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Posts from the ‘Documentation’ Category

Oct 28

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Taking Care of Numbers

Medicare is talking once again about value based purchasing in home health.  This is another name for pay-for-performance which was all the rage ten or so years ago and later, fell off the radar. Basically,  Medicare wants to increase payment to providers for being good providers and reduce payment to ‘bad’ providers.  Tonight’s post is about just one of many reasons why I do not like Paying for performance or outcomes.  Read between the lines and see if you can imagine home health and hospice providers chasing numbers when value based purchasing comes around.

My mother had a heart attack several years ago.  My father, an engineer and manager by education called me that Mama was having chest pain but that when he took her blood pressure it was fine.  I told him to take her to the hospital.  He proceeded to tell me that her blood pressure on the other arm was quite different.  A significant difference in readings between the two arms is characteristic of an aortic aneurysm so I told him even more emphatically to take her to the hospital.  He insisted on giving me the actual readings which were off by four millimeters of mercury easing my mind about aneurysms and such but I had not had any coffee so I hung up and after telling him I would see him at the hospital.

At the hospital, he asked me what MI was.  Mama had just been taken in the back and there was no credible information that she suffered an MI.  After a detailed explanation, he asked why they put it on the form between first name and last name.  Still no coffee.  This was going to be a long morning.  Daddy can’t hear very well and in his anxious state, I hated to leave him in search of caffeine.

I spent many years working in a cath lab.  Even looking at the clock, the number of minutes seemed excessive although not as excessive as the number of hours it felt like waiting.  Finally, the doctor called me back and showed me the films.

Nothing.  All I saw was wide open vessels.  Mind you, I’m good at this.  I can spot a diseased vessel that most people miss.  I did not see anything.

He repeated the films several times and challenged me, ‘You still don’t see it, do you?’  Grinning like the winner of an Easter egg hunt who found the golden egg, he showed me the culprit.  The tiniest branch of a branch of a branch at the apex of her heart originating at the right coronary artery was occluded.  He explained he couldn’t find it either which accounted for the delay.  He had to review the films and reshoot a couple of times to be certain.  Even with coffee and even if I had seen it, I might have written it off to a flaw in the images.

I was relieved.  Mama felt stupid as though she should have known that it was insignificant and Daddy continued to wax eloquently about the variable blood pressure readings.  All was well except my son was very angry that we forgot to tell him that his favorite person in the world had a heart attack.

A couple of days later, Daddy called to say Mama was tired and cranky and not able to do her stuff at church.  I went to see what was up and found that she had been placed on a beta blocker, aspirin and a statin drug because it was hospital protocol for anyone with a diagnosis of MI.  Mama is petite on good days and just short on other days and 25 mg of Lopressor was taking it’s toll on her.  She was fine after she stopped it.

She did not need any of the three.  Her drug of choice for pain is old fashioned Bufferin.   I have almost had to admit her to detox for it any number of times.  Her cholesterol is within normal limits and her coronary vasculature was award winning.  She exercises regularly and eats so well, I imagine there is an ICD-9 code for her self-imposed dietary restrictions.

Meanwhile, the hospital’s outcomes are keeping up with the Jones’s.  In the wisdom of evidence based practice my mother was prescribed three meds that would do her no good.  Granted, they were cheap and if I had to choose, I would prefer a global policy of prescribing them for everyone rather than miss a few who needed the medications.

I don’t have to choose as it turns out.  Medicare has already determined what pretty much every heart attack patient in the country needs.  With all of the critical thinking required to open a refrigerator door, our physicians order medications for all patients according to pre-printed recipe. The hospitals and the physicians with privileges at the hospitals are chasing numbers instead of taking care of individual patients.

What bothers me the most about treating the numbers is that although minor, there are side-effects to the medications prescribed to my mother as she was discharged from the hospital.  There was a potential for dizziness and orthostatic hypotension resulting in a fall from the beta blocker.  There are side effects of statins including memory loss.  An aspirin a day shouldn’t hurt anyone but nobody stopped to ask Mama what she ordinarily took for pain and too much aspirin can cause problems as well.  The chances of side effects for Mama outweighed the benefits of treatment.

Treating the hospital’s outcomes should never be mistaken for quality care of individuals.  This is something we need to remember when our reported data is being evaluated for purposes of payment.

Oct 6

9 Comments

My New Hero

 

Like most superheroes, it is best to worship him from afar.  In fact, I don’t know his name and do not want to because I like a world full of possibilities.  My new hero is a physician in Florida and because he remains anonymous, every doctor in Florida could be him.  Florida is even sunnier and warmer with all those potential superheroes in white coats.

There are some heroic physicians who save lives or invent new procedures.  For the longest time, I was leery of the Whipple procedure because I was unaware that it was named after Allen Whipple.  I thought the term ‘Whipple’ referred to a technique and I didn’t want to know anything more.

Other heroic physicians travel to countries far and wide taking care of patients that have no one else.  These docs and other healthcare providers also have my undying admiration.

My new hero is a different breed, though.  I know of him by a client’s report that he documented homebound status on a Face-to-Face encounter with the following:

He is.  This is a stupid question.

Many of you may think that compared to Christian Barnard or Allen Whipple, this isn’t really such a big deal.  You could be right but I don’t think so.

In order for Drs Whipple and Barnard and the like to be of value to society and their chosen field of medicine, three things must happen.   The first is that the patient must live long enough to have the procedure done.  The surgery must be performed on a candidate well enough to undergo the procedure.   The patient must receive nothing short of excellent care after hospitalization.   Sadly this involves money.   (Average operating room time alone, without physician charges costs $147.00 per minute.)

Meanwhile, home health agencies are being denied daily because the physician does not document how the patients condition confines them to the home.  Claims are denied even when patients are recently discharged from the hospital with a serious illness or surgery to replace something like a hip or heart or whatever.

When home health care agencies don’t get paid, they are faced with choices that eventually result in providing care that is substandard or closing their doors altogether.  That means a poor outcome for the replacement parts.

We have all tried, in our own way, to gently hint to Medicare that the F2F encounter document is stupid.  NACH has even filed a law suit full of big words spanning numerous pages.  Medicare responded that they may relax the requirement in the distant future but no further word has been forthcoming.  I suspect they just wanted to minimize the importance of NAHC’s lawsuit.  I could be wrong, though.  Never let it be said that I am always right.

My hero, the unknown physician, has described in five words, why Medicare is getting so little compliance on the F2F matter.  Please note that the physician wrote two complete sentences with both verbs and nouns and I hope he gets partial credit for writing a grammatically correct narrative that doesn’t simply restate what is written in the manuals about homebound status.

Like most docs our superhero probably saves a few lives here and there and makes other people feel much better about being alive when he isn’t answering stupid questions on a stupid form verifying that he saw a patient he just discharged from the hospital.

Luckily for my diligent client, the claim had not been dropped for the patient yet.   I hope they make a photo copy of the original document before they go waste another hour of their time and the doctor’s time by once again explaining what an expensive comment that was and asking for a do-over.  If this chart is ever summoned by the payor sources, I  think I would include the original and the Do-Over.  You know, just a subtle little message – because I am all about being subtle.

Will everyone please bow their heads and give my hero  a moment of silence in honor of his insight into our daily struggles.  It is the least we can do for a physician who has contributed so much to so many.  Hopefully there are more waiting to come out of hiding.

Jul 21

8 Comments

Physical Therapy Goals

The following is from a denial a client sent last week.  The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document.  That denial was overturned in favor of my client but the claim was denied again for a new reason.  You have to see this in order to believe it:

Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.

So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals. 

Did you happen to notice that the entire course of therapy was three weeks? 

Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted?  That really gets under my skin.

In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document.  They agency lost a full round of appeals before the reviewers found something else wrong with the chart.  Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met.  I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal.  In actuality, there were five of these I worked last week.

You have two choices.  First, you can write a short term goal or you can write a very long term goal.   The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged.   I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed.  Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?

An alternative solution would be to write a goal or two for the first visit or first week of therapy.  Some examples that come to mind from who knows where because I am not a therapist are:

  • The patient will agree to participate in their course of therapy by the end of the first visit.  (Chances are this is pretty accurate if the patient allows you in for a second visit).
  • The patient will have all prescriptions for pain filled prior to next visit.  (I do not like the way it sounds when therapists work with un-medicated patients.)
  • The patient will have DME delivered by end of day 4 of episode.  (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.

I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh.  I assure you that is not the case.  All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation.  Be bold about it.  Include page numbers.

I would be interested to hear what is happening in your offices.  Has anyone else seen denials like these?  If so, what contractor?  (Palmetto, NGS, CGS, etc.)  Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below. 

Jul 2

9 Comments

Face-to-Face Changes?

Many thanks to Tom Calhoun of Bayou Home Care for forwarding me the CMS update regarding proposed Medicare changes to the PPS system while I was out and about yesterday afternoon.   (Be sure to click on the link and watch the video on Bayou Home Care’s page.  You will understand why I am proud to be known a swamp rat).

Like everyone, I was excited to see CMS start to back off on the unclear, ambiguous and cumbersome requirements of the Face-to-Face requirement.  The proposed changes are as follows:

  • Eliminate the narrative requirement but the certifying physician would still have to document that a Face-to-Face visit occurred and include the date of the visit.  Since nobody can agree on the definition of a ‘narrative’, this is probably a good thing.
  • Medicare proposes the consideration of records from the certifying physician or discharge facility ONLY when determining eligibility.
  • Physicians billing for certification/recertification for home health services will be denied if a patient is found to be ineligible.

The requirement that only the physician or discharge facility will mean that we can no longer turn to specialists records or pharmacy and other providers of care to support arguments of eligibility or homebound status.  I’m not too worried but be very aware of this in the future should these changes come into law.

If you are interested in what your physicians bill for home health certification, check out   Propublica’s  Treatment Tracker and find your docs.   Most do not bill often enough for certification/recertification visits to suffer appreciably from this requirement but some do.

All of this sounds really good, huh? It is – if you are an agency who has never been denied for providing good care to an eligible patient due to a poorly constructed Face-to-Face document.

Word of Caution

I tend to be overly sentimental and my first response to this update was an outpouring of warm feelings towards Medicare.  Luckily, I forgot to post this last night and have had time to reconsider my emotional response.

The proposed regulations by Medicare, should they go into effect, will not address any denials that occurred prior to the changes.  Recently, Palmetto sent a memo to y’all reminding you that no matter when a patient was admitted, the Face-to-Face documentation must be included with an ADR.

In other words, these changes offer no avenue of relief for denials that have occurred in the past.  It also allows for limited denials related to the Face-to-Face document in the future if the start of care date occurred prior to the proposed changes.

The lawsuit filed by Bill Dombi, for NACH – your association – takes the position that the regulations written to satisfy the Face-to-Face requirement were never legal.  If NAHC prevails in the lawsuit, then agencies may have recourse for prior denials if all other criteria were met.

I emailed Bill Dombi to determine if I was understanding this correctly and his response was that I appeared to be correct.  That’s about all you will ever get from a lawyer without depositions, cataloged evidence, sworn statements and DNA – the appearance of being correct.   In this case appearance does count.

So, welcome the changes.  Rest comfortably knowing that there  is a little gang in congress who are willing to relax the requirements implemented by the Grammar Police.  This is a start – not the finish to the remediation of an unwarranted attack on home care for grammatical errors.

Under no circumstances, should you become complacent.  The denials that occurred in the past were unfair and new rules taking effect at a future date will not change that. Similarly, don’t overlook the significance of the proposed regulations as it is appears that someone in Washington is listening.

Again, Thanks to Tom and to Mr. Dombi for taking time out of their days to keep me informed.

Jun 11

3 Comments

NAHC v US DHS

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

I have never been a big fan of associations and organizations.  I am not a joiner in general.  Specifically, I have been very frank about my feelings towards the National Association of Home Care and Hospice.  I believe that in the past they took on causes that benefited some agencies at the expense of others.  In many ways, it is almost impossible to be an organization representative of all agencies of all sizes in all parts of the country.

As of June 5, that changed.  William A. Dombi, attorney for the plaintiff – your association – has filed suit against the US Department of Health and Human Services.  NACH is challenging the requirements regarding documentation of the Face-to-Face encounter.  They allege that Medicare is enforcing the Face to Face encounter requirements in ways that were never intended and are not legal.  They note that these retroactive denials are made outside of the consideration of the care needed by the patient or the quality of the care rendered to the patient.

This is good stuff, y’all.

Because I was so outspoken and passionately against the position NAHC took in the past regarding other issues, I owe it to the Association (and to myself) to be as outspoken and passionate in my support of this lawsuit.

If NAHC asks anything of its members, please cooperate to the best of your ability.  If nothing else, send the board at NAHC responsible for approving the filing of the claim a note of gratitude.  This is one position that NAHC has taken that benefits all agencies, patients, and the Medicare trusts.

I can respect that.

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