episode meet the standard of being reasonable and necessary and that care be rendered under the orders of a physician. This is the perfect time to read through the last episode to ensure that the documentation is complete and meets guidelines. Certain tasks can be delegated to non-clinical folks such as ensuring that orders are signed and that all visits are in the chart. In doing this, the nurse has to read only an episode worth of notes to ensure that the care plan has been followed and that documentation meets Medicare payment guidelines as well as the guidelines of any other payor source.

When cash is tight and nurses are scarce, it is tempting to omit this last step of a billing audit. Nowhere in CMS does it say that a nurse must audit the chart. But, when your turn comes to be viewed under a regulatory microscope, it would be best if you had all your clothes on or you will find yourself in regulatory hell.

NOTE:  Christopher Johnston, one of my favorite attorney’s is available at the Gachessin Law Firm in Lafayette, LA.  I hope you never need him but if you do, here is his phone number:  337-235-4576 or Chris@gachassin.com.   If nothing else, he is good for disturbing visuals you can share with your staff to drive a point home.

Jul 27

Know Your Numbers Part 3 – ICD-9 Coding

Although there is much more to legitimate and strong scores in PPS, it is impossible for a home health agency to thrive without adequate coding. In the chart below, we can see how a provider is scoring in the clinican domain over the course of six months. Remember, this chart says nothing about therapy or the functional domain. Only the questions in the clinical domain are counted.

 

The first thing you should know about the chart is that the three heavy horizontal lines represent the 10th, 50th and 90th percentile of multiple clients across the United States. This agency was scoring well above the 50th percentile range in March and April of 2008 but since then has hovered around the 10th percentile. Why? Did their patients change? Or more likely, did their staff change? These numbers beg questions and there may be reasonable answers indicating that the numbers are exactly where they should be. Only the agency can make that determination.

While it is impossible to make a truly knowledgeable determination without reviewing the clinical records of the agency, if I were a betting person, I would gamble that the ICD-9 coding is not where it needs to be.

How do you make that determination? You have to know your numbers. More importantly, you have to know how to work with your numbers.

  • Invest in coding skills in your agency. Some people take to coding more than others. It is like a puzzle to them. Take advantage of these people. Looking at the above chart, you can easily see how an agency would get a hearty return on investment by sending staff to coding classes.
  • Buy only the best coding books available. My personal favorite is the one by Decision Health. Regardless of which coding book you use, it must be introduced to the staff so that they can learn how to use it effectively.
  • If you have no coding talent in your agency, think about using a professional coder. Lisa Selman-Holman offers services for agencies that are paid by the clinical record. For a week or so, compare how a professional coding company performs next your agency’s internal efforts. It may be that your agency is doing a fine job but without specialized knowledge in coding, how do you know? Click here for more information.

     

The stark truth is that you cannot manage what you do not know. Having a working knowledge of ICD-9 coding and its effect on your agency is one more step to knowing your numbers.

 

We always welcome comments below or you can email us at haydelconsulting@bellsouth.com.

Jul 23

1 Comment

Know Your Numbers Part 2 – Case Mix Weights

Yesterday, we listed five questions that agency leadership should know in order to make informed decisions. Today, we want to discuss the first question in greater detail. What is your average Case Mix Weight?

Most software systems have the capability of running reports with this information on it. The problem is that once you get the number, what does it mean?

A case mix weight of 1.0 means that your agency gets exactly the base payment for the patient which is in the neighborhood of $2350.00 these days. Case mix weights below 1.0 means that you are receiving less per patient than the base pay and case mix weights higher than 1.0 pay a lot more. This much is simple.

The real question is whether or not your case mix weight is where it should be. An excessively high average may mean that your agency stands a better chance of scrutiny from our regulatory bodies. A low case mix weight may mean that your agency is under-billing for your patients.

In order to determine if your case mix weight is where it should be, an audit should be done on a significant number of your clinical records. This can be done electronically using a program such as Episode Master by Lewis Computer Services or PPS Plus. If electronic means are not available you can have clinicians pull clinical records and review data for accuracy. If you are using an electronic data, information should be obtained on all records. For agencies dependent on clinical record reviews, ten to twenty percent of patients should be sufficient. This can be part of your QA process.

I possible it is helpful to know the case mix weight of your competitors. If theirs is considerably higher and they are reputable agencies, ask how it is that an agency in your same community with the same patient population and referral sources and health care access can be scoring higher than you. Do your research.

Once you know your number and determine where it should be, it is time to take action. Be aware that with nurses, it may take up to 90 days to establish new patterns. In clinical record reviews look for trends and focus efforts where problems are identified. If coding is an issue, consider hiring a coding company for a brief period of time and compare their professional results with your agency’s results.

Finally, one of the greatest factors influencing case mix weight is episode timing. Agencies with a majority of patients in later episodes will score less than agencies with a fresh supply of patients. The answer is never to discharge patients that need care covered by Medicare but rather to intensify your marketing efforts to increase the percentage of ‘early’ patients in your case mix.

We will continue to explore these numbers in the coming weeks. Your comments are always welcome below and we appreciate your emails at haydelconsulting@bellsouth.net.

    

Jul 22

1 Comment

Know Your Numbers Part 1

Management of a Medicare Certified agency has never been a job that allowed for a wide margin of error. In the near future, with payment cuts looming, managing an agency without sufficient information will be a fast trip to failure.

Since the implementation of PPS, we have known that the clinical and business operations can no longer be separate in an agency. My successful clients work within a combined operations model while clients who struggle continue to try to separate these two intertwined components of a home health care agency.

Can you answer the following questions about your agency?

  • What is your average case mix weight for Medicare Patients?
  • What percentage of that case mix weight comes from ICD-9 coding?
  • Is your functional scoring representing the acuity of your patient mix?
  • What do your outcomes look like compared to your competitors?
  • How would you fair during a RAC audit?

If you know the answer to all of the above questions, my hat is off to you. If you know the answers and don’t like one or more of them, relax – you are still ahead of the game because at least you know where to focus your efforts. If you don’t know the answers to one or more of these questions, it is time to find out.

Most software systems should be able to report to you the average case mix weight for your patients. Although you will invariably ask, no one but you can determine what the correct case mix weight for your patients should be. If you have a lot of therapy and very few later episodes, I would expect it to be close to two. Lower therapy and later episodes may bring it down to around 1. The important thing is that you are not leaving legitimate money on the table which a surprising number of agencies do.

ICD-9 coding seems to get more and more complicated each passing year. How do you know that your coding is accurate? What checks and balances do you have in place? Is there a coding expert – certified or otherwise available to your staff?

Functional scoring is often overlooked in the OASIS assessment data. The full impact of the functional domain is not nearly as great as the clinical domain or but if your agency is losing an average of $50.00 per episode on functional scoring, it doesn’t take many episodes for that number to really add up to a real hit. Additionally, it is difficult to support therapy services when the functional domain is artificially low.

If you don’t know your outcomes as well as your competitors’ outcomes, you are operating blind. Your referral sources know them. The state knows them. Your patients have the ability to look at them. Agencies should be prepared to explain any poor outcomes and should be proudly displaying any good outcomes.

Finally, we are holding our breath here at Haydel Consulting Services. RAC audits have begun and CMS has a plan for expanding RAC audits. Keep in mind that Recovery Audit Contractors are paid on a contingency basis. They are financially motivated to find issues with your charts. Only a thorough pre-billing audit and sound billing policies will save you once your agency is selected for review.

In the coming weeks, we will be discussing each of these issues and how to use the information in managing your agency. If you have any questions or comments, please feel free to contact me below in the comments box or by email at haydelconsulting@bellsouth.net.

Jul 15

Billing Questions

In order to bill Medicare for home health services, all notes, orders and clinical documentation for the episode must be signed and in the medical record prior to dropping claims. Sounds simple, right? Homecare 101. And yet, our whole industry is plagued by rumors. Like old wives’ tales some of these false beliefs become so embedded within an organization that nobody has a clue that they might be doing anything inappropriate. Here are two of the billing myths I have heard lately:

  • Since agencies are paid per episode, it doesn’t matter if all visit notes are in the chart prior to billing. Only therapy notes are required to be in the chart prior to billing. And yet, here is what the OIG suggests as part of a plan to ensure that agencies comply with Medicare billing guidelines:

Provide for sufficient and timely documentation of all nursing and other home health services, including subcontracted services, prior to billing to ensure that only accurate and properly documented services are billed; Emphasize that a claim should be submitted only when appropriate documentation supports the claim and only when such documentation is maintained, appropriately organized in a legible form, and available for audit and review.

  • If an order is written after an episode ends such as when auditing clinical records, it is not necessary to wait for signatures because the order was not written during the duration of the episode. Here is how Palmetto GBA tells us to avoid denials:

When responding to an ADR, verify orders for all services billed are included with the medical records. Ensure physician orders, for all services billed, are obtained prior to providing the service and prior to billing Medicare, and are submitted for review. Ensure all oral/verbal orders are countersigned and dated by the physician before the final claim is billed to Medicare. In the event the physician fails to date his/her signature, write or date stamp the date the order was received back from the physician. The stamp date must include the word “received” and should be in black ink, as red and blue ink will not photocopy.

Even though it is not mandatory that agencies have a compliance plan, there are many good reasons to implement one. Chief among them is a promise by the Office of the Inspector General that sentencing guidelines are influenced by the presence of a compliance plan. Regardless of whether your agency chooses to implement a formal plan or not, these billing guidelines are mandates and must be followed. To do otherwise is to put your agency in serious regulatory or financial risk.

We always welcome your comments and questions below or if you choose, you may email us at haydelconsulting@bellsouth.net. As always we are available to assist agencies in implementing a corporate compliance plan. If you choose to go it alone, please refer to the OIG sample compliance plan.

« Older Entries