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Posts tagged ‘Medical Review’

Confined to the Home

Here’s the point of this entire post.  Medicare knows the definition of ‘homebound’.   Medicare states that patients don’t have to be bedridden but there must exist a normal inability to leave the home and that when the patient does leave the home it requires a taxing effort.

As it turns out, most of us and quite a few physicians also know the definition and write it verbatim on visit notes, care plans and face-to-face documents.  When Medicare documentation calls for ‘reason homebound’, they are not asking for their own definition.

So, here’s my way of avoiding those pesky denials related to homebound status and overturning the ones that do get denied.  At the time of admission or recertification document all of the reasons why the patient can’t just up and go and all contributing factors.

These are very incomplete lists but I always try to support homebound status with as many factors as are applicable to the patient.

Absolutes Supporting Reasons
Severe pain with ambulation multiple medications that can impair balance
Safety concerns due to recent hx of multiple falls. multiple meds that can impair judgment
Disoriented to person and place and must be supervised at all times urinary incontinence
Short of breath while talking, eating or repositioning in bed cumbersome assist devices
SaO2 drops to 87 with activity apprehension about leaving home
Unable to ambulate safely s/p hip replacement moderate pain after standing for extended periods
Impaired judgment secondary to psychiatric illness cannot open some doors, drive or use left arm to balance due to splint
High risk of infection due to open wound and compromised immune system. requires considerable effort communicate needs clearly due to residual aphasia and paralysis of dominant hand.


Note the difference between the Absolutes and Supporting reasons.  People are not considered confined to the home because of apprehension alone but it adds depth to a complete picture of a patient with severe pain when ambulating.

Patients short of breath while talking or eating who are also incontinent and rely upon an assist device to get to the restroom are at very high risk for falls.

Documenting all assessment findings that contribute to homebound status at least once an episode and then continuing to support these reasons in your visit notes may very well get you paid.

486 Summary Example:  Patient homebound due to hip replacement two weeks ago and cannot walk without another person assisting him with his walker.  He is taking narcotic pain medications which increases his risk for falls and there are steps without a bannister leading to the front door.

The truth is that we all meet Medicare’s definition of homebound status at times.  Isn’t it hard for you to leave the house in the morning?  Surely it is a taxing effort for you to make sure all the kids have their lunch and homework, find your keys, retrieve your cell phone from the litter box where the toddler put it and somehow make it to the car.  If a normal inability does not include four trips to the car and back to house to retrieve forgotten items including the baby, then crazy is the new normal.

Medicare doesn’t care about any of that. They want to know, from a clinical perspective, how the patients meet the criteria they set forth for us in the conditions of participation.  We need to paint a crystal clear picture and not just write enough to meet guidelines.  When you are finished documenting homebound status, there should be no question that the patient cannot and does not leave the home.

If there is a question, go take a second look.  If you cannot elaborate on ‘SOB with exertion’ (as I am after climbing 6 flights of stairs), your patient may very well not be homebound.

Of all the wild excuses for denials lately, this one is not so unreasonable.  We can do this without changing the law, involving physicians, and praying that the grammar police don’t get us.

Good luck.  I am very confident we can take this denial off the table.

The Checkbox Patient

You say the pain feels like an elephant sitting on your chest?  I'm sorry but that's not an option.  Let's move on.

You say the pain feels like an elephant sitting on your chest? I’m sorry but that’s not an option. Let’s move on.

I get frustrated when I see people try to squeeze an entire person into a series of checkboxes.  This has gotten under my skin for a long time.  Apparently, Medicare agrees with me.  Keep the following paragraph from the Program Integrity Manual in mind when you are shopping for software.

The Program Integrity Manual – the PIM – is the guidance CMS offers to the contractors including RACs, Zone, and MACs. It was updated in December. If you want the full document, google Medicare PIM chapter 3. Chapters 3 and 4 are where I spend a lot of time.  I provided the bold text.

The review contractor shall consider all medical record entries made by physicians and LCMPs. See PIM regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation.

The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service. See the Local Coverage Determination for further details.

CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/LCMP may choose any template to assist in documenting medical information.

Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.

Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.

If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.

So, be wary of programs that do too much for the nurses.  If a program doesn’t require at least a short narrative, it likely will not get done.  If a nurse has scrolled through 50 checkbox questions, said nurse is not going to want to double chart that which has already been documented.

Don’t let some software vendor sell you the moon when what you really need is a clean, consistently reliable system that helps nurses understand and communicate their information.  You need reports and communication.  You need support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.

You do not need any more denials.  I assure you.

Company May be on the way….

Lately, some agencies in Mississippi and Louisiana have been entertaining Zone Contractors.  They arrive at an agency and ask for 30 complete claims to be produced that day.  ZPIC activity is not public knowledge so I have no idea exactly how many agencies have been visited but it is substantial.  The ones that have come to my attention total approximately 15 locations with some providers sharing common ownership.

These agencies and the requested episodes are not chosen by mistake or randomly.  The Zone Contractors have been instructed to come up with innovative ways to detect billing patterns suggestive of fraud.  Before they arrive, they know which charts they want to review.   They may or may not visit the patient or the MD prior to their arrival at your agency.  There are rumors that I have been unable to substantiate that some staff members have been followed to determine if patients are visited and how long the employee stayed in the home.

How should you respond if visitors arrive at your office?  Here are my suggestions for what they are worth. 

  1. Do not panic.  They are contracted by Medicare and have every right to be in your agency.  They are there to do their jobs and no amount of attitude will get them to leave.  Be nice.
  2. Ask politely to see identification if they do not offer it right away.  Get the names of the individuals and write them down.  If they do not offer identification, call the Zone contractor for your area and verify that they are supposed to be there.  If you do not know the name of your zone contractor, look it up now and be prepared.
  3. Alert your administrator, your compliance officer and the DON that you have visitors.  Nobody else needs to know.  Quietly ask all unnecessary staff members to exit through the back door but advise them that they are to respond to any calls from the office stat.
  4. A list of episodes will be provided to you.  Assign one or two staff members to collect the documents and bring them to the DON or designee.
  5. The only review that is possible is a review for completeness.  Make sure that all notes are present.  If aide notes are missing, that is bad.  If skilled visits notes are missing do your best to find them.
  6. If you work at one of those agencies that is not above adding a date to legal document after the fact or signing someone else’s name, be aware that I have no use for your agency.  Also be very aware that you do not know what the Zone Contractor has already seen.  
  7. Number the pages and make two exact photocopies at the same time.  That way if something is missing, it is missing from both copies.  
  8. Ensure that senior management is present.  Nothing impresses your payor sources less than an owner or administrator who cannot be found while their agency is under fire.
  9. If you cannot locate visit notes or if upon a cursory review you find that claim should not have been billed (no signed orders or missed visits mistakenly logged as visits), back out the claim and include the paperwork with the information given to the zone.
  10. Do not make small talk with the Zone Contractor.  That pretty much never works out.

You do not have time to complete a clinical record review on 30 charts.  You will have the opportunity to supplement your information in the first two rounds of appeals and most agencies go at least two rounds.  Regardless of the quality of your records, expect a high rate of denials.  Also, expect that nothing will happen fast.

After they leave, go about getting caught up from what amounts to a day of not tending to your business.  Within the next week begin reviewing the photocopies you sent to identify your vulnerabilities.   Start supplementing documentation and gather supporting documents for any arguments you may produce.  When the results finally arrive, you will  be up against a deadline.

If your agency is blatantly fraudulent, get your billing caught up because the Zone can and will suspend payment if they find evidence of blatant fraud.  If your agency is not blatantly fraudulent, expect that within a year you may have your payment temporarily suspended for a few weeks after the second level of appeal and before an Administrative Law Judge.  Stack some bills now and get your creditors paid off in preparation for that time.

Remember, if things get tough, we can help you.  We have more than enough experience in appealing denials.  We have a great record with some clients and a pretty awful record with others.  You can probably guess what the difference is between the two groups.

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.

Deny, Deny, Deny

This horse will likely die of humiliation soon but please don't beat her. Her owners have put her through enough already.

It’s Mandy here.  Hope you all had a wonderful holiday.

So, we all know the old saying – Deny, Deny, Deny.  Well, apparently that’s what our zone contractors are so anxious to do.  They deny claims for the smallest little things like medical necessity. Whoever heard? Wink, Wink.

The truth is, these zone contractors get paid literally millions of dollars for ensuring that claims are paid appropriately. In order to make CMS feel good about al those millions of dollars, they have to offset the payment with a whole lot of denials. I wonder how they sleep at night?  Probably, pretty good laying on their big fat wallets.

But it doesn’t stop with the Zone.  Apparently, Palmetto and other MACs got jealous at all the attention the Zone contractors were getting and now they are flooding the market with ADR’s.  In some cases, the same agencies under a ZPIC audit are also getting ADR’s.  How can that be fair?  It probably isn’t, but we ain’t changing it so we have to live with it.

Palmetto GBA is so warm and fuzzy; they give us a list of the worst offenses.  Here are the most recently listed Top 10 reasons for denial:

    1. Documentation does not support homebound status.
    2. Lack of response to ADR.
    3. Information does not support medical necessity.
    4. Orders do not cover all visits billed.
    5. Unable to determine medical necessity b/c appropriate Oasis not submitted.
    6. Medical review HIPPS code change/Documentation contradict M item/s
    7. POC/Cert present and signed but not dated
    8. Dependent services denied because qualifying service was denied.
    9. Partial denial for therapy resulting in medical review HIPPS code change.
    10. Order not signed and/or dated timely.

What are we dealing with here?  Homebound, medical necessity, we know, we know.  Apparently, we don’t.  50% of this list is directly related to documentation.  Whether it be our Oasis, our skill, or our therapy notes, can we beat this dead horse anymore?

Attention DON’s and case managers! Calling all nurses and therapists! 

Big brother is watching.  We can no longer skate by with the minimum.  We must provide top notch care with top notch documentation EVERY, SINGLE visit for dwindling reimbursement.  What does that mean?  Only the best will survive, but we can do it.

Steps to take to alleviate denials:

  • Train staff based upon the most current guidelines not outdated belief systems
  • Make sure employees understand the definition of homebound status and how to document  it on every clinical note, including therapists
  • Don’t provide an opportunity for a medical necessity denial
    • Actually look at medicines every visit – truly groundbreaking idea
    • Develop working relationships with physician offices to open communication
    • document all changes to the plan of care
    • document all changes in condition
    • Ask for changes to the plan of care when necessary.
    • Always address caregivers in documentation – preferably by name.  Changes in caregiver status affect our patients.
    • educate all clinical staff to sign and date notes with a legible signature if you are not using electronic documentation
  • Train clerical staff to look for signatures and dates when filing as a double check system
  • Establish a follow-up policy for outstanding orders and stick to it.  Orders not signed within 30 days are not acceptable.  Hand deliver to the physician office if necessary.
  • Get a custom stamp that reads:  DATE YOUR SIGNATURE or something a little less subtle to put on MD orders and care plans

Everyone makes a few honest mistakes, but more than a few could land you in the slammer.    Be careful out there my fellow warriors.  Document, document, document!  Our nursing instructors were right!!

*Please note: No horses were actually hurt in the writing of this blog and I have never actually spoken to or met a zone contractor employee so I actually cannot vouch for their sleeping arrangements, personal appearances or opinions regarding home health zpic audits.  This is only a commentary and represents no actual employees of Zone Contractors.

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