J14 Surviving a Medical Review Sally.ppt [Read-Only]€¦ · • Reviews performed by NHIC,Corp....

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TMP-EDO-0006 V 1.0 07/06/2010 The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic or paper, is uncontrolled and

must be destroyed when it has served its purpose..

Surviving a MedicalReviewSally Rosiello BSN

June 1, 2012

DISCLAIMER

This information release is the property of NHIC, Corp., J14 AB MAC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide

Surviving a Medicare Audit TMP-EDO-0006 V.1.0 07/06/2010

for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NHIC, Corp. web site at www.medicarenhic.com and the CMS web site at www.cms.gov. The identification of an organization or product in this information does not imply any form of endorsement.

AgendaComprehensive Error Rate Testing (CERT)

Office of Inspector General (OIG) Reviews

Progressive Corrective Action (PCA) Process• Responding to an Additional Documentation Request (ADR)

Documentation

Home Health Advance Beneficiary Notice (HHABN)


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CERT J14 Totals55 claims reviewed

3 claims denied

2% Payment error rate

Awesome!


CERTDenial reasons• Error code 21-Insufficient documentation submitted

– Two claims

• Error code 35-unallowable service– One claim


OIG Work PlanTrends in Revenues and Expenses• Significant increase in Home Health payments

• Were billed services correctly paid?


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OIG Work PlanDocumentation must support the entries on outcome and

assessment information set (OASIS)• Diagnoses

• Upcoding

OASIS must be accepted into the state repository timely• Include tracking sheet or transmission record with records in

response to an ADR


Physician must date their signature

Plan of care must include all required items

Progressive Corrective ActionProcess developed by CMS for contractors to ensure Medicare

guidelines are followed

• Prioritize problems

• Service specific or provider specific

• Reviews performed by NHIC,Corp. staff


Progressive Corrective ActionProviders chosen by analysis of billing data

• Quarterly

• High level

• Comparison to peers– Number of visits

– Diagnosis

– Length of time on service


Length of time on service

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Progressive Corrective ActionTwo types of reviews

• Postpay

• Prepay


Progressive Corrective ActionEducational focus

• Result letter

• Additional review

• Education regarding guidelines

• Corrective Action Plan (CAP)


Corrective Action PlanProblems identified

Action plan to correct each problem• Begin with each denial reason & work backwards to correct each

issue

Timeline for implementation of each action

How corrective action will be monitored

Name of person responsible for carrying out each action of plan


Name of person responsible for carrying out each action of plan

Date you will implement plan

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Corrective Action PlanProblem-Physical Therapy (PT) and Occupational Therapy (OT)

services not reasonable and necessary• Educational conference call with NHIC,Corp. Provider Outreach &

Education (POE) on 04/10/12 was attended by M. Jones PT and J. Smith OT. They each met with their therapists and assistants to review information.

• M. Jones and J. Smith are assessing 20% of all therapy records to ensure patients meet guidelines and documentation is adequate


p g qbeginning 4/1/12 through release.

• Weekly staff meetings for all therapy staff to peer review documentation begun 3/21/12. M. Jones leads the meetings.

Corrective Action PlanProblem-Nursing services not reasonable & necessary• Educational conference call with NHIC, Corp. POE on 04/10/12 was

attended by all registered nurses and licensed practical nurses

• N. Nurse, Director Patient Services (DPS) is reviewing 40% of assessments for patients admitted for nursing services effective 4/13/12

• Nursing Supervisors are meeting every Wednesday to peer review nursing documentation and each follows up with nursing staff


nursing documentation and each follows up with nursing staff regarding suggestions. They report to DPS on specific findings effective 4/20/12

Responding to ADRsEach ADR lists records to be sent• Double check to be sure all needed records are included

–For correct patient

–For correct episode

–A visit note is included for each visit

–Evaluations and progress notes from prior episode if indicated

–Everything needed to “paint a complete picture” of patient


• ADR needs to be on top of records for claim

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Submission of RecordsRecords should be returned within 30 days of the date of ADR

An additional 15 days allowed• Allows extra time for mail issues & scanning

• Upon receipt of records the claim is “moved” – Claim will deny if not move


Electronic SubmissionElectronic Submission of Medical Documentation (esMD)

Uses a CONNECT–compatible gateway to submit records• Develop own gateway

• Health Information Handler (HIH)

Transmits electronic records securely


Records Submission ErrorsRecords not received timely• Results in 56900 reason code

• Goal must be to have records received in our office by day 30


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Records Submission ErrorsInsufficient documentation submitted• Missing visit note for one or more visits

• Missing therapy evaluation and progress reports that occurred in prior episode

• Documents submitted for wrong episode or wrong patient


OASISReviewers must ensure the OASIS was accepted into state

repository timely

Include tracking sheet or transmission record of OASIS when responding to an ADR


DOCUMENTATION


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Face-to-Face EncounterLabeled as face-to-face

Date of encounter

Homebound status

Services needed• PT, OT, Speech-Language Pathology (SLP), Nursing (NSG), home

health (HH) aide


health (HH) aide

Clinical information• Total knee replacement (TKR), difficulty ambulating, unsteady gait,

shortness of breath (SOB)

Certification statement

Dated signature

Face-to-Face EncounterDate of face-to-face encounter: 12/11/11

Homebound status: difficulty ambulating, unsteady gait

Services needed: • PT _X__ SLP ____ HH aide X

• OT ____ NSG _X__

Clinical information to support the need for services: Left total hip replacement (THR)


hip replacement (THR)


Signature: Dr. Jack Doe Date: 12/18/2011

Face-to-Face EncounterDate of face-to-face encounter: January 4, 2012

Homebound status: SOB

Services needed:• NSG _X__ OT _____ HH aide _____

• PT ____ SLP _____ Medical Social worker (MSW) _____

Reasons patient requires services: congestive heart failure (CHF) and emphysema


(CHF) and emphysema


Signature: Dr. W. Right Date: 1/4/2012

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Face-to-Face EncounterExample:

Dated timely

Nursing services needed


Physician name and date but not signed

Included an office visit note for this date and it is signed by h i i


physician• Initial visit with this physician. Her previous physician had retired

• Hypertension is reason for home care. Was on 2 medications for this and blood pressure (BP) was 160/80.

• No mention of homebound status other than she doesn’t drive– Not driving would not make her homebound

– Is doing gardening

QuestionIf face-to-face encounter occurred within 90 days before or 30

days after the start of care (SOC) but the signature is after those periods, will the face-to-face be acceptable as long as signature is dated before claim is billed?


AnswerYes, as long as the encounter occurred timely and signature was

obtained prior to claim being submitted, the face-to-face will be accepted


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Homebound StatusMain issue is how often patient leaves home for reasons other

than for medical care

Day care• Attendance at state licensed or certified day care can be acceptable


Homebound StatusPatient is mentally challenged and attends a “workshop” for the

mentally challenged three days a week. He is transported by van to the workshop. He uses a walker for severe arthritis and also has diabetes. The nurse visits twice a week to provide wound care. Would this be covered?


Homebound StatusWe would not consider a “workshop” the same as day care

unless it is meeting the statutory definition of a day care program. That is state licensed or certified or accredited by an accrediting body. Without documentation showing it is a day care program, services would be denied.


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Homebound StatusNurse visits a patient who explains she saw the physician

yesterday and she is now allowed to drive. She and her husband went out to dinner last night to celebrate. She is resuming her volunteer work at the local museum tomorrow. The nurse did not know this had occurred prior to the visit. Is the visit billable to Medicare?


Homebound StatusNo. Patient is not homebound so the patient is not eligible for

services under the home health benefit. Although nurse did not know this beforehand, visit should not be billed


Nursing DocumentationWhy does this person need skilled

nursing now?• Recent diagnosis, exacerbation, or hospitalization

• Change in treatment regimen


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Observation & AssessmentEvery visit has to be medically necessary

When condition stabilizes, additional visits no longer necessary


Observation & AssessmentPatient discharged from hospital with CHF. Plan to visit 2 times

a week for 3 weeks

2/7/12 Admission assessment: BP 148/74, pulse (P) 86 and regular, respirations (R) 22, Oxygen saturation 94% room air, weight 156 pounds, breath sounds clear bilaterally, intermittent cough-productive of clear mucous, 2+ non-pitting pedal edema. Feels tired, denies SOB. Reviewed medication regimen and verbalized understanding N Nurse


medication regimen and verbalized understanding. N. Nurse RN

Observation & Assessment2/10/12 BP 152/92 P 98 regular R 24 Oxygen saturation 92%,

breath sounds rales in bases, coughing more than last visit-non-productive, 1+ pedal edema. Feels tired-not sleeping well due to cough and sleeping in chair. Called Dr. Smith. Additional furosemide 40 milligrams (mg) orally ordered for today and increase dose to 40 mg daily. Patient and daughter notified. N.Nurse RN


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Observation & Assessment2/14/12 BP 136/80 P 80-regular R 20 Oxygen saturation 95%,

breath sounds clear, coughing intermittently-non-productive, 2+ pedal edema, feels “better”, no SOB. N. Nurse RN


Observation & Assessment2/17/12-BP 126/78, P 80 regular, R 18, breath sounds remain

clear. Oxygen saturation 94%, weight 155, States she is coughing less and now able to sleep in bed with an extra pillow, 1+ pedal edema. She filled her medication set correctly. N. Nurse RN


Observation & Assessment2/20/12 BP 132/80 P 82 R 18 Oxygen saturation 96% on room

air. Coughing occasionally-much less than last visit. Minimal edema. States her breathing is “good”. Breath sounds clear. Call to Dr. Smith. Discharge from home care today. N. Nurse RN


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Wound Care6/1/11 Right lower leg 4.0 x 3.4 x 1.7 centimeters (cm). Wound

bed has yellow slough, moderate amount, foul-smelling yellow drainage. Pain level 5/10. Taught wound care to daughter who is caregiver. Demonstrated ability to do wound care. Daughter to do wound care 5 days. Will visit twice a week to assess and do wound care. N. Nurse RN


Wound Care6/4/11 Right lower leg moderate yellow drainage. Wound bed

has small amount pink and rest yellow slough. Wound care per plan of care. Daughter expresses no concern with performing wound care. Pain level 5/10. N. Nurse RN


Wound Care6/8/11 Right lower leg 3.6 x 3.0 x 1.0 cm. Wound bed is 1/3

pink, 2/3 yellow slough with moderate drainage. Pain 4/10. Dressing per plan of care. N. Nurse RN

6/12/11 Right lower leg wound is 2/3 pink, 1/3 yellow with minimum drainage. Pain 4/10. Dressing per plan of care. N. Nurse RN


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Wound Care6/15/11 Right lower leg 3.3 x 2.5 x 0.5. Minimal yellow

drainage. Wound bed ¼ yellow, ¾ pink. Pain 3/10. Dressing per plan of care. N. Nurse RN

6/19/11 right lower leg. Minimal light yellow drainage. Wound bed ¾ pink, ¼ yellow. Pain 4/10. Dressing per plan of care. N. Nurse RN


Wound Care6/22/11 Right lower leg 2.8 x 2.0 x 0.3 cm. Wound bed is pink.

Minimal clear drainage. Pain is 2/10. Dr. Jones notified of improvement. Wound care updated. Dressing changed. Daughter instructed on updated wound care. Verbalized understanding. N. Nurse RN


Wound Care6/26/11 Right lower leg 1.9 x 1 x 0.2 cm. Wound bed pink with

no drainage. No pain. Dressing applied. Dr. Jones called. Discharge from home care. Daughter and patient agreeable. N. Nurse RN


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TeachingMedically necessary training to treat the illness or injury

Not repetitive training unless there is documentation explaining the need

• Caregiver no longer willing to assist. Need to train a second caregiver


TeachingDiabetes not controlled with diet and maximum oral hypo-

glycemics. Starting on insulin coverage.

2/1/12 Client demonstrated ability to correctly test blood using his monitor. Instructed on determining amount of insulin needed depending on blood test. Demonstrated drawing up insulin. Client able to demonstrate same with cues. S. Smith RN


Teaching2/2/12 Instructed client to use dart-like motion for injection.

Client able to draw up and administer injection with cues. Reviewed signs/symptoms of hypoglycemia and actions to treat. N. Nurse RN


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Teaching2/3/12 Explained need for rotation of injection sites with client

and provided diagram. Client able to state reason sites must be rotated and which areas are acceptable for injection. S. Smith RN


Therapy Coverage GuidelinesEffective treatment of the illness or injury

Potential for improvement in response to the therapy

Complexity requires the skills of a therapist


Therapy EvaluationWhy does this person need skilled

therapy now?• Illness or injury resulting in functional deficit

• Significant change of condition– Onset

Prior level of function

Current level of function


Current level of function

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Therapy EvaluationPrior therapy received for this problem• Skilled nursing facility or inpatient rehab facility prior to admission to

home care

• Prior home care or outpatient therapy

• Why is additional therapy needed?

• Is it really a new change of condition or is it decline from inactivity?

• Repetitive therapy must support the need for a therapist


Evaluation Example Date-1/6/12

Current complaint-Difficulty ambulating due to osteoarthritis

No new illness or diagnosis. Continues to take over-the-counter (OTC) medication for hip pain of 3/10. Daughter noticed decline ~4 weeks ago. States balance is poorer


Evaluation Example Prior level of function-Ambulated independently with sngle-point

cane (SPC) short distances without loss of balance

Prior therapy-Had outpatient PT for gait training 8 months ago because of osteoarthritis hips. Daughter states patient is not doing exercises independently. Daughter assists with them daily


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Evaluation Example Daughter states her mother is not as cooperative and less

compliant with instructions. Is oriented to time and place but does not remember instructions after 10 minutes. Agrees to a few therapy visits


Evaluation Example Current level of function-Again having gait instability. Has had 1

fall. Wide base of support, shuffling gait, stooped posture. Decreased step height and length. Refusing to use cane or walker. Ambulates short distances ~20 feet in home using furniture -walls for support . Difficulty with activities of daily living (ADL) due to poor balance.


Evaluation Example ROM• Hip flex L 100 R 90

• Hip extend L 10 R 10

• Knee flex L 90 R 85

• Knee extend L 10 R 10

Balance • Timed Up and Go 1 minute


• Timed Up and Go 1 minute

• Static balance 20 seconds

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Evaluation Example Goals• Safe performance of ADLs as evidence by Timed Up and Go less than

20 seconds

• Patient able to stand safely for two minutes


Evaluation ExplanationNo therapy for 8 months but no new illness or injury. Has had a

fall and gait is definitely unstable. Has been doing home exercise program (HEP) with help of caregiver. Reasonable to do some therapy visits to update HEP and additional gait training for safety


Therapy NotesDate

Services performed

Skilled treatment• Observations, judgments, cues, instructions given

• Progress towards goals

• When patient becomes independent with an exercise, transition it to home plan


home plan

–No longer skilled

Therapist signature

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Therapy NotesTransfer training-Chair to commode times five

Better:• January 10, 2012 Transfer training-Chair to commode times five.

Cued regarding correct weight shift. Performed with no loss of balance today. T. Therapist PT


Therapy NotesGait training-Ambulated 25 feet with rolling walker times two

Better:• February 3, 2012 Gait training-Ambulated 25 feet with rolling walker

times two. Verbal cues regarding correct hand placement, upright posture, and stride length. Needed frequent reminders. T. Therapist PT


Therapy NotesExercises: Leg lifts 3 sets of 15

Better: 2/12/12 Leg lifts 3 sets of 15. Cues provided for correct form to prevent back injury. A. Therapist PTA


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Therapy Reassessment 1/27/12 • Hip flex L 100 R 120

• Hip extension L 0 R 0

• Strength L 3+/5 R 4/5

• Pain: 3-6/10 pain meds adequate effectiveness

• Gait: Upright posture. Using quad cane for 150 feet. Now independent on transfer to car and WBAT. Having difficulty with


gstairs

• Signed B. Brown PT 1/27/2012

Therapy Reassessment Date- 2/17/2012• Knee Flex R 90 L 65

• Knee extension R 0 L 20

• Strength R 5 L 3+

• Transfers: Transfers chair to bed times 5 with cues for correct weight shift

• Gait: Using SPC for even surfaces 75 feet safely


g

• Signed T. Therapist PT

HOME HEALTH ADVANCE


BENEFICIARY NOTICE (HHABN)

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Reasons for NoncoverageBrief Description of Situation

Recommended Explanation for Header Section of the Option Box 1 HHABN

Care is not reasonable and necessary

Medicare does not pay for care that is not medically reasonable and necessary

Custodial care is the only care delivered

Medicare does not usually pay for custodial care, except for some hospice

i


services

Beneficiary is not homebound

Medicare requires that a beneficiary cannot leave home (with certain exceptions) in order to cover services under the home health benefit

Beneficiary does not need skilled nursing services on an intermittent basis

Medicare requires part-time or intermittent need for nursing services on an skilled nursing care in order to cover services under the home health benefit

Option Box Use

Triggering Event: Initiations

Box 1 Box 2

Box 3

Initiation of entirely noncovered treatment Yes No No

One-time noncovered


service or item, any Medicare benefit

Yes No No

One-time noncovered service, not a Medicare benefit

Voluntary

No No

Option Box UseTriggering Event: Reductions

Box 1 Box 2 Box 3

Any reduction for HHA reasons unrelated to coverage

No Yes No

A d ti b


Any reduction by physician order, no financial liability, HH benefit

No No Yes

Any other reductions –covered care Yes No No

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Option Box UseTriggering Event: Terminations Box 1 Box 2 Box 3

Any termination for HHA reason, no beneficiary liability

No Yes No


Covered care termination for coverage reason andnoncovered care will continue after coverage ends (also need Expedited Determination notice)

Yes No No

Long-Term Noncovered CareIf you have been providing one noncovered service and another

is being added, give the patient an HHABN with only the additional service.


Patient Refuses to Sign“If the beneficiary refuses to sign the HHABN, the HHA must

write that the beneficiary refused to sign on the HHABN itself, and provide a copy of the annotated HHABN to the beneficiary.”

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 60.4G.4.


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Patient Decides to Reduce or Change ServicesIf a patient decides to discontinue or reduce the services he or

she is receiving, no notice is required. Medical record should include information about the patient’s decision


Issues Identified With HHABNIncorrect reason was listed on the HHABN

Abbreviations used in the HHABN• Examples: PT, OT, SLP, SN, 2XW, nsg

Charge for services was not listed on HHABN

Supplies billed but not on the HHABN


Issues Identified With HHABN HHABN was provided over one year earlier• HHABN is only good for up to one year

HHABN was not appropriate for the entire episode• Example: An additional service was added during the episode. The

patient was receiving nursing services. Then HHA service was added to the plan of care during the episode. This would require a new HHABN be provided notifying the patient that the additional service will not meet Medicare guidelines and the patient may be financially


will not meet Medicare guidelines and the patient may be financially liable for these services.

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Issues Identified With HHABNWords “crossed out”• Suggest starting with a new form

• Mark as an error with a line through it and initials


Issues Identified With HHABNDates changed• Date was originally 2010 and it was changed to 2011

Document can not be altered after it has been signed• A new HHABN with a new signature is needed


Sample FormsWe will review sample HHABN forms


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Resourceswww.medicarenhic.com

[email protected]

http://www.apta.org/documentation• Defensible Documentation for Patient/Client Management

CMS Web site• http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-

HHA-Center


HHA-Center

ReferencesCMS Internet-Only Manual (IOM) Publication 100-02, Medicare

Benefit Policy Manual, Chapter 7, Home Health Manual

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, Sections 220 & 230

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Financial Liability Protection, Section 60



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