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Posts from the ‘ZPIC’ Category

Follow Up on Documentation Quiz

The documentation quiz was so much fun.  We must do it again soon!  I loved your responses.  I must admit, the bonus question about what would happen to the agency if ever they were ZPIC’d lacked originality most times.  The words ‘denial’ and ‘jail’ came up a lot.  Someone wrote that Medicare would be confused if they saw the documentation.  Another writer wanted to know how long the patient had been extinct if they were seeing a paleontologist.  Let me stop here and tell you that although I have looked and cannot find it written anywhere, it is my strongly held belief that Medicare does not pay claims on dead people.

My favorite was from a nurse who emailed me and wrote, “So, I spend a lot of time trying to teach nurses how to document.  I really don’t enjoy as much success as I would like but it isn’t for lack of trying.  If this sounds familiar, I plagiarized it.”  I love it when someone really understands my frustrations!

The one that almost made me score a 1 on M1610 was this one:

This am your bestest post I have ever seed. I am going to notify the paleontologist of the potential for increased humor if the examples are ingested topically first thing in the morning.

Now I have to go see my doctor for severe laughoutloud developed this morning!


PS…You just can’t make this stuff up…have you thought about a book?

I would like to write a book someday but I love the blog and it will do for now.  Writing is solitary.  Blogging is like spending time with a bunch of nurses a couple of times a week.  I learn more from y’all than you will ever learn from me and I miss spending a lot of time with nurses the way I did at the hospital or the large organization down the street from me.  When I visit agencies, I am always mindful that I am on someone else’s clock so I try to stay focused on my task at hand.  Boring…….

I wanted to follow that post with examples of good documentation but I can’t.  Good documentation includes too much information that should not be published on the internet.  Plus, it occurs over the course of an episode and includes things like lab follow up, med changes in the computer, etc.  No single note is good.  If you don’t believe me, I will send you four perfect notes with the identical language in them for four consecutive weeks.

I had one response that read as follows:

I review charts daily for my organization.
I do believe the documentation you show above could be used for educational purposes, or as a reason for dismissal.
I do not, however, understand the sarcasm. These snippets were written by, supposedly, professional people.
I am embarrassed for them. How can they call themselves nurses? Their documentation portrays them as ignorant, and puts them at risk for lawsuits. Who would be crazy enough to defend them?
I am not sure remediation would prove beneficial to either the agency they work for or the patients they service.
Feeling pretty good about the charts I review now.

I do understand this response.  The sarcasm is a product of my sense of humor; nothing more and nothing less.  As far as who would be crazy enough to defend them, I can give you some names but you would have to remember that while an agency is rather pathetic in its performance it does not mean that everyone associated with the agency is ignorant and pathetic.

I personally have charted that Dr. Kevin DiBenedetto was at the bedside attempting to urinate.  X3.  Unsuccessful.  (The doctor did eventually intubate the patient successfully and a few hours later I was finally able to go to the bathroom.)  According to my documentation, I also gave a complete blood bath that surprisingly, the patient tolerated well.  Another time, Super Nurse here got a patient and walked with him outside the day AFTER he died.

The difference between my erroneous documentation and the stuff I posted is that somebody found these mistakes almost as soon as they were made.  My back was covered.  If I had been asked a year later about a home visit where I walked with a patient outside the day after he died, I wouldn’t have been able to legitimately and ethically correct the date.  If Medicare had discovered it, it might have been viewed as fraud.  I would hate to be questioned in a deposition about how it came to be that my patient tolerated a blood bath well.  (“I told you I was good.  Now do you believe me?”).

These charts I took screen clippings of were spread over the course of a year.  How does that happen?  How can such outrageous documentation be present in the clinical records and everyone is clueless?  I assure you that it is NOT a nursing problem.

The first thing that the respondent above wrote was, “I review charts daily for my organization”.  It is an expense to the organization that employs this nurse that is not directly revenue producing.  It is very difficult to quantify the amount of value she brings to the organization in a spreadsheet.  There is no formula that says if she does ten clinical record reviews, the agency will be ahead X number of dollars. In fact, this nurse may do a lot of work that actually identifies errors that result in lower payment to the agency.  So, it stands to reason that the organization cares about the integrity of its documentation, ethics and is sophisticated enough to recognize the value of risk reduction.  I hope they call me if they get a ZPIC letter.  I like winning.

The organization which employs the nurse is also concerned about the quality of care.   He or she did not leave a name so I don’t know what pronouns are appropriate but the organization employing this nurse has created a culture based upon the quality of care of the patients.  Even the best, most caring non-clinical person cannot set policy about patient care.  You don’t see nurses trying to handle billing and accounts payable and you shouldn’t see CFO’s making clinical decisions.

This nurse also wrote that she wasn’t sure that remediation would be beneficial to the nurses or the patients.  Medicare agreed with her.  They didn’t do anything drastic like take back the provider number.  They did something much more effective.  They stopped payment completely and now the agency is gone.

ZPIC 1 – Agency 0

Oh, by the way, if I didn’t have a sick and twisted sense of humor, I would not be able to do my job.  I would rather work at Taco Bell if I took this stuff too seriously.   But I apologize if I offended you.

Short and Sweet Documentation Quiz

So, I spend a lot of time trying to teach nurses how to document.  I really don’t enjoy as much success as I would like but it isn’t for lack of trying.

After reading charts from agencies chosen for ZPIC audits, I decided it would be easier to teach you how NOT to document.  Please understand that if you document like the examples in our little documentation quiz that I cannot help you.  The best lawyer in the world probably cant even help you except to maybe reduce your prison term.

Take the quiz.  I can’t wait to see your answers.

What’s Your Average?

I have had a lot of questions this past week about lengths of stay for home health and what they should be.  One large company in our area has begun mass discharging at several locations throughout the state causing my clients to worry that maybe the big company knows something that my smaller clients do not.  Another client has a very short length of stay and wants to know if they should extend it.

If you want to know the facts as I understand them, the Zone contractors are looking at agencies with excessively long lengths of stay.  The clients that I have had this year average around five episodes per admission.  What’s more is that the Zone contractors look at total length of time on service regardless of the number of admissions.  Many of the clinical records we review have multiple admissions and discharges.  So, if you think by reducing you average length of stay by discharging and readmitting will fool anyone, you may be right but it won’t be the Zone you fool.

There are various published numbers about the average home health length of stay per state.  The Southern states where both income and education are lower than the national average tend to have average lengths of stays of around 2.4 episodes per admission.  Some of the Northeastern states where money and education are not in short supply have a much lower length of stay.

But, I really don’t care about what your average is.  People hear that their length of stay is average or below and they breathe a sigh of relief and go on about their business.  I had an agency where most patients were on service for about a year.  However, a cardiovascular surgery group referred several patients a week to the agency who were only seen for three visits.  Their average length of stay was quite acceptable.  The reality is that most of their census consisted of patients who did not meet eligibility criteria.

To be sure, every agency has a patient that continues to come up with new ways to challenge the nursing staff.  They are admitted with DM but right before discharge they fall and break their hip.  After therapy gets them back on their feet, they have a small MI.  Later it is a stroke, etc.  As nurses, we cannot and should not look at an arbitrary number and discharge a patient because they have been on service for two years.  And even one episode is too long for a patient who is not homebound.

As most of you know, I am an information junkie.  I love the numbers and they tell me a lot about clients.  But when it comes to taking care of patients our concern shouldn’t be length of stay.  There should be no mass discharges to lower averages.  The only questions that matter are:

  1. Is the patient under the care of a licensed physician operating within his scope of practice?
  2. Are the services required by the patient reasonable and necessary as defined in Chapter 7 of the Medicare Benefits manual?
  3. Is the assessment and the care plan of the patient accurate and sufficient to guide care?
  4. Can you provide the services?
  5. Can you document the services?

Oddly enough, it is question number five that most agencies get stumped on but I digress.

If you can satisfactorily answer all five of these questions upon admission and recertification, the patient should remain on service.  Regardless of the length of stay, any patient discharged requiring home health care that is covered by the Medicare Home Health benefit is being shorted the benefits that they rightfully deserve.

Numbers give us a place to start looking.  It would be rare indeed for an agency that only keeps eligible patients on service to have a length of stay of five episodes per admission.  Upon investigation of a new client, I will certainly keep numbers in mind as I review clinical records.  However, my recommendations to the agency are made based upon the patient’s needs and conditions.

Does following these guidelines mean that the Zone folks won’t come looking for you?  Probably assuming the same guidelines were in effect for the past three years.  In addition to Zone contractors, remember we have RAC’s, state surveys, accrediting organizations and numerous other regulatory bodies who are more than welcome to visit an agency at any time and look at your records.  Be ready.  All it takes is one disgruntled employee to file a complaint or a surveyor who didn’t get enough sleep the night before to make trouble for you.  You have no control over that.  What you can control is your ability to respond successfully to any sort of scrutiny.

Questions?   Post below or email me.

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.

Amuse Me!

As often as I can, I try to for write you, my faithful and beloved readers, a blog  post that pertains to our industry.  I try with varied success to make it entertaining or at least interesting.  If it is neither, then maybe it is written because it is something that you really need to know.  Now, you may not like my sense of humor or you may be completely bored by my posts in which case I suggest that you make use of your browser’s back or delete button.  But I at least try.

Field nurses, on the other hand, do not seem to care that I am bored to tears reading their documentation.    Look at the following example:

Actual Document

I can't make this stuff up.

There is nothing interesting about this documentation.  All of this with the exception of the teaching to take frequent rest periods and to take Lasix as ordered was on the flow sheet of the nurse.  I don’t care that the patient has bowel sounds in 4 quadrants.  I am so NOT interested in even and unlabored respirations.  Whoa, check out that amazing blood pressure!  Yippee.  The patient has the same pulses that are noted on the front of the visit note.

On the other hand, I know things that you don’t about this patient.  I know that she is also on potassium and I would have been interested in seeing that the patient was taught about the reasons why she needed to take her potassium as ordered along with the diuretic therapy.  Do you think if a patient keeled over due to low potassium that ‘taught to take Lasix as ordered’ will cover you in court?

Would that have been better than teaching a 94 year old patient with heart failure to avoid prolonged standing?  I am somewhat younger and no one has to teach me that!

What does, ‘take Lasix as ordered’ mean?  Again, I know things you don’t know.  I know that the patient has exceptionally poor vision, is at extremely high risk for falls and relies upon a walker to navigate in her home.  (You probably guessed that.)  Maybe it would have been better to teach the patient that when she took Lasix, it would be a good idea to be near ‘the loo’ as we called it in Australia.  Or if she had a bedside commode to make sure it was near to her after taking her Lasix to prevent falls.

Frankly, any good pharmacist will tell a patient how medications are to be taken.  It is the sole advantage of the home health care nurse to assess the patient’s ability to comply in the home environment.

Chances are if you cannot get me interested in anything you write, it is highly likely that you won’t be paid in a financial audit.  And that is the truth.  I am very interested in payment considerations.  So, tell me a story.  Prevent a fall and subsequent broken hip in an elderly patient.  Teach the patient something they can’t learn by reading Prevention Magazine or watching Television.  Remember that there are people out there paid to read nursing notes who have a burning desire to deny payment to your agency and I assure you that they have no sense of humor.

If none of that concerns you, think of me.  Yes, it is all about me.  Amuse me.


That’s all I have to say?  What say you?

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