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Posts from the ‘ZPIC’ Category

Jul 1

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Documentation – Again!

So, I am sitting at my desk reviewing clinical records for any number of reasons for any number of clients.  The ZPIC charts are the ones that tell the story.  It isn’t that they are any worse than any of the others.  Rather, they are the only ones that are reviewed in their entirety through multiple admissions and discharges for a period of two to three years.  That’s a lot of visit notes.

So, today, I am reading a chart of a 95 year old patient and when I start on episode three I noticed that she had fallen.  I jumped up from my chair and yelled with excitement.  Finally, something happened to the patient that warranted continued services.

Yes, folks.  That’s how low I’ve fallen in these dark days of clinical record review.  I am now celebrating when a 95 year old woman falls to the floor.  I find this mildly discomforting.

Now, just like all the other charts and all my other clients, when I call the nurse, I hear all sorts of things.  The patient had lost her medications for a few days or there was an unstable caregiver situation and numerous other things that warrant care from a home health agency.  But they are not in the chart.

And before I go to these agencies fully armed and ready for action, I have to have one of those talks with myself.  The vast majority of my clinical background is in the CCU’s.  I am proud to say that patient care always came first with me but I seriously doubt that my documentation would have withstood the kind of scrutiny that our small sector of the industry is subject to now.  I am once again reminded how there is often very little correlation between quality of care and quality of documentation.  Some of us just have better things to do.

And in the interest of fair disclosure, let me say that I really don’t know a whole lot of nurses who have lost their license, been sued and have their lives ruined because of poor documentation.  There is a really good chance that your documentation will never result in such a drastic outcome.

But I do know some nurses and agency owners and others who are in jail.  I know some nurses who are struggling to feed their families because they lost their license and we really aren’t qualified to do much else.   I know of a nurse who charted pedal pulses on a bilateral amputee.  She wasn’t trying to commit fraud.  She simply charted the same thing she always did out of habit one night when she was tired.  It didn’t help that her lawyer said to the state board of nursing, “So, you are telling me there is no place else in the body that you can have pedal pulses?”

So, the choice is yours.  You can play the odds and hope they stay in your favor or you can document correctly.  If you think about it, the odds are also in your favor should you choose to play Russian roulette.  You don’t play the odds with your life and you shouldn’t play the odds with your career.

Now I will get back to work and hope that the 95 year old falls again or better, gets an infection with a whole lot of medication changes.

May 14

Tell Me a Story

When working with ZPIC clients, it is important to remember that Zone Contractors have been told to address eligibility more so than quality of care. Quality of care issues are to be sent to local licensing agencies and QIO’s if found in excess in a chart. Keeping this in mind, there are only a limited number of factors that make a patient eligible for home health:

  • They must be under the care of a physician
  • They must be confined to the home
  • OASIS data must be accurate and timely
  • Care must be reasonable and necessary
  • Must need skilled nursing care on an intermittent basis for reasons other than obtaining blood
  • Must be a Medicare beneficiary

Mostly the eligibility requirements are easy to prove. If there is no signed order, the patient is not considered to under the care of a physician. If the patient’s clinical record does not consistently reflect homebound status, the patient is not considered to be confined to the home, etc. OASIS data is either transmitted or not. And if your patient isn’t a Medicare Beneficiary, you simply will not get paid. But what about demonstrating that the patient requires reasonable and necessary care for an intermittent period of time?

The best way that I have found to demonstrate that the patient is eligible for reasonable and necessary services is to write a good 486 summary. I understand that not everyone enjoys writing but anyone can put together a good summary. If your grammar and spelling stink, it does not matter. There is no eligibility requirement stating that good grammar and spelling are required to get paid. Furthermore, while templates can be a useful tool, it often happens that every single 486 summary in the agency looks pretty much identical. Templates also lead to summaries reading like this: During this episode, the patient experienced daily pain. The patient required assistance to bathe. The patient did not require assistance to transfer. The patient ambulated with an assist device.’ This ‘story’ tells me nothing that I want to read over and over again as I review 30,000 pages of documents for a single ZPIC audit.

So let’s try something different. I believe that you can write an excellent summary if you merely answer the following questions:

  • Why is the patient being admitted or recertified and what is the primary diagnosis?
  • On admission, what happened prior to admission to instigate the referral? (Patients do not just wake up and decide to join a home health care agency as though it were a gym.)
  • What secondary diagnoses affect the patient’s ability to participate or respond to the plan of care?
  • What medications does the patient take (list names only because full orders are on the 485)
  • What additions and deletions to the Medication list occurred during the last episode?
  • Is there any significant lab work or diagnostic test that was performed last episode? (Please do not write that NO lab was drawn last episode.)

Next Section – what did the patient look like last episode?

  • Give overall impression of neuro status. Was patient mostly oriented? Was the patient confused?
  • Did the patient have pain? If so describe. If the patient was taking PRN pain medication, state how much was taken and how often over the prior episode.
  • Did the patient have any heart or lung sound irregularities? If not, simply state that patients chest remained clear to auscultation and there were no murmurs, rubs or extra heart sounds appreciated.
  • Did the patient have any issues with his gut? Diarrhea? Constipation? Nausea? Vomiting? If not, state the patient experienced no GI distress. If so, try to tie it to a reason such as a drug side effect, a virus, etc.
  • Did the patient void okay? If incontinent, mention the skin integrity of the areas affected by incontinence.
  • What did the patients legs look like? Pedal pulses bilaterally? Skin flaky or peeling? Describe the patient’s gait.

Next Section – What happened that was extraordinary last episode? A fall? An illness or exacerbation? Surgery? MD visits with changed orders? Gimme something here, folks.

Next Section – What did you do about all the irregular findings?

  • When was the doctor contacted?
  • Were no orders given?
  • Did the MD change the plan of care?

Final Section:

  • What on earth do you think you are going to do for this patient?

Answer that question and you have demonstrated reasonable and necessary. Now the occasional missed weight and missed visit won’t count quite as much in a payment review.  As always, we welcome your comments and emails.

May 12

1 Comment

Losing the Dating Game

Any questions?

May 11

The Dating Game

This is a game you don’t want to lose, folks. Before you read any further, take a minute and dispose of your date stamp.

In reviewing claims for ZPIC audits, multiple problems with dates have occurred. If the date stamp pre-dates the date that the physician signed his orders it appears to be blatant fraud. Only an idiot would do this, right? Wrongo. We see it so frequently we are appealing to the ICD-10 folks to have date stamp incompetency included as an official disease.

Next, consider the MD who has a date stamp that looks exactly like yours. This results in conflicting dates all over the same document. If I were looking for a reason not to pay a claim, I would have it on the first page of the 485. I could move on to the next claim saving myself a lot of time and effort reading through all the nursing notes. This happens more often than you think. There are three very popular date stamp formats out there. Nobody seems willing to have a date stamp custom made with their name on it.

What if the physician either doesn’t date his signature or does so in a manner that is illegible. Some British educated physicians still use the date format used in most other parts of the world. September 7 would read 7.9 in the UK. When this happens, CMS has given us a very useful tool to verify signatures and dates. It is called a signature attestation form. Please put the following on your letterhead and make a ton of copies. You will need them.

“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Notice this form can be used to verify both signatures and dates.

In the past, we have always operated under a rule that was not enforced. We were taught by our fiscal intermediaries and state offices that if a physician did not date his signature, we could simply indicate on the 485 or other order when the document was received in the agency. This is not how the CMS guidelines read and they are now enforcing the rule that the physician must date his signature. The only written exception would be in a hospital or other facility where multiple clinicians were documenting on the same piece of paper and a reasonable assumption could be made as to when the entry was made. This does not happen in home health or hospice.

This is worth repeating:

  1. Throw away your date stamp
  2. Ensure that your MD dates his signature
  3. If not dated, use attestation form.
  4. Have a signed and dated signature and attestation form in place prior to billing.

I promise that you do not want to lose the dating game.

Mar 29

1 Comment

ZPIC Targets

Home Health and Hospice, as well as other post acute care providers have been under scrutiny before and this current emergence of ZPIC activity certainly won’t be the last time we are under scrutiny. But, unlike Focused Medical Review or even RACs, ZPIC audits begin with the presumption that the provider has committed fraud.

For our purposes, we will define Medicare Fraud as billing for services that were not covered under Medicare. Thats all the ZPICs are looking at – Billing. CMS instructs the ZPICs to refer serious quality issues to the state agency or QIO. In other words they do not care if your supervisory visits are made timely or if you followed orders and frequency. In fact, you may have had a stellar state survey and still find yourself in ZPIC sights.

To determine your risk level, first check your length of stay data on the top right corner of your case mix report from Casper. If your numbers are much higher than the reference mean, you may find yourself under scrutiny. If your average case mix weight is closer to three than two you are similarly at risk. Usually, high case mix weights are a result of therapy so be cognizant of how many of your patients receive therapy – especially when the number of visits is consistently at threshold levels. Finally, a high number of diagnoses that add to HHRGs can be suspect. If all of your patients have DM, you had better be able to explain why.

Hospices are looked at also for excessive lengths of stay and diagnoses that are not ordinairily terminal.



If your agency does not fit any of these profiles, you are most likely safe.  However, the ZPICs have a lot of freedom to look at who and what they want.  Multiple complaints to the Benefit Integrity Unit or state agencies may also spur an audit.


And remember, the vast majority of agencies will never undergo a ZPIC audit.  But should you find yourself in the ‘zone’ at least you will have a place to start damage control.


As always, I welcome your comments and shared experiences below.  And you can always email me.

							

		

			

			
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