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Posts tagged ‘ZPIC Documentation’

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 3.3.2.5 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.

Spelling Lesson


I received a request posted as a comment on a post written a while back called, ‘Documentation, Again!’  It reads as follows:

I wish you would follow up on this blog as it is connected to the number of visits that nurses are required to do on a daily basis. The “p” word – productivity is the game, as nurses will work off the clock to try not sink in case management and oasis issues. Somewhere in the world a daily productivity of 5.3 patients came around. However with the growth of paperwork and regulations, many nurses who are fighting to be there for their families in the evenings, work on paperwork out of fear. Home Health turnover is high because of this continued lie. You can’t tell nurses that they can completely finish 2 IAs and a visit, fully coding and doing 485 and 486 within 8 hours every time. I had a director who said that to do an IA you should stay in the home about 30 to 45 minutes then finish the paperwork later. Hum, check meds and do an assessment and ask oasis questions and go over plan of care in 45 minutes. How do we turn this lie around, without going to Labor Boards, etc. I believe that sometimes doing less turns out to be more money in the bank, if you focus on getting quality and consistency first, and building from there.

I am nothing if not accommodating, so please allow me to address this writers concerns directly.

Most people think that hell is spelled, H-E-L-L.  It is not.  Hell is spelled, Z-P-I-C.  However, if you are lucky enough to avoid a ZPIC, rest assured in the knowledge that more audits are coming our way.  The description sounds a lot like FMR pre-payment audits.  Don’t forget about the new Medicaid RAC’s.  Any way you look at it, you are likely to be scrutinized in the coming year or so by one or more payor sources who want their money back.

Two admits and a regular visit can be done but not every day. I couldn’t do it.  I am not that good and have no desire to be.

As far as charting after you leave the home, that’s not really such a good idea.  I think pretty much every nurse has been in McDonald’s or Starbucks charting when they realize they did not assess something.  Maybe they started but then the office called to see if they could do another admit and they got distracted.  A forgotten TUG score or temp are not really numbers you can just guestimate.  Well, you can but documenting your guesses is really crossing the line.

The flip side of not being a slave to an arbitrary number is that productivity often drops when nurses are paid salary.  It makes perfect sense on paper to have nurses on salary and ask them to maintain average and reasonable productivity standards but it just NEVER has worked.

I was in a client’s office about two and a half years ago reviewing clinical records when the Administrator, new to home health, asked me to look at productivity.  She wasn’t sure but she thought that maybe the RN’s should be able to do more than one or two visits a day.  I went about my business because obviously this home health newbie had her numbers confused.  Before I left, I asked to look at logged visits.  My next thought was that the person doing the logging was incredibly inept at clicking the mouse.  Productivity was so absurdly low that I didn’t believe it until I started asking the nurses.

Long story short, she went to pay per visit but didn’t want to cut their pay so she paid them more per visit than I have ever seen any nurse get paid per visit.  Sounds like a nut, doesn’t she?

If you think that, you would be wrongo.  Her agency, rural, had a greater margin than almost all of my other clients.  Her nurses suit up and show up and there is virtually no turn around unless someone is asked to leave.  Case conferences are attended.  Orders are written.  Follow up is a way of life at that agency.  Documentation is so good it bores me to tears and they are my only client who received a deficiency free survey this year.  If they are chosen for any other audit, I will not lose a minute’s sleep over it.

So my first thought is whether or not the 5.3’ers are salaried or pay per visit.  If they are paid per visit, are they making enough so that they can take care of their patients during working hours and be home with their families at a reasonable hour most nights?

I wonder how much those people who push for admissions to be submitted to the office within 8 hours are really losing.  Do they know what is in the clinical records?  Do they realize that unless nurses are blatantly committing fraud, the aggregate of errors is just about always in favor of Medicare?  Those agencies who are brag about 3 and 4 days from admit to RAP are flirting with regulatory and fiancial disaster. Speed and accuracy rarely go hand in hand.  The only time a nurse should not take a minute to reflect on her decision is when a patient isn’t breathing and they are turning blue.  Even then………..  you got four minutes to consider the most likely cause.

But you asked me specific questions.  First of all, I do not know where the 5.3 number comes from.  I do remember CMS publishing something like that many, many years ago but it wouldn’t be accurate now.  The next question is how to turn the lie around without a bunch of commotion, etc.  I can help you there.

  1. Get all the information you can about the agency as a whole.  This is not about you or the administrator/DON.  It is about whether or not patient safety is protected at such a fast pace. Information that is relevant:
    1. Hospitalizations as reported on CMS along side your three biggest competitors.
    2. Average HHRG’s or payment if you can get it
    3. Other outcomes are not as useful but run them anyway.  Choose your three biggest competitors and run the reports from Medicare.gov
    4. Number of call outs in the past 6 months from HR
    5. Do some research.  This problem wasn’t created overnight and it will not be solved overnight.  Two more weeks will not make a difference.  Once a day, look at 10 charts for one specific thing.  It will be real easy if you use point of care.  Suggestions:
      1. Home Health Aide supervisory visits
      2. Weights recorded and reported as indicated
      3. Physician notification of out of range parameters
      4. Lab drawn timely and reported.  If orders were issued as a result of the lab, are those documented and who was notified of them?  (Check your Coumadin patients.)
      5. Are diabetics taught foot care every episode and is it done per ordered?
      6. Is pain noted on the visit sheet and if so, what was done about it?
      7. I am willing to bet you ten thousand dollars that if you grab 10 485’s and look at all the medications, you will find issues.  Put them in the free Medscape interaction checker online or use iPhone/iPad app.  Look only at the most critical ones listed first.

When you bring these numbers to the administrator, present them in a way that is impersonal and spread throughout the entire body of nurses.  A lot of people want to know who did that, etc. with the goal being to fire the offender.  When it is a little bit of everyone, it is more likely a systems or process problem.   Explain why each area of compliance poses a threat to the agency.

Weights, lab and MD notification of out of range parameters are all deficiencies.  Weights are tied to Congestive Heart Failure and that is the only diagnosis that has been shown to have an influence on home health hospitalizations.  I hold Coumadin in the same esteem as I do Oxycontin bought off the street.  It is dangerous and a malpractice lawyer’s dream. If the agency is not performing in these areas they are at risk for so many things, it would require the whole internet to put together a complete list.

Payment per episode should be close to $2,200.00 if you have a modest amount of therapy.  It should be higher if a high percentage of your patients have therapy.  If it is lower, one of two things is affecting it.  The first is that the majority of your patients are old.  I guess technically they are all mostly old but I am referring to length of time on service with the agency.  The second reason may be because the nurses are underscoring in the OASIS dataset and time and education is required to do a complete and accurate assessment.

Now, if your administrator says that they are making a whole lot more than the average or if they say they will go ahead and write the supervisory visits or if they mistakenly believe that they are too large or too small to ever be of a concern to the feds, you need to take a hike.  It is Christmas.  Spend some time with your family.  Do some baking.  Start the New Year out in a new job.  Can’t afford it?  You can afford it more than you can afford to stay at an agency that cares more about arbitrary numbers than patient care.  Trust me.  I deal with this sort of stuff for a living.

Or have your administrator call me for an unbiased agency assessment by myself or a coworker.  As a consultant, I have the freedom to walk away and not have to worry about a job.

More on Medicare Fraud and Abuse


Apparently, HHS Secretary Kathleen Sebelius ad Eric Holder, the US Attorney General had a ‘summit’ regarding Medicare Fraud and Abuse.  You can read the whole report here.

At the summit, Secretary Sebelius announced that starting July 1, HHS will begin using innovative predictive modeling technology to identify fraudulent Medicare claims on a nationwide basis, and stop claims before they are paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made.

I think this is a good idea.  There are patterns of abuse that repeat themselves in almost every fraudulent agency and it is easy to write programs that identify them.   In one of my ZPIC audits that I am working, there is a clear and distinct pattern of low utilization combined with very long lengths of stay.  This is not to say that all patients had old start of care dates.  Many of the patients have been admitted and discharged several times over. The numbers you review regarding length of stay based on individual admissions may be lower than what the feds calculate based on the entire claims history of the patient.

Another pattern that shows up repeatedly is high therapy use.  I have two excellent clients that have inordinately high therapy use but I don’t worry about them.  Many of the patients are total knee replacements or other ortho surgery and after six to nine visits, the patients are discharged.  But if all of your therapy patients are being seen for ‘gait instability’ related to chronic illnesses and all of them receive 14 or more therapy visits, expect to find yourself on the ‘naughty list’.

Overuse of any one diagnosis code alerts the feds to potential fraud.  Not everyone with impaired vision has a diagnosis that can be supported with physician documentation.  And most who do will have other claims in the Medicare system that supports the diagnosis such as ophthalmologist claims and pharmacy claims for eye medications.  The feds access to information is unmatched.  If they use it properly, no one who is even an inch over the line will be spared.

What I find particularly sad is that when I look at agencies’ clinical records, I see some practices that are common, ineffective and are certain to place the agency on a watch list somewhere.  For instance, a nurse will have been taught, and in very good faith believes that if a patient has diabetes, it should always be primary because it pays more.  And then she goes to work for one of my clients and it may take a while before the diagnosis problem is discovered.  And yet, these same agencies are continually leaving money on the table by not assessing a patient accurately.  They routinely increase payment inappropriately by a few dollars while ignoring the hundreds of dollars per day they leave on the table.

Before I take on any client, I look at the CMS reported outcomes.  In particular, I look at the hospitalization rate calculated by CMS. There may be various reasons why different agencies send their patients to the hospital but when it comes to extraordinarily high hospitalization rates (over fifty percent), there is only one reason.  The agency does not discharge patients to the community.  In other words, most of the patients who are discharged from the agency are discharged because they are in the hospital over the end of the episode and the discharge is because the agency has not been able to follow OASIS requirements resulting in a discharge and readmit.  If you think the Feds don’t know this, consider that I know it and I have a fraction of one percent of the data the feds have available to them.

So, look at your numbers.  Look for patterns.  If you are concerned that the new data mining implemented in July may pick up on some unusual patterns in your agency call me.  I can be reached at 225.253.4876 or you can always email me.  I will find your patterns, deconstruct them and help you reconstruct your care so that you make as much money as you ethically can without creating patterns that even remotely resemble anything less than one hundred percent compliant with Medicare payment guidelines.

Amuse Me!


As often as I can, I try to for write you, my faithful and beloved readers, a blog  post that pertains to our industry.  I try with varied success to make it entertaining or at least interesting.  If it is neither, then maybe it is written because it is something that you really need to know.  Now, you may not like my sense of humor or you may be completely bored by my posts in which case I suggest that you make use of your browser’s back or delete button.  But I at least try.

Field nurses, on the other hand, do not seem to care that I am bored to tears reading their documentation.    Look at the following example:

Actual Document

I can't make this stuff up.

There is nothing interesting about this documentation.  All of this with the exception of the teaching to take frequent rest periods and to take Lasix as ordered was on the flow sheet of the nurse.  I don’t care that the patient has bowel sounds in 4 quadrants.  I am so NOT interested in even and unlabored respirations.  Whoa, check out that amazing blood pressure!  Yippee.  The patient has the same pulses that are noted on the front of the visit note.

On the other hand, I know things that you don’t about this patient.  I know that she is also on potassium and I would have been interested in seeing that the patient was taught about the reasons why she needed to take her potassium as ordered along with the diuretic therapy.  Do you think if a patient keeled over due to low potassium that ‘taught to take Lasix as ordered’ will cover you in court?

Would that have been better than teaching a 94 year old patient with heart failure to avoid prolonged standing?  I am somewhat younger and no one has to teach me that!

What does, ‘take Lasix as ordered’ mean?  Again, I know things you don’t know.  I know that the patient has exceptionally poor vision, is at extremely high risk for falls and relies upon a walker to navigate in her home.  (You probably guessed that.)  Maybe it would have been better to teach the patient that when she took Lasix, it would be a good idea to be near ‘the loo’ as we called it in Australia.  Or if she had a bedside commode to make sure it was near to her after taking her Lasix to prevent falls.

Frankly, any good pharmacist will tell a patient how medications are to be taken.  It is the sole advantage of the home health care nurse to assess the patient’s ability to comply in the home environment.

Chances are if you cannot get me interested in anything you write, it is highly likely that you won’t be paid in a financial audit.  And that is the truth.  I am very interested in payment considerations.  So, tell me a story.  Prevent a fall and subsequent broken hip in an elderly patient.  Teach the patient something they can’t learn by reading Prevention Magazine or watching Television.  Remember that there are people out there paid to read nursing notes who have a burning desire to deny payment to your agency and I assure you that they have no sense of humor.

If none of that concerns you, think of me.  Yes, it is all about me.  Amuse me.

And above all, DOCUMENT WHAT YOU TAUGHT.

That’s all I have to say?  What say you?

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