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Posts from the ‘ADRs’ Category

Sep 5

3 Comments

A Pound of Cure

There are so many agencies out there who honestly believe that they will never come under scrutiny.  Some think they are too small and others think they are too big and most think they do things the right way.  And now they have ADRs and they are not impressed with all my impassioned pleas to do whatever it takes to avoid a denial before ADRs start showing up.  Their ounce of prevention wasn’t quite a full ounce and a pound of cure is needed.

It isn’t a coincidence that the worst charts you have were chosen. The MACs and ZPICs are big brother’s younger siblings they are watching.  But wait, before you fill out the job application for the Taco Bell position, there may be some things you can do to control damage and ethically increase your odds of getting paid.

  1. Send the required information to the address on the ADR.  The number one reason for denial is that no records were submitted.  You may have only a very small chance of getting paid if you send it in but you have no chance of getting paid if it isn’t sent in.
  2. Look closely at MD signatures.  The physician must date his signature.  Your date stamp will not suffice to ensure that care plans were in the agency prior to billing.  If you find an undated signature, complete an Attestation form and hopefully the physician will have some record of when it was signed in his office.  An attestation form is a simple form that basically says the MD will get warts on his or her thighs, suffer from weeping eczema and learn all about same sex marriages in prison if the information on the form is untrue.  What you should NEVER do is write a date next to the physician’s signature.
  3. Look at the Start of Care date.  If it is older than 4 months, you better hope that the patient fell down the stairs prior to the episode in question.  If not, call every practitioner who saw the patient during that period of time and ask for copies of all lab and clinic notes to see if you can find something there.  If the patient allows, you can call their pharmacy and see if there were any meds ordered.
  4. Look at Homebound documentation.  Review the functional and neurological status of the patient and determine if the patient’s documentation supports that the patient is homebound.  If the only functional limitation he or she has is the need for a cane and they have no cognitive deficits, it begs the question of why the patient is homebound.
  5. Write a cover letter.  Include a detailed synopsis of why you believe the patient meets criteria for payment.  Homebound may be vague so tie it together.  Use big words like, ‘the patient is dependent upon cumbersome assist devices for ambulation and suffers frequent pain, urinary incontinence and poor vision which make it difficult to navigate independently outside of the home environment without assistance at all times.  He has a recent history of falls and takes multiple medications that can cause intermittent cognitive impairment and unsteady gait.  (Or you could say the patient needs a cane, takes Lortab and a sleeping pill and fell over the housecat but where’s the fun in that?
  6. Collect all information that validates the patient’s condition.  Lab for Pernicious anemia may be four months old.  Send it anyway.  If the patient had a CT of the head and they found a suspicious mass six months ago, send it.  Send anything that supports your reports of how ill the patient is.
  7. Write addendums if required.  If your nurse is certain that a particular event occurred but it was not documented, the time to document is NOW.  You should never go back and edit notes that are on the clinical records.  However, you can write a communication stating that effective on 01/01/2012 the patient had a seizure and went to the ER.  There is nothing shady about correcting documentation as long as it is done within ethical guidelines.
  8. Number your pages.  Simple but one problem I continually have is that charts were sent in with interim orders and somehow they are not noticed by the MAC o the ZPICs.  If there are page numbers at the bottom of each page, it is easier to convince whomever is reviewing your clinical records that day.
  9. Keep an exact copy of everything you send.  You have no earthly idea how many people do not do this.
  10. Back out claims for charts that should not have been billed.   If your chart is such that it should have never been billed, send it in anyway. Back out the claim, print the screen and attach it to the ADR documentation.

If you get denied, appeal it if you honestly believe it shouldn’t have been paid.  If it is a flat loser there is still value from the lessons you can learn from the chart.

We do look at ADRs and denials with more frequency than you could imagine lately.  We will be happy to review your records and also write arguments at the appeals level for you.  I must advise you that sending us the chart before you send it to the MAC is probably the best sequence of events.

I’m trusting y’all to keep us posted on what is going on out there.  Call me at 225-253-4876 or email me at my personal email address.

Sep 3

6 Comments

Getting Paid Part 2

Do the Right Thing

This isn’t some super moralizing appeal to your conscience to stop forging signatures or lying about visits you didn’t make.  Those kinds of people do not come here for news and information.  This is more of an appeal to nurses and clinicians to follow orders.

In the past several weeks, I have read many instances of nurses charting about why they did not do the right thing.

One of the most frequent excuses for a weight that is out of range and the nurse writes in parentheses that she used a different scale.  What does that tell you?  Here’s what it tells me:

  1. She does not know what the patient should weigh
  2. She has no idea if the patient is better or worse than before
  3. She did NOT follow orders
  4. She may be costing the agency money by setting her employer up for denials

I read a note last week that state the patient’s blood sugar was 370 but the son had only just now given insulin.   There was a note that the patient ate breakfast but no MD notification.  I suspect the patient eats breakfast regularly.  The question is whether or not the son is always able to give insulin timely.  If not, maybe a different kind of insulin would be better for the patient.

I have read may notes where the blood pressure exceeded either the MD parameters or just common safe practices and the nurse charts that the patient hasn’t had their medications yet.

In other words, nurses are spending time explaining away why they did not follow the care plan when they should be notifying the MD.  Maybe the blood pressure is extremely high every morning before medication. It certainly is more convenient if the patient strokes out in the morning but that is not a reason to let a patient’s pressure pound against their arterial walls every morning.

In order to get paid you must do the right thing.  If you do not communicate with the physician and if the care plan does not change, your patient is no longer eligible for services.  Explaining why YOU didn’t follow orders is not a billable skill.

Again, here is the language that I read repeatedly when appealing denials:

The records provided do not support that the skilled nursing services were reasonable and necessary for the treatment of an illness or injury. During the last certification period, there were no exacerbations, injuries or new diagnoses that would require continued skilled services.

Any questions?

Remember, answering to us is a lot more fun than answering to Palmetto or the Zone when you get ADRs.  And if you do get ADRs after reading this, I respectfully reserve the right to say, ‘I told you so’.

Aug 30

1 Comment

Getting Paid Under Scrutiny

In between hurricanes and frightful traffic, I have been fighting for money that other people want to take away from my clients.  My first intention was to show  you the language typically used in the denials I have been seeing from the Zone and the MACs.  Then it occurred to me to show you what was written when the claims were allowed.  This might be of greater value.

Medicare guidelines for reimbursement have been met. Patient received physical therapy services due to recent fall and weakness. Skilled nursing services for medication changes and observation and assessment of disease process. Therefore, it is allowed.

Medicare guidelines for reimbursement have been met. The patient required medication changes related to her hypertension and hyperkalemia. Therefore, the episode is allowed.

Medicare guidelines for reimbursement have been met. The patient had multiple medication changes related to blood pressure fluctuations that required monitoring. The skilled nursing services are approved.

Skilled nurse visits allowed due to patient requiring skilled nursing assessment and observation. Pt had upper respiratory symptoms and was started on prednisone and phenergan expectorant cough syrup. Documentation meets Medicare criteria for reimbursement.

There were plenty other claims paid.  Some were paid because the patient went into the hospital for heart failure of renal disease.  I did not use those as an example because it is not sound clinical practice to induce an exacerbation for payment purposes.

The difference between these claims which have been allowed and those which are denied begins with the nurse in the home.  Three things must happen in order to rightfully claim that an exacerbation has occurred.

  1. The patient’s condition must change.
  2. The nurse must communicate the changes to the MD
  3. The plan of care must change as a result of the changes

The nurses whose documentation resulted in payment above did not get a blood pressure of 160/95 and write it off to the fact that the patient just walked down the driveway to get his mail and ignore it.   They don’t just assume that everyone has allergies this time of year and make a note to check on the patient again next week.  These nurses may be very friendly but they do not make visits that only social in nature.  They take the time to communicate changes, get orders and document.

More important than surveys and payment is that this careful attention to patients results in better care.

The parameters that are not mandated but are shown to be good practice when writing care plans can be an invaluable tool.  Everything else aside, if your patient exceeds parameters by only a fraction and you do not call the MD, you have not followed orders and that results in a survey deficiency.

When you communicate with the physician, have all the information required.  What has the blood pressure been over the past several weeks?  Is there anything else going on with the patient?  Were there any med changes?

Here is a visit note written in a claim that was denied.

take meds as directed

I am horrified that one of my peers actually accepted money from her employer for this level of nursing.  It does not require the skills of a licensed nurse to tell the patient to take meds exactly as prescribed.

Agencies can implement all kinds of strategies, hire the best consultants (if we’re available), set arbitrary visit rates and lengths of stay but unless the nurses visiting the patient take the time to really take care of the patient, it is all for naught.

But if you have good nurses, we can and will see you through a little regulatory scrutiny.

Be sure to drop me an email if you are getting any strange ADRs.  I am particularly interested in those with a reason code of 5Z5NP.

Jun 6

4 Comments

The Gimme’s

There is nothing in the world that I hate to see more than the ‘gimme’s’ – you know those denials that should have never happened.  It is especially painful to see them in documentation that otherwise met all Medicare criteria.  The good news is that these are preventable.

  1. MD failed to date his signature. 
    1. To reduce these denials you do have legal avenues to pursue.  For 485’s, keep a stack of attestations statements at the desk of the employee who receives and or files the orders.  When she notices that a date is missing, instruct her to copy the 485 and bring it to the DON or marketing department for rapid return to the MD.  If you do this as soon as it is received, the MD will remember signing it and will be less likely to refuse to sign.
    2. On all other forms, reverse the Signature and Date lines.  Make the date line stand out. 
    3. Pay a bounty for all undated signatures found in the clinical records.  If your home health aides came in one weekend and found 40 orders without signatures and you paid them $25.00 for each signature, it would still be less than one episode.  Who do you want your money to go to?  Loyal employees or back to CMS after you worked hard for it.
    4. Look into electronic signatures.
  2. Missing documentation
    1. In some patients, a single visit note can downgrade a chart to a LUPA.  Worse, you cannot demonstrate that you followed orders.  If an order is missing for a skill, then the visits for the skills are discounted, as well.
  3. No end in sight for daily visits.
    1. If you are below age 40, you may not be familiar with this reg but it is indeed a regulation.  Any time a patient is seen daily by the nurse for a period of 21 days or longer, there must be an end in sight to skilled care.  The only exception is diabetic patients.  Consider a patient that requires daily wound care and you provide it every day for 60 days don’t get paid for it.  You’re looking at a denial of 8k to 10k.  That’s a lot of consulting hours that you could have received from us.
  4. Face to Face Documentation
    1. Write a letter to all of your physicians explaining very clearly this condition of payment.  Furthermore, advise the MDs that you are aware of other agencies who do complete the Face to Face documentation for their signatures and in doing so, the docs may be unwittingly participating in Medicare fraud. 
    2. For physicians who have been late and uncooperative with face to face documentation, send someone to the MD’s office with a blank form at the time of the next referral and wait for it to be completed and signed before admitting the patient.  If it takes too long, start practicing the violin or, if you are an accomplished violinist, the tuba.
    3. If an MD has not returned the form and you have no other independent verification that the visit was made, prepare an HHABN for the patient and discharge them.  Explain to the patient that they absolutely can continue home health care services but they will be responsible for payment as their physician has not met the Medicare Conditions for Payment.
    4. If there is independent verification that the visit was made – written instructions, a copy of a prescription, etc., turn it over to the agency administrator.  On admit, look for these things!
    5. Do NOT become violent with the MD.  Legislation is being introduced in several states that will relax the penalties for Doctocide if lack of Face to Face documentation is used as a defense but thus far none of the new laws have been implemented. 
  5. Unlicensed Staff
    1. This happens very rarely but it is a nightmare when it does.   If you find out that a physician was not licensed in your state and your state did not allow physicians from other states to sign orders, every patient you have admitted to that doc is unbillable.  Worse, state Medical Practice acts vary.  Do not assume that because you did something in VA that it is okay to do in Montana.  Look it up.
    2. Similarly, Registered Nurses and Therapists who admit patients and have allowed their license to lapse have created documentation which determined an episode payment that is not billable. 
    3. This happens so rarely but when it does, it can cause total devastation to an agency.  Worse, it is usually not an oversight but a nurse or MD who has not disclosed that their license has been revoked.  This is easy to fix by having all of your clinical staff run and print their own licensure verification at the beginning of each quarter.  Hold their patients if they do not comply.  Get the office to verify MD’s every 3rd referral or once a month, etc.

Effective this year or maybe last, (who knows anymore with all the changes in health care), any provider who receives money from Medicare in error has sixty days to return it.  Failure to do so will elevate that erroneous claim to the status of a ‘false claim’ and the penalty is triple the amount of the original claim.

I hate the Gimme’s but if I worked for  Palmetto or one of the other MACs I would love them.  Once an undated signature is found, reviewing the rest of the chart becomes unnecessary.  On to the next.  But remember, I hate the denials resulting from a ‘Gimme’ but not as much as the agencies who end up on focused review because of the Gimmes or the owners who must have that conversation about trade school vs college with their kids.

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