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Posts tagged ‘Palmetto GBA’

Care for the (whole) Person with Diabetes


A couple of months ago, I contacted Palmetto GBA about the LCD requiring agencies to obtain Hemoglobin A1C’s on diabetic patients every 90 to 120 days.  Included were the ADA guidelines as well as a Medscape continuing education offering that spoke to the dangers of over-testing.  Palmetto agreed to reconsider the current Local Coverage Determination and today, a response was received from Dr. Harry Feliciano MD, MPH – Senior Medical Director of Palmetto GBA.

It seems that Dr. Feliciano read the information I sent and additional research concerning the prevalence of hospitalizations related to hypoglycemia.  He pointed out that the research I sent excluded diabetics who were on insulin and agreed that the current LCD should be updated.

As such, we can expect some changes in late April to be effective in early May regarding Palmetto’s policy regarding A1C’s.  Based on information from Dr. Feliciano, I would expect to see:

Testing reduced to twice yearly for stable diabetic patients who have met their treatment goals. 

Physicians may adjust treatment goals to lessen the risk of hypoglycemia.

Patients receiving insulin will continue to have quarterly A1C testing.

Patients who have their diabetic therapy changed or are not meeting treatment goals should have quarterly A1C’s monitored.

The purpose of requesting a reconsideration was to lessen the risk of denial for patients who are provided care by your agency.  I am not going to insult you by reminding you that you still have to give appropriate care to patients with diabetes.  You already do that, even when documentation is lacking.  But is it enough?  I ask because the incidence of diabetes keeps climbing and the costs are staggering – 245B per year.  If you do the math, 245B is roughly equal to a whole lot of misery for millions of people.  Maybe its time we up our game.

For very good reasons, the OASIS data set and Home Health compare put a premium on diabetic foot care but there is more to good diabetic care than looking at feet.  The following is from the ADA guidelines regarding diabetes and older adults.

Recommendations[1]

  1. Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. E
  2. Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. E
  3. Older adults (>65 years of age) with diabetes should be considered a high priority population for depression screening and treatment. B
  4. Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B
  5. Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E
  6. Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E
  7. Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E
  8. Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E
  9. When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E
  10. Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E
  11. Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose lowering agents based on their clinical and functional status. E
  12. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E

How many of you ensure that your patients have annual eye exams?  How well and how often do you screen for depression?  Do you run through the PH2 on the OASIS or do you stop and consider each answer carefully in both what is reported to you and what is revealed by other factors?  When was the last time diabetic training for staff was offered at your agency?  If you are visiting a hospice patient, have you adjusted the diabetic regime to provide for comfort as opposed to tight glucose control?

Clinical Record Review

Here are some of the things I see when reviewing records.

  • A patient is taught to drink juice and have a snack when experiencing hypoglycemia.  The same patient is dependent on a walker, has vision loss, moderate to severe pain and is occasionally confused.   Documentation is absent any provisions made for a patient who cannot stroll to the fridge and pour some juice.
  • A patient has a CBG barely over the reporting parameters and the nurse explains it by reporting the patient just ate and took insulin late.  No MD notification. If you think that’s okay, look at the upper parameter.  If it is 150, you might get a pass on patient care but it’s probably double that.  More importantly, surveyors take exception to nurses not following orders.
  • Teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.
  • Patients are scolded when they are discovered eating something that will likely raise their blood sugar such as a donut or jam.  Manners, please.  These patients are our elders and they deserve respect.  Nobody was ever embarrassed to the extent their A1C dropped to below 7.
  • Generic teaching of medications that have very specific and unique side effects.

So maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care.  The lowered frequency of A1Cs only applies to stable diabetics with no changes to their treatment but these patients also need eye exams, assessment for depression and emergency teaching for hypoglycemia.  Even if they have been a diabetic for ten years and have been stable for almost as long, make sure they know which medications might cause lactic acidosis and to notify the agency when their activity changes to prevent hypoglycemia.  If you believe that the physician is overly optimistic about your patient’s diabetic goals based on your assessment of the patient in their home environment, respectfully bring it to their attention.

All of these interventions take very little time and can easily be included in care plans when the primary diagnosis is something else.   If we don’t take advantage of ensuring that diabetes is addressed completely when it is not a crisis, the costs – both human and economic – to treat complications will be significantly higher.

To help you get started, her are some resources that may help in developing skills required to assess and treat diabetes.  Please take the time to read one or two and if you find anything that helps your patient care, please share.

Resources for Diabetes

2016 Diabetes Guidelines

2016 Guidelines for Mobile

Lower Extremity Amputation Prevention (LEAP) program

Depression and Diabetes

Coping with Diabetes in Adults

Treatment of Diabetic Ulcers

Diabetic Retinopathy from National Eye Institute

Kidney Disease of Diabetes

Neuropathies in Diabetes

[1] American Diabetes Association. Older adults. Sec. 10. In Standards of Medical Care in Diabetesd2016. Diabetes Care 2016;39(Suppl. 1):S81–S85

Does Anyone Work at Palmetto GBA?

Do real people work at Palmetto? Is 7-10 days a reasonable wait time when your agency is at risk?

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Physical Therapy Goals


The following is from a denial a client sent last week.  The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document.  That denial was overturned in favor of my client but the claim was denied again for a new reason.  You have to see this in order to believe it:

Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.

So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals. 

Did you happen to notice that the entire course of therapy was three weeks? 

Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted?  That really gets under my skin.

In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document.  They agency lost a full round of appeals before the reviewers found something else wrong with the chart.  Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met.  I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal.  In actuality, there were five of these I worked last week.

You have two choices.  First, you can write a short term goal or you can write a very long term goal.   The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged.   I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed.  Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?

An alternative solution would be to write a goal or two for the first visit or first week of therapy.  Some examples that come to mind from who knows where because I am not a therapist are:

  • The patient will agree to participate in their course of therapy by the end of the first visit.  (Chances are this is pretty accurate if the patient allows you in for a second visit).
  • The patient will have all prescriptions for pain filled prior to next visit.  (I do not like the way it sounds when therapists work with un-medicated patients.)
  • The patient will have DME delivered by end of day 4 of episode.  (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.

I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh.  I assure you that is not the case.  All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation.  Be bold about it.  Include page numbers.

I would be interested to hear what is happening in your offices.  Has anyone else seen denials like these?  If so, what contractor?  (Palmetto, NGS, CGS, etc.)  Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below. 

A Gross Distortion of Truth


Implemented in 2011 as part of the ACA, the Face-to-Face requirement was mandated as a way to prevent Medicare fraud.  Well known cases of fraud involved agencies paying physicians who have never seen a patient to sign orders.  The best known case is that of Jacques Roy in Texas who defrauded the government of 450M by running an orders signing factory. There are more cases like this but these agencies are in the minority.  Although it is inconvenient at times, it should not be too difficult to satisfy this requirement to prevent additional fraud and abuse.

    1. The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.
    2. The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.
    3. It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.
    4. It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

I received a copy of a face-to-face document last week and posted it below.  This patient has Parkinson’s disease, congestive heart failure and chronic pain.

image

As many of you can guess, it was denied.  Nobody doubts that the patient was eligible for services or that the services provided were reasonable and necessary.  The physician saw the patient on the 26th as indicated in the documentation and also daily while he was hospitalized.  Physical therapy was indicated as the reason for services in a section of the document I could not clip without revealing personal health care information.

So why was payment denied for this patient who met eligibility requirements and received much needed covered services?  The physician did  not write a ‘narrative’ because the silly doctor thought it was self evident why someone with diagnoses of pain, Parkinson’s Disease, congestive heart failure who kept falling despite use of an assist device was confined to the home.

This particular document was appealed recently so it was easy to find but I have scores of them in my computer from numerous clients from all over.  And most will be denied.

Medicare states:

The face to face requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition

Nobody could possibly have more knowledge of the above patient’s condition than the physician who saw the patient daily in the hospital and then signed a face to face document.  Shame on that physician for failing to use verbs and pretty language to describe the patient better.  Perhaps he thought the document to which the face-to-face encounter was attached would be read.  Wrongo.  As with all statutory denials, the work is over when the claim is denied.  Why take your time to read an entire chart or even the care plan if the claim does not meet billing requirements.

Adding to this are the thousands of face to face encounters that meet all requirements and are denied regardless.  When this happens, an appeal is sent to the QIC (the next level of appeal) and often the QIC finds that the face to face encounter did satisfy all requirements but another reason for denial is found.  This tactic essentially robs the agency of one level of the appeals process.  

After working in post acute care for all these years, my faith lies in home health and hospice.  We have not lived up to our potential as a sub segment of the industry, but we are getting closer every day.  It will be a moot point when congress and other policy makers hear information painting a picture of our industry as blatantly fraudulent and unable to follow even the simplest regulation designed to prevent fraud.  That is my concern.  We will be somehow be left behind as new budgets are developed and our reputation is tarnished.

And to this day, I believe that if we did live up to our potential, congress would be lining up to ask how we wanted to be paid instead of  dismissing us as criminals in scrubs.  We will never live up to our potential as long as education, consulting, inservicing budgets are dedicated to teaching nurses how to review the face to face document to fund payroll.

Most importantly, I want copies of all face to face documents that have been denied if you don’t mind sharing.  You can sanitize them by removing personal health information or I can send you a HIPAA agreement so you can send them as is.

I am losing faith that our government, the one who wants to control 20 percent of our economy with the ACA is being truthful when they state that the purpose of the face-to-face encounter is to combat fraud.  Color me cynical but I see it being bastardized as a way to deny providers payment for covered services rendered to eligible providers. 

 

Face to Face–Your Results


A few weeks ago, you were invited to take a quiz on the home health requirement for face – to – face encounter documentation.  If you haven’t already done so, please go take the quiz now.

The results were interesting to say the least.  You know when a face to face encounter must be done and you are very clear about your (non) role in the creation of the document.  Where you fell off was in the questions regarding who signs the face-to-face document.  If your overall score was not what you hoped, rest assured that your colleagues are right there with you.

Here are some of the more interesting responses.

Less than 50 percent of you knew that if a patient died prior to the 30th day and a good faith effort was made for the patient to have a face-to-face encounter, you may still bill.  This is not a suggestion regarding how to get around those pesky MD’s who refuse to sign, by the way.

image

The question that was particularly disturbing was a true/false question inquiring if it was true that the same physician who signed the 485 must also sign the face-to-face encounter document.  If you answered that question correctly, you are among a 35 percent minority.  A full 65 percent of you answered it incorrectly. (Green is good, pink is bad – I did not choose the color scheme.)

image

Similarly, less than half of you knew that if the hospital documentation was used as the face-t0-face encounter it had to be labeled as such and the date of the encounter had to be included.  When you consider many of the discharge summaries, they often apply to the entire hospital stay.  A visit date must be identified and declared as THE day the encounter occurred.  image

Rest assured, other than these very three common reasons for denial, y’all knew your stuff very well. 

So what do these results mean? If I was paid by your agency to come in and teach y’all about the face to face encounter and after I left, you continued to get denied, would you consider me to be an effective teacher?

The truth is that Palmetto GBA is responsible for educating you on the face-to-face to requirements.  This is part of their contract with CMS. 

Here’s the part that keeps up at night.  If all of you were to learn exactly what a perfect face to face documents looks like and then you all taught ten people who in turn taught ten people, by the end of next week literally billions of people would know everything there is to know about the face to face document. 

And not one patient would receive better care because the physician forgot to label the hospital documents as the face-to-face document. 

Just sayin…  Palmetto GBA, take it for what it is worth but I respectfully suggest you might have a little more work to do in the realm of face-to-face document denials. 

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