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Posts from the ‘Home health diagnosis coding’ Category

Basic OASIS Competency


Do you dare? Here is a basic OASIS competency test.  It could be that you know more than you think you do or it could be that you might want to spend some quality time with chapter 3.  You never know until you try.  Click the OASIS icon below to take the test.

More on Medicare Fraud and Abuse


Apparently, HHS Secretary Kathleen Sebelius ad Eric Holder, the US Attorney General had a ‘summit’ regarding Medicare Fraud and Abuse.  You can read the whole report here.

At the summit, Secretary Sebelius announced that starting July 1, HHS will begin using innovative predictive modeling technology to identify fraudulent Medicare claims on a nationwide basis, and stop claims before they are paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made.

I think this is a good idea.  There are patterns of abuse that repeat themselves in almost every fraudulent agency and it is easy to write programs that identify them.   In one of my ZPIC audits that I am working, there is a clear and distinct pattern of low utilization combined with very long lengths of stay.  This is not to say that all patients had old start of care dates.  Many of the patients have been admitted and discharged several times over. The numbers you review regarding length of stay based on individual admissions may be lower than what the feds calculate based on the entire claims history of the patient.

Another pattern that shows up repeatedly is high therapy use.  I have two excellent clients that have inordinately high therapy use but I don’t worry about them.  Many of the patients are total knee replacements or other ortho surgery and after six to nine visits, the patients are discharged.  But if all of your therapy patients are being seen for ‘gait instability’ related to chronic illnesses and all of them receive 14 or more therapy visits, expect to find yourself on the ‘naughty list’.

Overuse of any one diagnosis code alerts the feds to potential fraud.  Not everyone with impaired vision has a diagnosis that can be supported with physician documentation.  And most who do will have other claims in the Medicare system that supports the diagnosis such as ophthalmologist claims and pharmacy claims for eye medications.  The feds access to information is unmatched.  If they use it properly, no one who is even an inch over the line will be spared.

What I find particularly sad is that when I look at agencies’ clinical records, I see some practices that are common, ineffective and are certain to place the agency on a watch list somewhere.  For instance, a nurse will have been taught, and in very good faith believes that if a patient has diabetes, it should always be primary because it pays more.  And then she goes to work for one of my clients and it may take a while before the diagnosis problem is discovered.  And yet, these same agencies are continually leaving money on the table by not assessing a patient accurately.  They routinely increase payment inappropriately by a few dollars while ignoring the hundreds of dollars per day they leave on the table.

Before I take on any client, I look at the CMS reported outcomes.  In particular, I look at the hospitalization rate calculated by CMS. There may be various reasons why different agencies send their patients to the hospital but when it comes to extraordinarily high hospitalization rates (over fifty percent), there is only one reason.  The agency does not discharge patients to the community.  In other words, most of the patients who are discharged from the agency are discharged because they are in the hospital over the end of the episode and the discharge is because the agency has not been able to follow OASIS requirements resulting in a discharge and readmit.  If you think the Feds don’t know this, consider that I know it and I have a fraction of one percent of the data the feds have available to them.

So, look at your numbers.  Look for patterns.  If you are concerned that the new data mining implemented in July may pick up on some unusual patterns in your agency call me.  I can be reached at 225.253.4876 or you can always email me.  I will find your patterns, deconstruct them and help you reconstruct your care so that you make as much money as you ethically can without creating patterns that even remotely resemble anything less than one hundred percent compliant with Medicare payment guidelines.

May I Have Your Attention, Please?


I’ll be brief here. I am very, very busy and really don’t have time to blog today but I have a message and an insatiable desire to share it.

Ladies and Gentlemen:  Please give your patients’ medications the attention required to ensure a safe and therapeutic outcome!

In reviewing clinical records for multiple clients, these are just a few of the things that I have seen with alarming frequency in the recent past:

  • An abundance of Tylenol ordered to the extent that patients took all that was ordered, they would likely die of liver failure.  But most don’t die of liver failure, so that begs the question of whether or not we are really checking medications as well as we should.
  • Far too many narcotics and sedatives in the elderly population.  If you stop and consider that falls are the number one cause of accidental death in persons greater than 65 yrs of age and that narcotics and other sedatives can only increase their risk of falls, all the little pieces start to add  up to a lot of dead  Medicare beneficiaries.  If that doesn’t disturb you (and the fact that it might not, disturbs me), then remember, you cannot bill on patients after the date of death.
  • Grossly inappropriate doses on the plans of care.  What’s wrong with these orders?
    • Scopolamine 10 mg i PO three times a day for dizziness.
    • Lortab 10/650 one or two tabs every 4 hrs prn pain
  • Duplicative drug therapy.  Seriously, how many inhalers does one patient need especially if they all contain albuterol?  Does Prilosec work better with Nexium enhanced by Zantac?  Did I miss an FDA alert?
  • Finally, how is it that a patient can go for an entire episode with no new orders for medications and yet the next 485 med list is radically different from the prior one?  Does the patient routinely go to the doctor the day before the recert visit and get his meds changed?  Surely, we aren’t missing any changes along the way.  That would be so unlike a good home health care or hospice nurse.

Sorry for the sarcasm.   I am barely keeping my head above water with all these clinical record reviews.  One thing for certain is that as more and more agencies go to computerized point of care charting, bad information is going to be even more readily available to caregivers.  And that scares me.

So, do me a favor.  Write a comment about a medication error or potential error that you caught before harm was done to the patient.  Tell the rest of us how you caught it and how you fixed it so we can learn, too.

I Thought Turkeys Could Fly


You know, it is entirely possible to be in this job going 30 years and still realize that you missed something really important. This happened to me this weekend when I was trying to catch up on CEU’s and found a great free online course about Coumadin.

If you are as old as I am, you probably remember the Classic WKRP in Cincinnati episode where Mr. Carlton says, “As God as my witness, I thought turkeys could fly”. Click here to view it if you missed this 1978 Thanksgiving Classic.

I had my own Mr. Carlton moment this weekend when I read about Coumadin drug interactions. Obviously, it is going to react with other drugs that thin blood like NSAIDs and Aspirin but Bactrim?

I had no earthly idea that Bactrim could affect PT/INR levels. It is a miracle that I don’t have a license to prescribe because I would have never thought twice about prescribing Bactrim or another sulfa drug to a Coumadin patient who had a UTI.

And while I feel a bit foolish, as I review clinical records, it appears that I am not the only one who didn’t know this. If you don’t have time to take the CEU course referenced above, please be aware that it is recommended that Coumadin dosage be reduced by 50 percent while a patient is taking Bactrim and for the following week. And if at all possible, try to persuade the MD to use another antibiotic (but not a mycin) if there is an effective alternative.

On the lighter side of things, I did know that turkeys couldn’t fly.

If you have any questions, I suggest that you take the CEU course. Apparently, I may not be the best person to answer Coumadin questions. But feel free to leave comments below.

Case Conferencing


When it comes to good patient care there is no substitute for case conferencing. In my years of experience, I have seen agencies who chose not to conduct a structured case conference, agencies who held a meeting where patients were discussed just long enough to meet minimum standards and I have seen agencies that make the absolute most out of a weekly or bi-monthly case conference. Guess which agencies do better overall?

With OASIS-C now a reality, there are even more reasons to conduct a thorough case conference that includes process measures. In doing so, discharge reviews will be much easier to perform.

These are some of the processes I’ve seen at various agencies over the years that make case conferencing more effective. Pick and choose those ones that you like and send us any other ideas we might not have heard.

  1. Prepare a list of patients up for recert in advance so that charts can be reviewed by the RN who will do the recertification visit.
  2. Invite all disciplines involved in care. I have seen some agencies where aides are not included. This is a critical mistake.
  3. Ensure that all the questions you want answered in case conference are addressed. You may want to make a short form or post the questions in the agency. That way the nurse who is reviewing the clinical record prior to case conference is aware of the information that she will be asked. Consider the following questions:
    1. Has the patient seen the doctor this episode and if so, why?
    2. Was any lab drawn? What are the abnormal results?
    3. Were there any medication changes?
    4. Was the patient taught on all medications?
    5. Did the patient go to the hospital at all? Why?
    6. Does the patient have heart failure? If so, what are the weight ranges?
    7. Does the patient have diabetes? What are the blood sugar ranges?
    8. Did any falls, injuries or other adverse events occur during the episode?
    9. Did the patient have a wound? Describe at beginning and end of episode. State wound care and any changes that occurred in the last episode.
    10. How was the patient’s pain managed? Were any interventions implemented with or without success?
  4. If a staff member is not able to attend, try to include them on the telephone.
  5. Get signatures of all attendees.

Or you could just pull the staff in from the field, feed them donuts and do the bare minimum to demonstrate compliance to the care coordination condition of participation. Either way, it costs whenever you bring field staff in for mandatory meetings. Why not get the most for your dollar?

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