3/21/2018. Foundation Management Services, Inc All rights reserved. Unauthorized reproduction is strictly prohibited.

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1 Keys to Documentation Success in Home Health Coding DISCLAIMER This material is designed and provided to communicate information about compliance, ethics and coding in an educational format and manner. The author is not providing or offering legal advice, but rather practical and useful information and tools to achieve compliant results in the area of clinical documentation, quality, and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 1

2 OBJECTIVES Discuss common documentation deficits seen in home care Explain vulnerabilities related to documentation and coding, how it could lead to an audit or loss of revenue Provide strategies to query physician to obtain needed documentation in a timely manner ACCURACY IN DIAGNOSIS CODING If Diagnosis Code is present on UB-04, without supporting documentation in medical record: Financial consequences for the home health agency Audit liability If CMS software finds discrepancy in codes submitted on UB-04, OASIS, etc: Possible payment suspension ADR by MAC or other government entities Requirement of HIPAA Compliance ACCURACY IN DIAGNOSIS CODING If condition present, without supporting documentation: Do not report the condition Query the physician if questions on documentation can be clarified More Specific Codes = Fewer denied claims Fewer claims pulled for review / determination Optimal reimbursement rates Better resource utilization All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 2

3 DOCUMENTATION: OBSTACLES Often it is difficult for agencies to obtain adequate documentation to assign the most specific code. Physicians are not taught to document for accurate code assignment. Physician billing is not dependent on ICD-10 codes. Most clinicians do not understand the code set or the documentation necessary for specific code assignment. DOCUMENTATION: DEFICITS General documentation deficits: Laterality Ulcer severity Pressure ulcer not staged Fracture specificity Type of dementia Type of heart failure Reason for therapy DOCUMENTATION: EXAMPLE Patient is admitted with a stage 3 pressure ulcer of the coccyx. Therapy will also be seeing the patient for abnormality of gait due to a malunion of the left tibial fracture. The focus of care is the ulcer. It is an early episode with low therapy. M1021: L Pressure ulcer stage 3 coccyx M1023: S82.202P Left tibia fracture, subsequent encounter, malunion M1023: R26.9 Unspecified abnormality of gait Note: Available abnormal gait clinical points = 0 All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 3

4 DOCUMENTATION: EXAMPLE Patient admitted with a stage 3 pressure ulcer of the coccyx. Therapy will also see patient for abnormal gait resulting in the patient being unsteady on his feet due to a malunion of a left tibial fracture. The focus of care is the ulcer. This is an early episode with low therapy. M1021: L Pressure ulcer stage 3 coccyx M1023: S82.202P Left tibia fracture subsequent encounter malunion M1023: R26.81 Unsteadiness on feet Note: Available abnormal gait clinical points = 8 DOCUMENTATION: EDUCATION STRATEGIES Education Strategies: Determine agency s top 10 diagnoses Review the specific codes related to these diagnoses and determine what the clinician needs to document. Educate clinicians on the documentation needed specific to the top 10 as priority HEART FAILURE 17 code possibilities for Heart Failure All receive case mix points Specificity needed: Left-sided, Right-sided Systolic, Diastolic, or Combined Acute, Chronic, or Acute on Chronic All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 4

5 COPD One of the more difficult conditions to code correctly Specificity needed: Uncomplicated versus acute exacerbation (decompensated) If asthma present, need type (mild, moderate, or severe; intermittent or persistent) Infection present (pneumonia, bronchitis, bronchiolitis)? Infection AND acute exacerbation End Stage COPD documented need exacerbation status DEMENTIA Specificity needed: Vascular Dementia (due to infarction of the brain due to vascular disease) In other diseases (Alzheimer s, Parkinson s, with Lewy-bodies, etc) Senile Dementia, Pre-senile Dementia, Primary degenerative, etc Behaviors exhibited: aggressive, violent, combative, and/or wandering ULCERS Pressure Ulcers / Pressure Injury Stage 1-4, unspecified, and unstageable Site: Location Laterality Clinicians no longer report healed stage 3 & 4 PUs on OASIS BUT we are still required to code them ** Code assignment may be based on medical record documentation from clinicians who are not the patient s provider, since this information is typically documented by other clinicians involved in the care of the patient (ie, nurses or therapists for pressure ulcer stages), but the diagnosis of pressure ulcer must be documented by the patient s provider. (Guidelines Section I.B.14)** All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 5

6 ULCERS Non-Pressure Chronic Ulcers Type : stasis, arterial, diabetic Location Laterality Severity Limited to skin breakdown Fat layer exposed Muscle involvement with or without necrosis Bone involvement with or without necrosis Gangrene present or absent Stasis ulcers versus Varix: with or without varicose veins **The severity of the ulcer may be determined and coded based upon nursing documentation, but the physician must document the ulcer diagnosis** FRACTURES Pathologic or Traumatic If pathologic, associated disease process: Osteoporosis, Neoplasm, etc Specific Anatomical Site: For example: Femur: Head, Neck, Intertrochanteric, or Shaft Displaced or Non-Displaced Laterality Type: Open or Closed Healing status: Routine, Malunion, or Non-healing Encounter Type: Initial, Subsequent, or Sequela Query Process All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 6

7 QUERY DEFINED Bing search: Medical Query written question to a physician to obtain additional, clarifying documentation to improve the specificity and completeness of data used to assign diagnosis and procedure codes in the patient s health record WHEN TO QUERY Concurrently when coding a record is difficult and the pt s record contains: Information that is conflicting, Ambiguous, inconsistent, illegible, or incomplete Clinically relevant information (lab tests, diagnostic evaluation, etc) not addressed Clinical indicators present without associated / underlying diagnosis Office of Inspector General (OIG) defines assumption coding as: Assuming (and coding) from the clinical evidence on the patient s record the the patient has certain diagnoses in the absence of the physician s explicit documentation of diagnosis. PHYSICIAN QUERY Providing specific documentation is not new for physicians Acute Care Settings: Clinical documentation specialists Physicians are required to provide any additional needed documentation within a specific time period HH agencies asking for more specific information should not be a new process for the physician All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 7

8 QUERY PROCESS Communication Paper (fax) Electronic Verbal Template Follow up Queries should be part of the permanent record QUERY FORM Centers for Medicare and Medicaid Services supports the use of query forms as a supplement to the health care record. Demonstrates compliance with acceptable query processes QUERY FORMAT Generally includes the following: Patient name Episode/Admission date Patient s DOB Date of query Name/contact information of person requesting information Statement of issue/question All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 8

9 QUERY FORMAT Statement of issue: Written as a question Include clinical indicators from documentation available Ask the physician to make a clinical interpretation Format should not lead physician to a diagnosis QUERY TYPES Open ended Questions Multiple Choice Questions Yes/No Questions QUERY EXAMPLE The patient s hospital discharge summary notes state that the patient has a history of chronic CHF and a new diagnosis of Afib. The patient complains of SOB with activity. A recent echocardiogram report showed left ventricular ejection fraction of 25%. A recent EKG shows Afib with a heartrate of 110. The patient s home medications include Metoprolol XL, Lisinopril, Coumadin and Lasix. The admitting physician dose not mention heart failure as a diagnosis. Query opportunities: Specificity and type of heart failure Specificity of A-fib All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 9

10 QUERY EXAMPLE (CONT) It is noted in the hospital discharge summary that the patient has chronic CHF, and a recent echocardiogram states an EF of 25%. Do you agree that the patient has a diagnosis of chronic diastolic heart failure? NON-COMPLIANT LEADING ASSUMING QUERY EXAMPLE (CONT) It is noted in the hospital discharge summary that the patient has chronic CHF, and a recent echocardiogram states an EF of 25%. Can a confirmation of heart failure and the type of HF be further specified? Chronic systolic heart failure Chronic diastolic heart failure Chronic systolic and diastolic heart failure Other explanation of clinical findings Unable to determine Findings of no clinical significance QUERY EXAMPLE (CONT) It is noted in the H&P that the patient has a new diagnosis of Afib, and the EKG report indicates Afib with HR of 110. The patient was started on Coumadin and Metoprolol XL. Can this diagnosis be further specified? Paroxysmal Afib Persistent Afib Chronic Afib Other explanations of clinical findings Unable to determine Findings of no clinical significance All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 10

11 WHEN NOT TO QUERY The information is clinically insignificant The information is from a previous episode and not the current episode The organization s policies and procedures restrict queries in certain situations The benefit is strictly for increased reimbursement CLINICAL DOCUMENTATION IMPROVEMENT PROJECT CDI has arrived on doorstep of HH Purpose is to review concurrently for conflicting, incomplete, or nonspecific documentation The goal of a CDI program is to identify clinical indicators that ensure conditions are supported by the ICD-10 codes Documentation is translated into ICD-10 codes CLINICAL DOCUMENTATION IMPROVEMENT PROJECT CDI processes achieve precise data to: Support the complexity and severity of the patient illness Focus on documentation used for coding Improve documentation quality Improve outcomes, risk adjustment, NRS, and revenue stream Goal: obtain accurate and complete information in a timely manner to facilitate efficient clinical delivery. All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 11

12 CDI BACKGROUND Physician participation in hospital CDI programs is required Compliance statistics are kept per physician to monitor how many queries are sent, how many are answered in 48 hours and how many are outstanding after 48 hours. High level provider documentation is required in a hospital setting and it is now on the doorstep in a home health and hospice setting. CDI IN HOME HEALTH Need to have buy in from: Administration/owner Referring physicians Demonstrate physician and clinician documentation deficit Compare current HHRG and what the HHRG could have been with additional documentation CDI IN HOME HEALTH Claims denial/rejection 27.5% coding knowledge deficit 72.5% documentation deficit PPS HHRG reimbursement 51% decrease in case mix value 39% of the 51% from diagnosis codes (mainly use of unspecified codes) All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 12

13 CDI SPECIALIST ROLE Communicate with physicians on documentation improvement issues concurrent with the admission Currently: role of clinician or coder CDI specialist looks for what has not been documented Coding specialist looks for what has been documented CDI review occurs prior to coding Bridge between clinical language and coding language ADDITIONAL STRATEGIES: Gather as much information as possible at time of referral H&P, Operative Reports, Physician Progress Notes, Discharge Summary, lab and diagnostic reports, etc Provide a list of compliant query options for your most common diagnoses Involve the entire intake team: Clinical Manager Sales / Clinical Liaison Intake Coordinator Admission Nurse / Therapist Clinical Documentation Improvement Specialist Coding Specialist SUMMARY High Quality Documentation: Will increase the benefits of the new coding system Is consistently being demanded by other initiatives Leads to accurate coding Is critical for the appropriate reimbursement needed to provide high standards of patient care and the survival of your home health agency All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 13

14 CONTACT INFORMATION Jennifer Collins, RN, BSN, HCS-D, COS-C Regional Education Consultant Foundation Management Services PHONE: FAX: All rights reserved. Unauthorized reproduction is strictly prohibited. (03/18) 14