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Posts tagged ‘documentation’

Aug 7

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Unbelievable

There comes a point when you are in this business long enough that you think you have seen everything.  Today I saw something that I never even thought existed.  A long term client received their ZPIC results from AdvanceMed.  In my life, I never thought I would see anything like this.   

Make no mistake.  This is a good client who acquired an agency several years ago and then called me to look at it.  I explained that most people performed due diligence before buying an agency.  As luck would have it, it was a great agency but once sold, there was nobody there who knew the business side of homecare and they were a little less than profitable.

So after a few months, a new administrator was hired.  She has an MBA but she sold drugs prior to accepting this position. (She will read this and get mad if I do not clarify that she sold pharmaceuticals.)  The only home health experience she had was well, frankly, none.

One of the first things I did was encourage her to pay her staff per visit instead of hourly because their overall productivity was about 2 visits per day.  That was a mistake.  I should have told her exactly how much to pay per visit.  But, I left that open and so she pays her nurses a ridiculously high per visit rate.  Her field nurses make more than I do and they only work three days a week.

And because they are down the bayou, their length of stay is about the twice the national average and they have a lot of therapy.  It is difficult to educate people who have never been to school and South Louisiana is known for its large Catholic families so lots of repeat teaching is needed as family members rotate in and out.   Two of their largest referral sources are orthopedic surgeons and as such an enormous amount of their patients require therapy. 

So what do these overpaid nurses with time on their hands do all day?  They talk on the phone and write stories.  They love the copy machine so they make copies of pretty much every piece of paper they can find and give it to people.  Then they call the people they gave them to just to be sure they got them.  They play with scissors and tape and send all these lengthy faxes to the MD with the med profiles taped on them so the doc can see everything they are taking.  I keep trying to show them how to cut and paste the meds on the faxes and remind them that even if the computer explodes, they will still be able to get to their documents.  I cannot begin to imagine what they spend on paper. 

Once or twice a week, they all sit down and have lunch together and talk about their patients in case conference.  This of course is documented.  It is rare that at least one or two nurses don’t come to the office to chart in the afternoons.  The geography is such that it makes more sense to chart in the office since they turn their notes in timely.  (What else do they have to do?)  In fact, some of the most entertaining reading I have done in the past year has been in their charts.  I am still on the fence about how much is appropriate to chart about the infected penile prosthesis but I know more than I wanted.

Probably the owners would take exception to their over paid, underworked employees but since they were making money they never really noticed.  And because they were paid per visit, it didn’t really cost them too much.

They are my only client who as had a deficiency free survey in the past several years.

And their ZPIC result?  AdvanceMed determined they were overpaid by a little less than 2 percent*.  

I am in awe. 

There are lessons here to be learned unless you are my client in which case, there is a well deserved good night’s sleep waiting for you.  Pleasant dreams.

 

*For those of you unfamiliar with the ZPIC process, most results are well over 50 percent and I have yet to see an overpayment assessed at less than a million.  This agency’s overpayment was measured in tens of thousands.

Aug 6

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3 Errors

I’ve been reviewing charts all week and the same errors keep showing up over and over again.  I know the nurses doing the charting and they are not as dimwitted as they may seem on paper.  In fact, I would wager a bet that the only nurses who have never made at least one of these errors has only a passing acquaintance with the truth.

Charting Bilateral Pedal Pulses on an Amputee

The same nurses who did this also charted on the surgical wound, the therapy the patient was receiving and otherwise did an excellent job of documenting.  So, why are they charting about pedal pulses on an amputee?  Because they are used to checking the box that says a patient has bilateral pulses. The same thing happens in M1030 which asks about therapies the patient is receiving at home and when they overlook an Ostomy in the OASIS questions.  My theory is that if you give a nurse a check box, it will be checked.

Charting Tip

When a patient does not meet the response you typically chart greater than 90 percent of the time, mark it when  you notice it.  Even if you do not have time to complete the entire document, respond to those questions that you may answer incorrectly at a later time out of habit.  Outsmart yourself so you don’t end up trying to explain to some board of nursing how you were able to find a pedal pulse in some other part of the body.

Underscoring Functional Limitations

Look at the question about ‘locomotion’.  Response 2 reads: 

Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.

This response is usually selected when a patient requires a walker and it may be correct but keep reading.  If the patient requires human supervision or assistance to negotiate stairs or steps or uneven surfaces, the correct response is 2.  This is true even of patients who do not require a walker.

Charting Tip

Mentally break this question in two. 

  • Does the patient need a two handed device? 
  • Can they negotiate stairs and uneven surfaces without human assistance or supervision?

Transferring

Most people think of transferring as moving from one place to the other.  In general terms, that’s close but OASIS gives us a very complicated and lengthy definition of transferring.  Here it is step by step (there should be an app for this one).

  • Begin with the patient in a supine position (laid out flat on their back)
  • The patient then gets to a position sitting on the side of the bed.  The methodology must be chosen by the patient  because there is an uncharacteristic lack of instructions in the manual.
  • The patient then stands and pivots. (I had entire tennis lessons which focused on pivoting.  If your patient is a retired tennis pro you might be in luck).
  • Then the patient sits.

But Wait!  That’s not all.

  • The patient must now be able to stand again
  • Pivot
  • Sit on the side of the bed
  • Somehow get flat on his back again.

Could there possibly be more to it than this?  Absolutely.  There are some patients who do not have a place to sit next to their bed.  Their instructions are even lengthier. 

  • Begin with the patient laid out flat again
  • The patient then gets to a position sitting on the side of the bed.
  • The patient then stands and pivots.
  • The patient safely proceeds to the place where he or she normally sits.  This may be the kitchen or the porch or the toilet.  The destination is not defined but I’m going to out on a limb and tell you that it does mean a seated position on the floor because they could not support their weight.
  • Then the patient sits.  I suspect that there may be a little pivoting involved here as well but the directions are not clear. 
  • The patient must now be able to stand again
  • The patient makes his or her way back to the bedroom as the return trip begins
  • Once again they pivot (Group and Individual Pivoting lessons are available from HCS)
  • Sit on the side of the bed
  • Somehow get flat on his back again.

Here’s the fun part.  If your patient typically gets up in the morning and goes outside on the porch to enjoy his coffee but requires help to make the distance, you can greatly improve your outcomes by….  wait for it…  putting a chair next to his bed.  There are some patients who because of shortness of breath, weakness from a recent injury or pain, just need to sit for a few minutes before continuing their journey to the great outdoors or wherever they sit.  Not only will your outcomes improve but a patient who previously had to wait on someone to help them get up is no longer trapped in the bed until someone has the time to get to them. 

What’s more, if you recall that the definition of the day in question refers to the 24 hours prior to and including the visit, you can still improve outcomes even if you put the chair in place on admit. 

Charting Tip

Print the list and keep it with you.   It is rather complicated.

That’s all for today folks but there is sadly more where that came from.  If you have never made any of these errors, it is probable that nobody is reviewing assessments at your agency.  One of the best investments is a data scrubbing program.  My personal favorite is Episode Master although I am angling to have the name changed to Episode Mistress.

Look for more next week.

Mar 26

6 Comments

Skilled Charting

Our small little company probably sees more denials than anyone else other than say Palmetto or one of the Zone contractors.  So we make a lot of fuss about documentation and getting paid but while we are very good about finding errors, we don’t offer as much as we should in teaching documentation with payment in mind.  I’m not going to bother with that now as I have a lot to do so let me just show some examples of bad, better and really good documentation.

Skilled Teaching – Diet

Bad:  taught low sodium diet.  (worse if this is not the first time)

Better: Taught patient how to read food labels for sodium content.  Used handout attached.

Best: Taught American Heart guidelines for low sodium diet according to handout pages 1 and 2.  Copy attached and left in home folder.

Homebound Status

Bad:  SOB on exertion (everyone gets short winded if they exert themselves enough)

Better:  Patient is short of breath when walking 20 feet.

Best:  Patient is unable to leave the home due to SOB r/t CHF, arthritic pain and impaired judgment due to narcotic medications.  Requires cumbersome assist devices and at least one person to help leave the home.

Diabetes Foot Check

Bad:  Taught patient to perform foot care.

Better:  Inspected all surfaces of feet.  No problems noted.  Patient was able to demonstrate foot care with a mirror.

Best:  Inspected all surfaces of feet while simultaneously instructing patient on foot care and (proper footwear), (risks of decreased sensitivity), (risks of going without shoes), (when to see podiatrist), (importance of annual eye exam).  Take your pick and rotate through the list.

PT/INR

Bad:  PT/INR drawn per orders and brought to lab.

Better:  PT/INR drawn per orders.  Called team leader to watch for results.

Best:  10:00  PT/INR drawn.  Dosage of 5 mg/day Coumadin noted on lab slip.  4:00 pm  MD confirmed receipt of lab.  INR 2.8.  No new orders.

Any0ne else care to add to the list? Yes, you’ll chart a little more but if you blow off the recap of what is on the flow sheet – assessed all body systems, patient awake alert and oriented times 3, denies pain, etc., etc., you may find that you write less and say more. Better yet, you will get paid for your hard work and your outcomes will improve as well.

Mar 22

1 Comment

ADR Checklist

Prissy the Pit Bull available at no charge to review your records. We guarantee they will not be denied for lack of signature. We do not guarantee they will be paid.

Make no mistake that what I am about to say is shameless self promotion.  The safest way to ensure that any medical records requested by a payor source meet standards are to have them reviewed by someone with experience and who does not know the patients or the agency.  This doesn’t always ensure payment but it can alert you to your vulnerabilities so that you can make a plan before the next dance with your MAC.

Short of the the level of security offered by Haydel Consulting Services, you can do your own reviews.  More important than the actual content of the review is the attitude of the person doing the review.  Attacking the charts like a rabid Pit Bull will ensure that most errors are identified but Pit Bulls do not implement action plans.  Your reviewer needs to be cognizant of the fact that any errors or omissions identified are  tools to help cover their coworkers back and they need to be willing to help out their colleagues.  If they can be ethically corrected, they should be.  If they cannot, a team with members from every part of the organization needs to implement a plan to prevent repeat errors.

Here is what I look for:

  1. Orders signed and dated by physician.
  2. Face to face in all charts.
  3. Medications
  4. Diagnoses – note meds came first.  Are there any meds for dx’s not listed.
  5. Frequency – does it correspond to the patients’ needs?
  6. Functional status – if the patient is minimally impaired in the functional domain, are they homebound for psychiatric reasons?
  7. Is teaching original and relevant?
  8. If re-teaching is present, is the reason why re-teaching was necessary explained?
  9. Does teaching require the skills of a nurse?  It does not require the skills of a licensed nurse to tell a patient to take medications timely.
  10. ARE THERE ORDERS FOR THERAPY?
  11. Are therapy re-evals done on schedule?
  12. Is there any lab or other diagnostic tests that support care for the patient even if they were performed in a prior episode?
  13. If subcutaneous injections are given, is there a reason why the patient cannot be taught?
  14. Is there a documented predictable end to daily skilled visits when daily nursing visits exceed 21 days?
  15. If the patient is seen for Management and Evaluation, is an RN performing the visit?
  16. If Observation and Assessment is documented as a skill, are there any clear indications that the patient is likely to become unstable?
  17. Are patient and clinician signatures consistent throughout the record?
  18. Are there any hospital or MD reports that will support services?
  19. Does the clinical note contents support OASIS?
  20. Is the primary diagnosis the focus of care?

Notice again that two questions that are critical to payment are asked last.  It is only after reading the entire episode that you can truly answer these questions.

There are so many other important elements in a chart that are required in order to reflect good clinical care.  This is a payment review only.  So, if the patient had 12 nursing visits scheduled and two were missed, that will not affect payment but I want to go on record as saying that it is unacceptable to find out about two missed visits on ADR review.

If you find egregious mistakes that cannot be ethically corrected, back out the claim.  For instance, if there were no therapy orders after the initial order to evaluate and treat, back out the claim and resubmit it less the therapy.  Print all paperwork and send it with the ADR.  This will not prevent a denial but you won’t look stupid either.  After that, find the therapist culprit and violate your work place violence policy.

I am very interested in knowing who is getting denied for what.   Please email me privately if you have the goods.

And if you are not pleased with what you are finding, do not hesitate to call us.

Feb 26

A Slap in the Face

So last week I was reviewing clinical records at the office of one of my favorite clients.  A patient had been admitted six months after having half of her foot removed.  She had not walked since the surgery and was confined to the bed and the chair.

The first thing I noticed was that the description of the surgical wound sounded as though it were partially granulated instead of fully granulated.  Six months is a long time but remember, amputations are not cosmetic surgery.  It would not be unheard of to have a wound slow to heal in someone with circulation impaired to the extent that part of a foot needed to be removed.

I also questioned the diagnosis sequence and a couple of the OASIS questions in the functional domain.

Med orders on the 485 indicated that the patient was on both Dilaudid an Lortab but the chart only mentioned Lortab as being used for pain.  My most humble opinion is that if pain is being managed with Lortab, the Dilaudid should come off the orders – especially after the first episode.  The reason I feel this way is because if the patient had a sudden need for stronger pain relief, she may have other needs than Dilaudid that should be addressed immediately.

She had both therapy and nursing ordered.  The nurse was quick to realize that the new orthopedic ‘boot’ designed to help her walk was causing the surgical wound to become red and irritated.  Both the nurse and the therapist addressed this with the MD and the people who made the boot.  I certainly cannot complain about that.  But, after the boot was refitted properly, the nurse stayed in the home weekly even though therapists should be able to assess wounds.

In summary, I saw was that OASIS scoring left the agency with less payment than they were ethically entitled to for a very expensive patient and services being provided that may not have been required.  And of course, there was the regulatory issue with duplicate pain meds.

While I was busy finding fault left and right, the most important thing almost escaped my attention.

After two episodes the patient who had part of their foot removed and had not walked in six months prior to admission was ambulating with a walker.  The last nursing note state that the patient was in the kitchen upon arrival making coffee and using her assist device.

I am still not happy with the chart.  My slap in the face comes from the fact that sometimes we forget that documentation is second to our real mission of providing care in the home.  It is a very close second but failure to acknowledge what these incredible nurses and therapists did for the patient is the kind of attitude that deserves a slap in the face.  If those of us who review charts on a regular basis cannot read between the lines and respect the care given to patients, we have no right to expect respect from field clinicians when we tell them all the things they did wrong.

Having said that, I have seen like a billion ADR’s and ZPIC denial letters but I have never seen one like the following.  Please forward to me if you have.

Dear Administrator:

After careful review, our Medical Review department has determined that the cases mix weight determined by your OASIS data is in error.  Specifically, a surgical wound and the functional domain were underscored resulting in a lower payment for this patient.  In light of these egregious errors, Palmetto GBA (ZONE contractor or MAC of your choice) is adjusting your claim to reflect the correct diagnosis, surgical wound and functional status of your patient.  This will affect the overall denial rate on your current edit.

As a provider, you have certain rights to appeal.  Please see attachments on how to appeal a Medicare decision regarding payment.

Sincerely,

(Insert the name of your MAC or Zone Contractor)

PS  please advise your nurse to take Dilaudid off the current med list and ask the patient to place it in a Ziplock bag with a large note that tells the patient to please call the nurse immediately should it be required in the future.

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