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Posts tagged ‘value based purchasing’

Episodes and Flu

In today’s lively discussion we will discuss the subtle differences between periods of time referred to as episodes and drive home the reason it matters.

It’s that time again. Most patients who were admitted or recertified to home healthcare this month and for the next several months will have some part of their care delivered after October 1. This is really important to note because any patient who is discharged or transferred to an inpatient facility on or after October 1 will receive some part of their care in the ‘Influenza Vaccine Data Period’. The specific questions about vaccines can be found in the OASIS transfer and discharge assessments beginning with M1041.

M1041 is a trick question. It asks if any part of the ‘episode of care’ include any dates on or between October 1 and March 31. Most veteran home health nurses understand that an episode of care is quite different from an episode which is a 60 day period of time. Newer nurses and therapists may not pick up on the nuances differentiating an Episode of Care from a generic 60 day episode.

An Episode of Care begins at admission OR Resumption of Care and ends at the time of Transfer or Discharge. Got that? As such, an Episode of Care can be equal to a 60 day episode but it could also be longer or shorter than a plan episode.

Let’s take a look, shall we? In the illustrations below, the grey arrows represent generic 60 day episodes. The white boxes will show various events that might occur creating an Episode of Care that is different from a plain episode.

Episode of Care equals generic episode

In the next example, an Episode of Care equals two regular episodes.

2 episodes – 1 Episode of Care

The last example shows how multiple Episodes of Care can occur within one episode. The white squares are one episode of care while the black squares represent the second Episode of Care.

2 Episodes of Care in 60 day episode

Since the actual questions are not asked until transfer or discharge, the challenge is to make the information readily available for the clinician who completes the transfer or discharge OASIS. It is also your challenge if you perform transfers and discharge assessments to make sure you have the information available.

Why is this important?

  1. Many agencies have outcomes posted on Home Health Compare indicating that you really don’t care if your patients get the flu. Or worse – you really want the patient’s to get flu.
  2. Value Based purchasing will likely include information about vaccines. ‘Value Based Purchasing’ means agencies with good numbers will make more money and that money will come from poorly performing agencies. If that doesn’t alarm you, break it down. Do you really want to fund an increase in revenue to your largest competitor who knows how to distinguish between Episodes of Care and generic 60 day episodes?
  3. The flu kills a whole lot of people every year and our elderly are the most vulnerable. While there is concern about the validity of the published numbers, nobody doubts that the flu can take a senior citizen with heart failure out of the game permanently. In 2013, the CDC reports that over 50,000 people died from the flu but last year the number was likely under 5,000. The flu varies wildly and waiting to see how bad it will be does not work.

Most assessment tools in computer software or handwritten, include questions about vaccinations on admission and resumption of care. The problem is getting the information right. The checkboxes are not completely trustworthy without dates.

So, M1041 researches patients on service from Oct. 1 through March 31. It isn’t until M1046 which strangely directly follows M1041 with no mention of 1042, etc. that the clinician is asked if the patient had a flu shot. There are 8 possible responses.

  1. Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)
  2. Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)
  3. Yes; received from another health care provider (for example: physician, pharmacist)
  4. No; patient offered and declined
  5. No; patient assessed and determined to have medical contraindication(s)
  6. No; not indicated – patient does not meet age/condition guidelines for influenza vaccine
  7. No; inability to obtain vaccine due to declared shortage
  8. No; patient did not receive the vaccine due to reasons other than those listed in Responses 4 – 7.

Going back to the second diagram showing how one Episode of Care can go on through discharge over multiple episodes, it is easy to see how the correct response might be hard to find. If you’re really not fond of your coworkers, imagine that it could be you out there doing the discharge and having to click through 200 or so screens to find where a nurse offered the vaccine.

The information reported on Home Health Compare reflects only the number of patients who have received the flu vaccine. If they received it from you during another Episode of care, their physician or any other provider, they obviously go into the mix. What does not get counted are the patients who have been offered and declined the vaccine.

Your numbers should be very close to 75 percent on home health compare. If they are not, there is a really good chance somebody does not understand the differences between an Episode of Care and a 60 day episode.

There it is. Three pages, three unskilled illustrations and almost 100 words so your clinicians will be able to correctly assess whether or not your patients have been vaccinated against the flu. It shouldn’t be this hard, folks. And guess what? We haven’t even touched on Pneumonia or Shingles. Let’s see what washes out in the final regs, first.

Good Luck

Change on the Horizon

The 2015 update to  Home Health PPS is considerable and provides for major and minor changes, plus a lot of interesting information.  Here’s the bullet points.

Reduction in Payment

No news here.  Everyone was expecting a decrease in payment.  It comes to approximately $81.00 subtracted from the standard episode rate.  The standard episode rate is that dollar amount which is adjusted by OASIS and other factors to find the final payment rate.  In contrast, the per visit rate has gone up slightly. 

Face to Face documentation requirements

A face-to-face document is still required but the narrative section has been removed effective January 1, 2015.  Within the regulations the effect of the Face-to-Face requirement has been described as follows:

  • The error rate for home health claims was calculated to be 17.5 percent.
  • The majority of home health improper payments were due to “insufficient
    documentation” errors. “Insufficient documentation” errors occur when the medical documentation submitted is inadequate to support payment for the services billed or when a specific documentation element that is required (as described above) is missing. Most “insufficient documentation” errors for home health occurred when the narrative portion of the face-to-face encounter documentation did not sufficiently describe how the clinical findings from the encounter supported the beneficiary’s homebound status and need for skilled services, as
    required by §424.22(a)(1)(v).
    • CMS-1611-F  Page 37

ImportantAll episodes beginning with an OASIS Start of Care assessment will require  Face-to-Face documentation.  While the risk of denial related to the narrative has been reduced, agencies will have far more opportunities to make an error.  This includes patients who return to service after being discharged and patients who were in the hospital over day 60 of an episode and must be readmitted for purposes of billing. 

MD/hospital documentation:  The regulations state that if requested, an agency must cough up the hospital’s documentation if the patient was admitted directly from the hospital or the physician’s notes that demonstrates eligibility.  This should be happening already but from reading clinical records, it is obvious that often the nurses caring for the patient are not reading the hospital documentation.  Do not wait until 2015 to add getting the MD records in the chart prior to billing.

Interesting and Important:  I think the following excerpt is saying that if agencies provide the physician with the information to support eligibility, the physician may use it if he or she signs off on it.   This is in stark contrast to not being able to help the physician compose the narrative.  Read for yourself and feel free offer your own opinion.

The initial assessment visit must be done to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The Medicare CoPs, at §484.55(b), require a comprehensive assessment to be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care, and for eligibility for the Medicare home health benefit to be determined, including homebound status. We would expect that the findings
from initial assessment and/or comprehensive assessment of the patient would be communicated to the certifying physician.

The certifying physician can incorporate this information into his/her
medical record for the patient and use it to develop the plan of care and to support his/her certification of patient eligibility. The certifying physician must review and sign off on anything incorporated it into his or her medical record for the patient that is used to substantiate the certification/re-certification of patient eligibility for the home health benefit.

End in Sight

Twice in the Federal Regs, there is a directive that all patients whose care extends into a second episode, must be recertified with a documented estimated end in sight for skilled care.  I really thought I missed something in the proposed regs but Lisa Selman-Holman did not see it, either.  Regardless of who saw what, the directive is in place.  Be careful of ‘statutory’ reasons for denial.  This has the potential to be like dates, signatures, etc.  Once it is identified that a recertification did not meet requirements, a full denial can be issued.


There are some changes to the payment calculations.  I am hoping that someone with a better head for math than myself with go through all the numbers and explain to us the difference.  Consider that a cry for help.

Data Submission

There has always been a provision in the Prospective Payment System for a 2 percent penalty for those agencies that did not submit OASIS data.  Nobody knew what that meant.  Did it mean penalties for no data submission or less than 100% data submission?  It has finally been clarified for agencies as 70% of qualifying episodes in 2015 with gradual increases over the next several years. 

Since it is now a requirement for payment that the OASIS data used to determine payment be in the state repository prior to billing, this new definition strikes us as ‘late’ for lack of a better word.  If you are not sure of your data submission status, call us now. You need help.

Value Based Purchasing

Value Based Purchasing is recycled Pay-for-Performance.  The actual indicators that will factor into any payment adjustments have yet to be determined which was common theme in the P4P predecessor.  Although this is not our first rodeo with the concept of Value Based Purchasing, this one may stick.  Keep your ears to the ground for more information.

These regulations run through 259 pages but like most, there is a lot of fluff and stuff inserted between the good stuff.  Take some time and read through the comments and look at some of the data.  We will be doing so as well and posting anything interesting or important we find.

Good luck.  It’s always an adventure when the regulations are changed.


Taking Care of Numbers

Medicare is talking once again about value based purchasing in home health.  This is another name for pay-for-performance which was all the rage ten or so years ago and later, fell off the radar. Basically,  Medicare wants to increase payment to providers for being good providers and reduce payment to ‘bad’ providers.  Tonight’s post is about just one of many reasons why I do not like Paying for performance or outcomes.  Read between the lines and see if you can imagine home health and hospice providers chasing numbers when value based purchasing comes around.

My mother had a heart attack several years ago.  My father, an engineer and manager by education called me that Mama was having chest pain but that when he took her blood pressure it was fine.  I told him to take her to the hospital.  He proceeded to tell me that her blood pressure on the other arm was quite different.  A significant difference in readings between the two arms is characteristic of an aortic aneurysm so I told him even more emphatically to take her to the hospital.  He insisted on giving me the actual readings which were off by four millimeters of mercury easing my mind about aneurysms and such but I had not had any coffee so I hung up and after telling him I would see him at the hospital.

At the hospital, he asked me what MI was.  Mama had just been taken in the back and there was no credible information that she suffered an MI.  After a detailed explanation, he asked why they put it on the form between first name and last name.  Still no coffee.  This was going to be a long morning.  Daddy can’t hear very well and in his anxious state, I hated to leave him in search of caffeine.

I spent many years working in a cath lab.  Even looking at the clock, the number of minutes seemed excessive although not as excessive as the number of hours it felt like waiting.  Finally, the doctor called me back and showed me the films.

Nothing.  All I saw was wide open vessels.  Mind you, I’m good at this.  I can spot a diseased vessel that most people miss.  I did not see anything.

He repeated the films several times and challenged me, ‘You still don’t see it, do you?’  Grinning like the winner of an Easter egg hunt who found the golden egg, he showed me the culprit.  The tiniest branch of a branch of a branch at the apex of her heart originating at the right coronary artery was occluded.  He explained he couldn’t find it either which accounted for the delay.  He had to review the films and reshoot a couple of times to be certain.  Even with coffee and even if I had seen it, I might have written it off to a flaw in the images.

I was relieved.  Mama felt stupid as though she should have known that it was insignificant and Daddy continued to wax eloquently about the variable blood pressure readings.  All was well except my son was very angry that we forgot to tell him that his favorite person in the world had a heart attack.

A couple of days later, Daddy called to say Mama was tired and cranky and not able to do her stuff at church.  I went to see what was up and found that she had been placed on a beta blocker, aspirin and a statin drug because it was hospital protocol for anyone with a diagnosis of MI.  Mama is petite on good days and just short on other days and 25 mg of Lopressor was taking it’s toll on her.  She was fine after she stopped it.

She did not need any of the three.  Her drug of choice for pain is old fashioned Bufferin.   I have almost had to admit her to detox for it any number of times.  Her cholesterol is within normal limits and her coronary vasculature was award winning.  She exercises regularly and eats so well, I imagine there is an ICD-9 code for her self-imposed dietary restrictions.

Meanwhile, the hospital’s outcomes are keeping up with the Jones’s.  In the wisdom of evidence based practice my mother was prescribed three meds that would do her no good.  Granted, they were cheap and if I had to choose, I would prefer a global policy of prescribing them for everyone rather than miss a few who needed the medications.

I don’t have to choose as it turns out.  Medicare has already determined what pretty much every heart attack patient in the country needs.  With all of the critical thinking required to open a refrigerator door, our physicians order medications for all patients according to pre-printed recipe. The hospitals and the physicians with privileges at the hospitals are chasing numbers instead of taking care of individual patients.

What bothers me the most about treating the numbers is that although minor, there are side-effects to the medications prescribed to my mother as she was discharged from the hospital.  There was a potential for dizziness and orthostatic hypotension resulting in a fall from the beta blocker.  There are side effects of statins including memory loss.  An aspirin a day shouldn’t hurt anyone but nobody stopped to ask Mama what she ordinarily took for pain and too much aspirin can cause problems as well.  The chances of side effects for Mama outweighed the benefits of treatment.

Treating the hospital’s outcomes should never be mistaken for quality care of individuals.  This is something we need to remember when our reported data is being evaluated for purposes of payment.

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