1. Practical and Succinct Solutions
to Coding: Obstacles Facing
Home Health Coding and
Reimbursement Accuracy
Presented by
Susan Carmichael
MS, RN, CHCQM, COS-C, ICM, FAIHQ
EVP, Chief Compliance Officer
Select Data
2. Objectives
Discussing increasing numbers of Complexities in Home
Health that challenge reimbursement and the financial and
quality outcomes bottom line
Exploring Regulatory Issues and Agency Finances
Making Connections Between Coding, the POC, and
Keeping Your Reimbursement
Looking at Potential Impending Audits and Queries and
their Impact
ICD-10…Will you be ready or will you be one of the
agencies expected to have significant delays in payment?
3. The Forces are coming together and
They are Driving Finances
Changes in Case Mix Dollar Payment
Coding Changes and Survey Sanctions
Increased Audits
Confusion re newer requirements ;i.e Face to Face,
Therapy requirements
New Chronic Care Models
Affordable Care Act: EMR, Data Analytics
And Everything Starts with Solid Coding
Are you Keeping Up?
4. A lot is happening…
Administrative Simplification Act (transition to 5010) FY 2010-2014
Meaningful Use EHRs 2011-2015
Health reform Initiatives i.e.
ACOs 1/2012 and advancing
Value-based purchasing 2013
Chronic Care Models: Guided Care
Patient Centered Medical Home
Transitions of Care
Readmission payment penalties 2013 Impact on Home Health
Rebasing
PECOS
ICD-10, OASIS-C1, HIS, Hospice Pharmacy requirements
6. The Coding team
The Coding Specialist is the one who can verify
adequacy of initial documentation for the codes
assigned, but more importantly, that means:
verifies the reasons for the episode of care.
If your coder is not challenging documentation
adequacy and specificity, raising questions for the
clinician and the physician, and asking for H&Ps
and other data, you may be at risk.
7. M1800
Is your coding team looking at the functional
scores of M1800?
Do your clinicians understand how to answer that
question? Clinicians may mark “0” as default
answer just because the patient lives alone or does
not have a caregiver. “0” or “1” is to be used when
the patient has a high level of functionality
Incorrect answers mean increased audit risk. This
M question supports reimbursement and is a focus
for audits
8. Proper Coding Sets the Scene for
Quality Outcomes
Coding is not just assigning a code to a diagnosis. It is so
much more!
The clinical assessment must be complete enough to drive
and justify a plan of care for 60 days prospectively
Auditors look at OASIS answers
They look at the diagnoses code because those codes tell
them about the patient and their needs
The frequency and duration must be in sync with the
diagnoses assigned
10. Documentation Accuracy
Diagnoses and the ICD-9 codes reported on
each and every claim must match the
diagnoses reported in M1022
The OASIS, POC, and the UB-04, must all
match
Added to that is the primary reason the
physician ordered home health care. Let’s
discuss F2F.
11. The OASIS M1016
M1016 refers to diagnoses requiring Medical or
Treatment Regimen changes within the past 14 days prior
to the SOC
The diagnoses of the past 14 days prior to the SOC must
be listed
Are the coder s requiring completion of M1016 by the
clinician? Surveyors can ask who is completing the OASIS
questions. Remember the regulations, only one clinician
completes the OASIS integrated assessment. This is NOT
to be completed by a coder or clerk.
12. Coding Guidelines
M1020a/M1022b/M1024a-f
Must be cautious as to risk of up-coding and down-coding
Sequencing must be reflected by specific documentation
Record must reflect homebound status and medical
necessity or it can not be coded. Is that verified first?
Has the coding specialist assessed that there has been a
review of each medication?
The coding specialist must be certain substantive
documentation exists to support each and every code
assigned or the code must be omitted or documentation
must be obtained.
13. Internal auditor
Do you employ an internal auditor sampling coding
monthly for accuracy?
For instance, have you audited wounds and useage of the
correct aftercare code? There is a significant number of
codes This is an audit focus.
Frequently, audits reveal the coder was unaware that
aftercare for traumatic fractures is excluded from V58.43
and should instead be reported with codes V54.10-V54.19
(Aftercare for healing traumatic fracture).
This is one of, at least 10 areas that should be audited.
14. The billing pre audit
There should be a review checklist for the
OASIS, the POC, the UB-04,
Codes must match on all three documents
The documentation must substantiate the
codes chosen
The codes can significantly impact
reimbursement and result in under or up
coding. Can you afford the Risk?
15. Therapy documentation is a
focus
The coding specialist is seeking
clarification of medical necessity, viewing
clearly defined goals, and proper diagnostic
codes
6/30/11 large HHA had to settle with DOJ:
Price $65 million dollars! Related to
primarily therapy overutilization not
justified by assessment or plan of care.
That was expensive lack of
16. Therapy: Abnormality of Gait
If 781.2 Abnormality of Gait is used to justify PT care, PT
needs specific documentation to support gait and
balance and strength e.g. TUG or Tinetti Test Tools. Gait
training should be specific with objective measurement
progress. The gait should be described specifically and
graphically; ataxic, spastic, staggers with increase in
ambulation of ___feet this day. Lack of documentation
specifics means the coding team must request more detail.
Is the coder verifying the detail of the therapy
documentation?
17. Therapy: Difficulty in Walking
If 719.7- Difficulty in walking is coded, the therapist
should be clear that this is due to e.g. degenerative and
chronic joint disease. This code is used for e.g. gait
deficiencies due to lower extremity joint stiffness or
effusion. If this is not documented the visit is at risk as is
the plan.
Is the coding team requesting documentation to
support the diagnosis?
18. Therapy: Muscle Weakness
If muscle weakness 728.87 is coded, there should
be manual muscle strength tests indicating
weakness. The therapeutic plan should have
specific exercises and goals related to the
weakness. NOTE: Absence of a specific exercise
plan can jeopardize visit payments.
Who is challenging therapy for the SPECIFIC
documentation needed?
20. The Case for the Matrix
Having specific matrixes creates
consistency in coding.
Matrixes provide guidelines to be certain
supportive documentation is present.
Lack of documentation places
reimbursement in jeopardy.
Establishing such matrixes requires hours of
time invested, but is necessary.
21. RACs, MACs, Z-Pics:
The Auditors are Unleashed
What are your agency case mix averages by
admission: clinician: diagnosis?
Do you know your top five diagnostic patient
profiles?
How do you set visit frequencies? Formula-based
or what seems right?
Are you making visits that have no impact on
patient outcomes?
Are you auditing for homebound status?
22. RACs, MACs, Z-Pics:
The Auditors are Unleashed
Are you making visits that have no impact
on patient outcomes?
Are you auditing for medical necessity?
Does supply usage have adequate
supportive documentation?
Do you know what coding, operational, or
billing edits you are routinely triggering?
23. RACs, MACs, Z-Pics:
The Auditors are Unleashed
Are you auditing documentation for medical necessity?
What is your cost per visit by discipline?
What is your recertification percentage?
How are you applying the data collected to your business
processes?
24. RACs, MACs, Z-Pics:
The Auditors are Unleashed
The RACs, MACs, MICs, and Z-PICs are
now in place. The auditors are expected to
perform. They have been chosen based
upon performance.
Algorithms and Matrixes are in place using
Predictive Analytics.
The NEW RAC is dedicated to home
health, hospice, and DME
25. RACs, MACs, Z-Pics:
The Auditors are Unleashed
CMS is using predictive models to identify
patterns found in transactional data gathered to
identify risks and potential future behaviors.
Auditors are looking at diagnoses in relation to
visit frequencies and re-certifications.
They are looking at HIPPS scores compared to
visit frequencies and durations. They should be
looking at these.
26. RACs, MACs, Z-Pics:
The Auditors are Unleashed
They are looking at predictive models that
capture relationships among many factors to
allow assessment of risk or potential
associated with a particular set of
assessment/care frequency/payments
expected. In other words, what are the
guiding decision-making factors for
agency transactions?
27. RACs, MACs, Z-Pics:
The Auditors are Unleashed
Predictive analytics look at past performance to assess how
likely an agency is to exhibit a specific behavior in the
future. Poor coding performance places an agency in
jeopardy.
That behavior is then compared to other agencies’
behavior in order to calculate risk then encompasses
models that seek out subtle data patterns that answer
questions about that agency’s overall performance.
These analytics quickly become fraud detection models.
28. RACs, MACs, Z-Pics:
The Auditors are Unleashed
Predictive analytics look at past performance to assess how
likely an agency is to exhibit a specific behavior in the
future.
That behavior is then compared to other agencies’
behavior in order to calculate risk then encompasses
models that seek out subtle data patterns that answer
questions about that agency’s overall performance.
These analytics quickly become fraud detection models.
29. RACs, MACs, Z-Pics:
The Auditors are Unleashed
What happens if compliance measures are not
employed?
Targeted Medical Reviews (TMRs)/(ADRs)
Additional Documentation Requests will rise.
There will be claim denials and Medicare audits
per the OIG as new fraud and abuse
countermeasures are put into place.
30. RACs, MACs, Z-Pics:
The Auditors are Unleashed
Annually, CMS receives 1.2 billion claims.
That breaks down to 4.3 million claims per work
day,
574,000 claims per hour, and
9,579 claims per minute.
Fraud and abuse are on the rise and the pressure is
on. An increasing number of agencies are seeking
outside expertise.
32. RACs, MACs, Z-Pics:
The Auditors are Unleashed
RACs- The contingency motivated Recovery
Audit Contractors (retrospectively focused). The
RAC Demonstration Project of 2005-2007
recovered over $1.3 billion, most due to medically
unnecessary services (45%), incorrect coding
(35%), and insufficient documentation (10%).
With four RAC approved firms covering specific
geographic regions, this auditor is expected to
continue their positive recovery program. The
RAC demonstration project yielded a cost of
only ,22 cents for every $1.00 recovered.
33. RACs, MACs, Z-Pics:
The Auditors are Unleashed
MACs – Medicare Administrative Contractors have been
transitioning in and replacing the Regional Home Health
Intermediaries (RHHIs). There are 15 MACs with 4
focusing only on DME claims. Though providers fear the
RACs, they are well aware of the power of the MAC. This
auditing body can impose “severe administrative
action” such as up to 100% prepayment review,
payment suspension, and use of statistical sampling for
over payment estimation of claims (current and
prospective focus).
MACs have power and Congress is encouraging them to
use it.
34. RACs, MACs, Z-Pics:
The Auditors are Unleashed
CERTS - To better calculate the performance of the FIs
and MACs, as well as to look at the reasons for their
errors, CMS decided to look at a number of additional
rates. The additional rates include
1) provider compliance error (how well providers prepared
claims for submission)
2) paid claims error rates (measures how accurately FIs
and MACs make coverage, coding, and other claims
payment decisions). CERTs randomly select a sample of
about a 100,000 claims each reporting period.
35. RACs, MACs, Z-Pics:
The Auditors are Unleashed
CERTs review the claims for proper Medicare
coverage, coding, and billing rules, and if not in
compliance, they assign an overall error rate.
CERTs also identify if providers received
overpayment letters or notices of adjustments to
be made for claims that were overpaid and
underpaid. CERTs are considered the Quality
Improvement specialists who track and trend the
performance of fiscal intermediaries and Medicare
Administrative Contractors.
36. RACs, MACs, Z-Pics:
The Auditors are Unleashed
Z-PICs- The Z-PICs act with the Department of
Justice and FBI and act as the investigators when
fraud is very strongly thought to have been found.
The Z-PICs have the power to suspend claims
for up to a year and the agency has no appeal
recourse during that time. That power can
cripple or financially devastate an agency. They
have become very aggressive.
37. RACs, MACs, Z-Pics:
The Auditors are Unleashed
The HEAT is the technologically oriented
auditing body using state of the art analytics
to expand the CMS Medicaid provider audit
program. This program leadership has
meetings with top anti-fraud leaders in
Congress/Law enforcement/Private sector.
38. Retaining Your Dollars
Be certain a clinical documentation chart audit is available
for all disciplines for clinical records, documentation must
be consistent, complete, and defendable..
The following items should be included in every clinical
note:
Homebound status: Identify what taxing effort was
exerted if a patient left the house since the last clinical
visit. Be certain all assistive devices are listed and/or the
caregivers needed, the purpose for leaving the home, and if
this was expected and/or a part of the careplan. Initially,
this is reviewed by coding.
39. Retaining Your Dollars
Identify what skilled the visit. If teaching was conducted,
was it initial teaching, reinforcement teaching, or was it re-
teaching? Identify in objective terminology measureable
progress towards goals; ie for the psych nurse, what
evidence toward cognitive structural behavior was
identified? For physical therapy, how many feet were
walked since the last visit and where does this relate to the
plan? For the SN, did the patient identify at least two key
side effects for their medications? Does the patient know
what their medication is for and what it is expected to do
for them? Do they know how to safely take their
medications?
40. Retaining Your Dollars
• Compare the Visits to the POC: Compare the
visit to the plan that is compared to the
assessment. Have physician orders or notification
for changes in condition. Note all change of
condition clearly.
• SN should be reviewing the body systems noting
VS and pain assessments
41. Retaining Your Dollars
• When Teaching: Note if the teaching is
New, Reinforced Teaching, or Re-teaching
of the same subject to, perhaps, another
caregiver. Note the caregivers willingness
and capacity to learn and carry out the
learning skills. Note the patient and
caregiver’s learning in percentage; ie 70%
or 80%.
42. Retaining Your Dollars
• Specificity of wounds, skin conditions,
falls risk, depression, and the focus of care
are necessary. Auditors look for detail; for
reasons that support skill. No skill can mean
denial of visit payment. Recertification
requires significant specific documentation
• Let’s discuss.
43. Retaining Your Dollars
• Interdisciplinary communication:
Comments to the physical therapist or the
home health aide or other disciplines should
be clearly noted. The visits should show the
progress of the care in relation to the plan of
care.
• This information is reviewed by the coder
for recertification.
44. Survey Provisions go into Effect
7/1/2014
• Monetary sanctions between $8500-
$10,000
for condition level deficiencies that place a
patient in immediate jeopardy
Fines of $8500 for repeat deficiencies
Fines of $400 -$5000 per day for other
deficiencies not placing a patient in
jeopardy
45. Sanctions
• Monetary sanctions are not the only sanctions that
CMS may impose.
• Alternative or additional sanctions include
suspension of payments for new admissions and
new episodes of care, temporary management of
care, mandated directed inservices and training, as
well as the temporary management of deficient
agencies including making personnel changes and
providing necessary interventions to assist the
agency back into compliance.
46. Surveyor and Documentation
• The rules place much more pressure on a home health
agency requiring excellent documentation of care
following a careplan that is consistent with the needs
identified in the patient clinical assessment.
• It will require coding to the highest level of specificity.
• If outcomes are not achieved because needs were not
appropriately identified, visits were missed, or care was
not appropriately delivered, an agency could face
sanctions.
47. Survey Provisions
• The New Proposed Rules would place
increased pressure on agencies for excellent
documentation of care following the
construction of a careplan consistent with
the patient assessment.
• Does your Coding Team challenge the
adequacy of the documentation to
support each diagnosis?
48. Surveyors
• Care should be modified for Patient
Response
• Decrease frequency as safety and learning
is achieved
• Well established care, properly coded
prompts outcomes
• Eliminate missed visits, poor compliance,
patient and caregiver disconnect
49. Surveyors
• Looking for Responsible Reasonable Rehab
services as well as general care delivery
• Contractors are the agency responsibility
• Are orders and goals tracked and updated?
• Does the Recertification process require
a review of the prior episode coding?
Will your recertification reflect real
Need?
50. ICD-10 Are you Preparing for
ICD-10?
• “ICD-10 requires changes to almost all clinical and
administrative systems. It requires changes to business
processes.”CMS
• ICD-10 is one of the most significant events
planned for the industry.
It impacts all Home Health departments.
Training needs exist for Coding, Billing, Nurses,
Therapists, Office personnel, IT, and others.
Do not waste this year. Assist clinicians to document with
more specificity.
51. Clinical Algorithms
• Increased specificity in data means more
robust design of algorithms to predict
outcomes and care
• Increased coding detail offers capability to
find previously unrecognized relationships
of diseases and variables
52. Coding Detail
• Increased specificity in data means more
robust design of algorithms to predict
outcomes and care
• Increased coding detail offers capability to
find previously unrecognized relationships
of diseases and variables
53. ICD -10
• ICD-9-CM codes will not be accepted for
services provided on or after 10/1/2015
• ICD-10 codes will NOT be accepted for
services prior to 10/1/2015
• Do not wait to improve on required
documentation
• Get started NOW!
54. Increased number of digits and
codes
CD-10 Codes provide greater detail in diagnoses and
procedural description
Greater number also. 16,000 to more than 68,000
codes. Use of combination codes
ICD-10 codes have up to 7 digits and more alpha
characters. The first digit is alpha. A code will
be considered invalid if not coded to full number
of characters (3,4,6,7)
Systems will be required to accommodate ICD-10
codes
55. Coding Changes
• Injuries are grouped by anatomical site
rather than injury category
• Post operative complications have been
moved to procedure in the specific body
system chapter
56. Differences
• ICD-9-CM Digits 2-5 are numeric
• ICD-10-CM Digits 2 and 3 are numeric, digits 4-7 are
alpha or numeric
• ICD-9-CM Decimal point after 3rd
digit
• ICD-10-CM Decimal point after 3rd
digit
• ICD-9-CM Dummy placeholder? NO
• ICD-10-CM Dummy placeholder? YES
57. Increased Specificity
•
ICD-9-CM 17 Chapters and V/E code chapters
•
ICD-10-CM 21 Chapters- V/E codes in disease
chapters
•
ICD-9-CM 13,000 disease plus V and E codes
•
ICD-10-CM 68,000 disease codes, including V
and E codes
58. Increased Specificity
• ICD-9-CM Codes usually do not indicate timing
encounter
• ICD-10-CM Codes specify initial and subsequent
encounters
• ICD-9-CM No differentiation between left/right
• ICD-10-CM Differentiates between right and left
59. Increased specificity required
• Requires expertise in
anatomy,
physiology, and
diagnostics
The Coding specificity is far greater than
ICD-9-CM and the need to better
understand A&P and diagnostics is vital
60. Provider Impact
• Billing and Eligibility Transactions
– New codes mean greater specificity
– Means detailed documentation
– CMS states there will be increased
rejections, denials, and pends as both
plans and providers get accustomed to the
new codes
61. Technology Impact
• Modifications to Field sizes
• Alphanumeric Composition
• Decimal Use
• Redefining Code Values
• Edit and Logic Changes
• Table Structure Modifications
• Forms
• Interfaces
62. Business Ops and Clinical
Impact
• Modifications to Field sizes
• Alphanumeric Composition
• Decimal Use
• Redefining Code Values
• Edit and Logic Changes
• Table Structure Modifications
• Forms Interface
63. Time to Make a Decision
• If You are Comfortable that your coding
Team can be educated fully and completed
in time and be trained economically- Start
your Transition Plan NOW!!
• Include Anatomy, Physiology,
Pathophysiology, Diagnostics,
Pharmacology training for Coders and
Clinicians. Accent the specificity needed.
64. Third Party Expertise Option
• If you are already concerned about
reimbursement and cannot afford to not
only send your coding team for the over 50
training hours experts say are necessary but
must also incur the cost of a replacement
team to code and incur the costs of parallel
coding (ICD-9 and ICD-10 simultaneously
month prior to October 1, 2015, then you
should consider third party expertise.
65. If We Can Assist you in this
Decision
• Assisting Home Health and Hospice
Agencies for over two decades…..Contact:
• Susan Carmichael
• MS, RN, CHCQM, COS-C, ICM, FAIHQ
• Executive Vice President, Chief Compliance Officer
• 4155 E. La Palma Ave Suite 250
• Anaheim, CA 92807
• 714.524.2500 x235
• 949.584.6296 Cell
