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Posts from the ‘ZPIC’ Category

Work with Me, Folks!!!

deniedFor the past several months, I have been arguing with pretty much every payor source for home health there is trying to get clients paid.  After working with dozens of clients in multiple states, I am fairly confident in stating that some of you simply do not want to be paid.  If you did, you would give me and other consultants and lawyers something with which to work.  Just to be clear, I cannot work with:

  1. ‘Take meds exactly as ordered’.  (variant:  take meds at the same time each day.)   It does not require the skills of a licensed nurse to tell the patient to take meds exactly as ordered. The general rule of thumb is that if you can learn it on Oprah, it probably isn’t skilled.
  2. Duplicate medications.  Alone, duplicate medications place a patient at high risk for adverse events.  Combined with number 1, it shows anyone who cares to read that the patient should not take meds exactly as ordered.
  3. I read this in a clinical record:  I noticed the patient had enough money to buy cigarettes, but claims she can’t afford her medical supplies.  Work with me people!  You don’t get paid for your personal judgment.  The patient was at 77 percent of the poverty level. Refer to evidence based practice when you feel tempted to commit to legal documentation your personal disapproval.
  4. Prior to charting edema on a lower extremity, please ensure that the extremity is present.  I promise that if you have check boxes for right and left pedal edema and you pull all your patients who have less than two lower extremities, you will find phantom edema.  The same applies to diabetic foot teaching, pedal pulses, etc.
  5. It is not enough for a physician to document that a patient has a diagnosis.  You must also know what the diagnosis is and how to provide nursing care for the condition.  I just read an admit for a patient who was referred with Pickwickian Syndrome which was named for a very round faced portly character in the first novel written by Charles Dickens.  Because Mr. Pickwick was known largely for his girth, the condition has been renamed  ‘Obesity Hypoventilation Syndrome.  There were no orders for diets or attention to respiratory status.  I  don’t think the nurse looked up Pickwickian, do you?
  6. Diabetes Type I and II are not interchangeable.  Work with me, folks.  These older names for diabetes confused a lot of people so they have changed to simply Type I and Type II.  Type I diabetes accounts for less than 5 percent of diabetes in the elderly.  What on earth are y’all gonna do when when they recognize diabetes 1.5 as a separate diagnosis? (For now, just code as 250.00.)
  7. MD Awareness Month.  It must be MD Awareness Month because every day I read about an MD who is aware.  It goes something like this.  ‘Pt’s blood pressure is 190/100.  Patient has not taken medications.  MD aware.’  I believe that is a convoluted way of stating that you didn’t call the physician as warranted by the MD stated parameters.
  8. Someone named Pt/Cg is wandering through the homes of all home health care patients in the country.  Typically this occurs in computerized documentation that has not been edited correctly.  It makes less than no sense that you taught pt/cg in an Assisted Living Facility that Alzheimer’s is a progressive neurological disease which results in mental deterioration and eventually death.  Which caregiver did  you teach?
  9. Notifying the caregiver is a bad idea.  Imagine if you had an INR come back high and you notified the caregiver to hold the Coumadin and documented that you did so.  What if the patient had multiple caregivers and none of them held the coumadin?  What if the patient had a bleed into their brain and none of the caregivers remember the conversation and you didn’t write down a name.  Think that’s over the top?  It is.  But it happened to a client a year or so ago.  Caregivers have names for a reason.  Use them.
  10. Repetitive teaching.  The second most common reason for denial is that the documentation does not meet the standards for reasonable and necessary care.  Teaching is the most frequently provided skill in home health.  You with me?   So, in order to be paid for your services, you must teach original material or have a reason for re-teaching.  It is unreasonable to teach diabetic diet, foot care, skin care and insulin injections in a single visit.  Don’t chart that you did.  Use teaching guides.  Your patient is elderly, in pain, has poor vision, intermittent confusion, and takes drugs that impair mentation.  That might be something to keep in mind. Take your time.  Teach at the pace the patient learns and document what you did.

So, maybe I am a little frustrated this weekend but I love my job and I love home health and I take it a little personally when payor sources deny claim after claim sending the message to my clients and colleagues that what we do is not worth getting paid.

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.

Thanks AdvanceMed!

Still working a ZPIC so I am short on time to keep you up to speed.  Luckily, AdvanceMed has done most of my blogging for me tonight.  On a spreadsheet from the Zone, there is a column for the reasons for denial.  Below are some examples.  Read your charts and see if maybe one or more claims could be denied for the same reason.  If the answer is yes, it isn’t too late to do something about it.  Call us!

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The nurse continued to visit for observation and assessment when there were no acute changes in condition and no changes in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. There had been adequate time since start of care of XXXXX to have completed teaching in previous episodes. The medications:  glimeperide, quinapril, atenol, and aspirin are indicated as new on the 485; however, there is no skilled service documented related to these medications.

The documentation provided does not support that skilled nurse visits are reasonable and necessary. The SN continued to visit for observation and assessment when there was no acute change in condition, no new orders, or change in the plan of care. There has been sufficient time since the start of care of xxxx to complete the teaching that was provided in this episode. The documentation provided does not support an exacerbation of the diagnoses as indicated per the 485. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation provided does not support an exacerbation of the diagnoses.

The skilled nurse continued to visit for observation and assessment of patient’s condition when there was no acute change in condition, and no new orders or change in the treatment plan. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation does not indicate that there is likelihood of a change in patient’s condition that requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures. The records provided do not support an exacerbation of the diagnoses as noted on the 485, or a severity rating of 4 for the arthropathy diagnosis. There has been sufficient time since start of care date of xxxxx to complete teaching.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. Sufficient time has been allowed to accomplish teaching in previous episodes since the start of care date of xxxx. The nurse provided teaching related to a medication that was not new or changed. The nurse continued to provide observation and assessment when there were no new orders or change in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The skilled nurse provided teaching on hypertension, fall precautions, range of motion exercises to help joint pain and relieve pressure on bony areas, low sodium diet, taking all meds as ordered, and ways to keep BP down. There has been sufficient time since start of care of xxxx in which to have completed this teaching.

So, there you have it.  What you are looking at represents about 2M dollars in denials.



Medicare 101

We have a lot of challenges in Home Health next year.   No savior came to our rescue.  Congress has absolutely no reason whatsoever to overlook home health when cutting the budget.  They also  have every reason in the world to come after home health for fraud and abuse and they have with a vengeance.  They show no signs of stopping now and if you have been paying attention, nobody is safe.  I have clients with as few as 100 patients undergoing a ZPIC audit and we know that the larger companies are not excused from scrutiny, either.

So before you get serious about implementing new programs and creating new ways to improve care while reducing costs, spend a little to make sure that you as a nurse or you as agency are building upon a sound foundation that protects you if you find yourself under scrutiny.

Take the Medicare Quiz and when you are through, you will see your results immediately.  Let me know what you think of it.

Good Luck.


Spelling Lesson

I received a request posted as a comment on a post written a while back called, ‘Documentation, Again!’  It reads as follows:

I wish you would follow up on this blog as it is connected to the number of visits that nurses are required to do on a daily basis. The “p” word – productivity is the game, as nurses will work off the clock to try not sink in case management and oasis issues. Somewhere in the world a daily productivity of 5.3 patients came around. However with the growth of paperwork and regulations, many nurses who are fighting to be there for their families in the evenings, work on paperwork out of fear. Home Health turnover is high because of this continued lie. You can’t tell nurses that they can completely finish 2 IAs and a visit, fully coding and doing 485 and 486 within 8 hours every time. I had a director who said that to do an IA you should stay in the home about 30 to 45 minutes then finish the paperwork later. Hum, check meds and do an assessment and ask oasis questions and go over plan of care in 45 minutes. How do we turn this lie around, without going to Labor Boards, etc. I believe that sometimes doing less turns out to be more money in the bank, if you focus on getting quality and consistency first, and building from there.

I am nothing if not accommodating, so please allow me to address this writers concerns directly.

Most people think that hell is spelled, H-E-L-L.  It is not.  Hell is spelled, Z-P-I-C.  However, if you are lucky enough to avoid a ZPIC, rest assured in the knowledge that more audits are coming our way.  The description sounds a lot like FMR pre-payment audits.  Don’t forget about the new Medicaid RAC’s.  Any way you look at it, you are likely to be scrutinized in the coming year or so by one or more payor sources who want their money back.

Two admits and a regular visit can be done but not every day. I couldn’t do it.  I am not that good and have no desire to be.

As far as charting after you leave the home, that’s not really such a good idea.  I think pretty much every nurse has been in McDonald’s or Starbucks charting when they realize they did not assess something.  Maybe they started but then the office called to see if they could do another admit and they got distracted.  A forgotten TUG score or temp are not really numbers you can just guestimate.  Well, you can but documenting your guesses is really crossing the line.

The flip side of not being a slave to an arbitrary number is that productivity often drops when nurses are paid salary.  It makes perfect sense on paper to have nurses on salary and ask them to maintain average and reasonable productivity standards but it just NEVER has worked.

I was in a client’s office about two and a half years ago reviewing clinical records when the Administrator, new to home health, asked me to look at productivity.  She wasn’t sure but she thought that maybe the RN’s should be able to do more than one or two visits a day.  I went about my business because obviously this home health newbie had her numbers confused.  Before I left, I asked to look at logged visits.  My next thought was that the person doing the logging was incredibly inept at clicking the mouse.  Productivity was so absurdly low that I didn’t believe it until I started asking the nurses.

Long story short, she went to pay per visit but didn’t want to cut their pay so she paid them more per visit than I have ever seen any nurse get paid per visit.  Sounds like a nut, doesn’t she?

If you think that, you would be wrongo.  Her agency, rural, had a greater margin than almost all of my other clients.  Her nurses suit up and show up and there is virtually no turn around unless someone is asked to leave.  Case conferences are attended.  Orders are written.  Follow up is a way of life at that agency.  Documentation is so good it bores me to tears and they are my only client who received a deficiency free survey this year.  If they are chosen for any other audit, I will not lose a minute’s sleep over it.

So my first thought is whether or not the 5.3’ers are salaried or pay per visit.  If they are paid per visit, are they making enough so that they can take care of their patients during working hours and be home with their families at a reasonable hour most nights?

I wonder how much those people who push for admissions to be submitted to the office within 8 hours are really losing.  Do they know what is in the clinical records?  Do they realize that unless nurses are blatantly committing fraud, the aggregate of errors is just about always in favor of Medicare?  Those agencies who are brag about 3 and 4 days from admit to RAP are flirting with regulatory and fiancial disaster. Speed and accuracy rarely go hand in hand.  The only time a nurse should not take a minute to reflect on her decision is when a patient isn’t breathing and they are turning blue.  Even then………..  you got four minutes to consider the most likely cause.

But you asked me specific questions.  First of all, I do not know where the 5.3 number comes from.  I do remember CMS publishing something like that many, many years ago but it wouldn’t be accurate now.  The next question is how to turn the lie around without a bunch of commotion, etc.  I can help you there.

  1. Get all the information you can about the agency as a whole.  This is not about you or the administrator/DON.  It is about whether or not patient safety is protected at such a fast pace. Information that is relevant:
    1. Hospitalizations as reported on CMS along side your three biggest competitors.
    2. Average HHRG’s or payment if you can get it
    3. Other outcomes are not as useful but run them anyway.  Choose your three biggest competitors and run the reports from
    4. Number of call outs in the past 6 months from HR
    5. Do some research.  This problem wasn’t created overnight and it will not be solved overnight.  Two more weeks will not make a difference.  Once a day, look at 10 charts for one specific thing.  It will be real easy if you use point of care.  Suggestions:
      1. Home Health Aide supervisory visits
      2. Weights recorded and reported as indicated
      3. Physician notification of out of range parameters
      4. Lab drawn timely and reported.  If orders were issued as a result of the lab, are those documented and who was notified of them?  (Check your Coumadin patients.)
      5. Are diabetics taught foot care every episode and is it done per ordered?
      6. Is pain noted on the visit sheet and if so, what was done about it?
      7. I am willing to bet you ten thousand dollars that if you grab 10 485’s and look at all the medications, you will find issues.  Put them in the free Medscape interaction checker online or use iPhone/iPad app.  Look only at the most critical ones listed first.

When you bring these numbers to the administrator, present them in a way that is impersonal and spread throughout the entire body of nurses.  A lot of people want to know who did that, etc. with the goal being to fire the offender.  When it is a little bit of everyone, it is more likely a systems or process problem.   Explain why each area of compliance poses a threat to the agency.

Weights, lab and MD notification of out of range parameters are all deficiencies.  Weights are tied to Congestive Heart Failure and that is the only diagnosis that has been shown to have an influence on home health hospitalizations.  I hold Coumadin in the same esteem as I do Oxycontin bought off the street.  It is dangerous and a malpractice lawyer’s dream. If the agency is not performing in these areas they are at risk for so many things, it would require the whole internet to put together a complete list.

Payment per episode should be close to $2,200.00 if you have a modest amount of therapy.  It should be higher if a high percentage of your patients have therapy.  If it is lower, one of two things is affecting it.  The first is that the majority of your patients are old.  I guess technically they are all mostly old but I am referring to length of time on service with the agency.  The second reason may be because the nurses are underscoring in the OASIS dataset and time and education is required to do a complete and accurate assessment.

Now, if your administrator says that they are making a whole lot more than the average or if they say they will go ahead and write the supervisory visits or if they mistakenly believe that they are too large or too small to ever be of a concern to the feds, you need to take a hike.  It is Christmas.  Spend some time with your family.  Do some baking.  Start the New Year out in a new job.  Can’t afford it?  You can afford it more than you can afford to stay at an agency that cares more about arbitrary numbers than patient care.  Trust me.  I deal with this sort of stuff for a living.

Or have your administrator call me for an unbiased agency assessment by myself or a coworker.  As a consultant, I have the freedom to walk away and not have to worry about a job.

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