Home Care Auditing: What s all the MOOing About? Objectives. Medicare Home Care Conditions of Participation

Transcription

1 Home Care Auditing: What s all the MOOing About? Catherine Niland AHIA 2008 Annual Conference September 2008 Objectives Overview of Home Care Medicare Home Care Prospective Payment System Financial and Operational controls 2 Medicare Home Care Conditions of Participation Patient must require skilled care (RN, PT, Speech therapy) No willing or able caregiver available Services must be provided on an intermittent basis May be daily for a short duration or less frequently over a longer period of time Cannot be for one-time only visits, with few exceptions Plan of Care must be completed and signed by the physician prior to billing final claim Services must be reasonable and necessary Services must be provided in a place of residence used as the patient s home (may be home, senior apartment, assisted living facility, etc.) Patient must be homebound Episode of care is 60 days; may have unlimited number of episodes as long as above criteria met 3 1

2 Home Bound Status Must be determined prior to start of care Patient must be confined to the home A normal inability to leave home; Leaving home would require a considerable and taxing effort; Leaving home requires the assistance of another person. Confinement due to medical, psychiatric, or physical condition May leave home infrequently for medical appointments or non-medical reasons for short duration (i.e. attend church) Attendance at Adult Day Care does not disqualify homebound status (Program Memorandum A /6/01) 4 Plan of Care Plan of Care (form 485) must be completed prior to provision of care Must indicate type, duration and frequency of all services and treatment orders May be verbal order initially With subsequent episodes of care, new or updated Plan of Care required, along with new orders Verbal orders received during episode of care modify the plan of care Physician MUST sign the Plan of Care and all verbal orders prior to billing final claim for the episode 5 Type of Services Skilled Nursing Care Care that may only be performed by RN (or LPN in certain circumstances) Includes wound care, medication administration, and patient/caregiver education Home Health Aide Provide assistance with Activities of Daily Living (such as bathing, grooming, dressing, walking, etc.) May perform some light housekeeping duties in addition to ADL assistance; however, homemaker-type services alone are not covered by Medicare May only be provided with other skilled services 6 2

3 Type of Services Physical Therapy Provided by licensed therapist or therapy assistant; may not be performed by therapy aide Includes instruction for a Home Exercise Program (HEP) Speech Therapy Performed by licensed therapist Includes cognitive and/or speech therapy Occupational Therapy May only be provided as an adjunct to Physical &/or Speech therapy; can continue after other skilled services are discontinued Provided by licensed therapist and/or assistant, no aides 7 Type of Services Social Work May assist the patient with other needs, such as arranging for housekeeping services, transportation, obtaining DME, etc. May also arrange for other services, such as Nutrition/dietary t counseling May only be provided when another skilled service is provided 8 no PPS!!! Cartoon by Tom Wilson Universal Press Syndicate 9 3

4 Home Care Prospective Payment System Implemented October 2000; major revision effective 1/1/08 Affects Part A payment only Established Consolidated Billing for all disciplines, non-routine supplies, outpatient therapies, and some wound care treatments Requires OASIS (Outcomes and ASsessment Information Set) completion by home health clinicians (RN, PT, SLP) 10 OASIS Assessment Required at start of episode, resumption of care, and end of episode Specific time frames required for each assessment Within 5 days of Start of Care Within last 5 days of 60 Day episode Within 48 hours after d/c from inpatient admission greater than 24 hours Transfer to new HHA or d/c and readmit to same HHA within 60 days At discharge Must be encoded and submitted within 30 days of the assessment 105 items make up current version B-1(MO questions) 23 items used to help determine Home Health Resource Group (HHRG) Medicare payment Assessment items grouped by Clinical (C), Functional (F), and Service (S) Domains NOTE: Home care Medicare payment driven by clinician documentation NOT physician documentation 11 OASIS Reimbursement Items Clinical Domain Diagnosis Coding MO230 Primary Diagnosis MO240 Secondary Diagnoses MO246 Case Mix Diagnosis (if V or E code in MO230) Wounds MO450/460 pressure ulcers MO476 stasis ulcers MO488 wounds Also Pain, Vision, Dyspnea, Bowel incontinence, Ostomy Functional Domain MO650, MO660, MO670, MO680, MO690, MO700 Dressing, Bathing, Toileting, Transfers, and Locomotion Service Domain MO110 1 st -2 nd episode or 3 rd or later episode MO826 Number of projected therapy visits 12 4

5 Home Health Resource Group (HHRG) Once OASIS completed, reimbursable items from each domain is used to determine the HHRG Represented by 6 digit alpha-numeric code CxFxSx 1 st 2 characters represent clinical domain score 2 nd 2 characters represent functional domain score 3 rd 2 characters represent service domain score HHRG of C1F1S1 indicates lowest level of service, C3F3S5 is highest HHRG translated to HIPPS (Health insurance prospective payment system) code for billing purposes 13 HIPPS Codes HIPPS is 5 character code 1 st position character is number 1 to 5; represents severity level (# therapy visits and episode sequence) 2 nd position character is A, B, or C; represents Clinical Domain score 3 rd position is F, G, or H; represents Functional Domain score 4 th position is K, L, M, N, or P; represents Service Domain score 5 th position is either S, T, U, V, W, X or 1, 2, 3, 4, 5, 6; alpha represents non routine supplies (NRS) provided and numeric represents no NRS provided C1F1S1 1 st episode/no therapy/no NRS would be: 1AKF1 C3F3S5 4 th episode/20+ therapy/ NRS 99 points would be: 5CHPX See Exhibit A for calculation table 14 Calculation Table- Exhibit A Definitions of Severity Levels by Grouping Step: HIPPS Code 1st & 2nd Episodes 3rd+ Episodes All Episodes 0 to to 19 0 to to therapy therapy therapy therapy therapy visits For this In HIPPS visits visits visits visits level Enter this value: position: (grouping step): 1 to 5 1 Clinical Severity Level: 0 to 4 0 to 6 0 to 2 0 to 8 0 to 7 C1 A (by point scores- Pseudocode 5 to 8 7 to 14 3 to 5 9 to 16 8 to 14 C2 B 2 Appendix Table 5) C3 C Functional Severity Level: 0 to 5 0 to 6 0 to 8 0 to 7 0 to 6 F1 F (by point scores- Pseudocode F2 G 3 Appendix Table 5) F3 H to 5 14 to 15 0 to 5 14 to 15 S1 K (one group) Services Utilization Level: 6 16 to to 17 S2 L 4 (by number of therapy visits) 7 to 9 18 to 19 7 to 9 18 to 19 S3 M S4 N 11 to to 13 S5 P NRS no NRS NRS Points provided provided 0 NRS-1 S 1 NRS-Supplies Severity Level: 1 to 14 NRS-2 T 2 (by NRS point scores to 27 NRS-3 U 3 Pseudocode Appendix Table 7) 28 to 48 NRS-4 V 4 49 to 98 NRS-5 W NRS-6 X

6 PPS Reimbursement Reimbursement split into Request for Anticipated Payment (RAP) and Final Claim Initial RAP payment 60% of reimbursement; claim 40% RAP/claim payment split 50% with subsequent episodes RAP not considered claim except for purposes of False Claims Act RAP establishes in the Common Working File which agency is providing service for an episode RAP must be submitted within 60 days of start of episode or will be denied; may resubmit if delayed beyond 60 days Claim won t be paid without RAP on file (except in certain circumstances) 16 How the PPS Works- Quick Summary Complete the OASIS by performing an initial assessment Use decision tree logic to determine an initial Home Health Resource Group (HHRG) score Submit a Request for Anticipated Payment (RAP) and receive 60% reimbursement (initial episode) or 50% for subsequent episodes Perform an end-of-episode assessment and submit a claim with the final HHRG score Receive final adjusted payment For subsequent episodes, end-of episode assessment used to determine next episode HHRG 17 LUPA Low Utilization Payment Adjustment (LUPA) 4 or fewer visits in the episode Adjustment to HHRG reimbursement amount Additional add-on ($91.80) for LUPA that occurs as the only episode or the 1 st episode of home care benefit use New benefit effective 1/1/08 Requirements: 4 or fewer visits HIPPS code on claim begins with 1 or 2 indicating early episode Claim admission date and from date are the same Source of Admission is not B or C 18 6

7 PEP Partial Episode Payment (PEP) Prorated payment adjustment when patient changes HHA during an episode New 60 day period begins when patient transfers from one agency and goes to another or When patient discharged and readmitted to same HHA during same 60-day episode 1 st HHA or episode gets prorated HHRG; 2 nd HHA or readmitted episode gets full HHRG 19 Non- Routine Supplies (NRS) Prior to 1/1/08 home care agencies generally did not bill for non-routine supplies; reimbursement poor and not worth effort to collect data Effective 1/1/08, additional reimbursement now available from $14 to $551 per episode OASIS responses used to calculate amount of reimbursement (indicated by HIPPS 5 th character) See Exhibit B for calculation table (Table 7 of Pseudocode Appendix Tables) 20 Table 7- Exhibit B HHA PPS Grouper 0202 Logic January 28, 2008 Pseudocode APPENDIX TABLES Table 7: Nonroutine Medical Supplies (NRS): Case-Mix Adjustment Variables and Point Scores (Table taken from Table 10A of Final Rule CMS-1541-FC) (1) (2) (3) ROW VARIABLE DESCRIPTION Points SELECTED SKIN CONDITIONS: 1 Primary diagnosis = Anal fissure, fistula and abscess 15 2 Other diagnosis = Anal fissure, fistula and abscess 13 3 Primary diagnosis = Cellulitis and abscess 14 4 Other diagnosis = Cellulitis and abscess 8 5 Primary diagnosis = Diabetic ulcers [* SEE NOTE] 20 6 Primarydiagnosis = Gangrene 11 7 Other diagnosis = Gangrene 8 8 Primary diagnosis = Malignant neoplasms of skin 15 9 Other diagnosis = Malignant neoplasms of skin 4 10 Primary or Other diagnosis = Non-pressure and non-stasis ulcers[* SEE NOTE] Primary diagnosis = Other infections of skin and subcutaneous tissue Other diagnosis = Other infections of skin and subcutaneous tissue 7 13 Primary diagnosis = Post-operative Complications Other diagnosis = Post-operative Complications Primary diagnosis = Traumatic Wounds and Burns Other diagnosis = Traumatic Wounds and Burns 8 17 Primary or other diagnosis = V code, Cystostomy care Primary or other diagnosis = V code, Tracheostomy care Primary or other diagnosis = V code, Urostomy care OASIS M0450 = 1 or 2 pressure ulcers, stage OASIS M0450 = 3+ pressure ulcers, stage OASIS M0450 = 1 pressure ulcer, stage OASIS M0450 = 2 pressure ulcers, stage

8 Table 7- Appendix B Continued 24 OASIS M0450 = 3 pressure ulcers, stage OASIS M0450 = 4+ pressure ulcers, stage OASIS M0450 = 1 pressure ulcer, stage OASIS M0450 = 2 pressure ulcers, stage OASIS M0450 = 3 pressure ulcers, stage OASIS M0450 = 4+ pressure ulcers, stage OASIS M0450 = 1 pressure ulcer, stage OASIS M0450 = 2 pressure ulcers, stage OASIS M0450 = 3+ pressure ulcers, stage OASIS M0450e = 1(unobserved pressure ulcer(s)) OASIS M0470 = 2 (2 stasis ulcers) 6 35 OASIS M0470 = 3 (3 stasis ulcers) OASIS M0470 = 4 (4+ stasis ulcers) OASIS M0474 = 1 (unobservable stasis ulcers) 9 38 OASIS M0476 = 1 (status of most problematic stasis ulcer: fully granulating) 6 39 OASIS M0476 = 2 (status of most problematic stasis ulcer: early/partial granulation) OASIS M0476 = 3 (status of most problematic stasis ulcer: not healing) OASIS M0488 = 2 (status of most problematic surgical wound: early/partial granulation) 4 42 OASIS M0488 = 3 (status of most problematic surgical wound: not healing) 14 OTHER CLINICAL FACTORS: 43 OASIS M0550=1(ostomy not related to inpt stay/no regimen change) OASIS M0550=2 (ostomy related to inpt stay/regimen change) Any `Selected Skin Conditions` (rows 1-42 above) AND M0550=1(ostomy not related to inpt stay/no regimen 14 change) 46 Any `Selected Skin Conditions` (rows 1-42 above) AND M0550=2(ostomy related to inpt stay/ regimen change) OASIS M0250 (Therapy at home) =1 (IV/Infusion) 5 48 OASIS M0520 = 2 (patient requires urinary catheter) 9 49 OASIS M0540 = 4 or 5 (bowel incontinence, daily or >daily) 10 NOTE: * If episode receives points for diabetic ulcers, it cannot also receive points for Non-pressure and non-stasis ulcers. 22 Why CMS Changed the Home Care PPS We have tried to strike a balance between simplicity and complexity. The new system is more complex than the old system but this a natural outgrowth of our attempt to pay more accurately for the range and intensity of home health services that can be provided to our beneficiaries. 42 CFR part 484 Medicare Program; Home Health Prospective Payment System Refinement and Rate Update for Calendar year 2008; Final Rule Federal Register, August 29, 2007, page Remember: PPS stands for Please Pay SOMETHING!!!! Michael O. Leavitt, US Secretary of Health and Human Services 24 8

9 ICD-9 Coding Accurate diagnosis coding is critical Non-specific code use can impact amount reimbursed Not otherwise specified code when specific information available for osteomyelitis site unspecified gains no points; for lower leg gains 2 or 5 case mix points Diagnosis documented but not included in OASIS Diabetes adds 2 to 5 points to the case mix score for a 1st episode. Even if patient is stable, diabetes can affect resources used, and should be included. In above 2 examples, 2 points could change HHRG from C1 to C2, with increase of $323 Correct coding guidelines apply- and if it isn t documented by the physician it can t be coded 25 Consolidated Billing Requires that all services related to the treated condition, including medications and supplies, to be included in the HHRG payment. Exception: any osteoporosis medication is included, whether related to condition or not. Excludes: Physician professional services Including Physician-provided therapy Technical component of physician services must be billed to and reimbursed by the HHA Dialysis services Epoetin Alfa (Epogen) for dialysis patients Ambulance services Durable Medical Equipment Customized prosthetic devices 26 Consolidated Billing Exclusion, continued: Certain chemotherapy items and their administration Services that are exceptionally costly, intense, or emergent are also excluded. CMS has an Excel workbook file containing complete lists of all codes ever subject to consolidated billing provision of HH PPS. It is available online at: &billing.asp 27 9

10 28 Intake and Insurance Verification Physician order received prior to start of care Payer information verified Appropriate pre-certs and referrals obtained prior to start of care Medicare as Secondary Payer (MSP) Questionnaire completed appropriately Health Insurance Query for Home Health (HIQH) to verify no other agency providing care When required, Advance Beneficiary Notice (HHABNs) is obtained and completed appropriately Tracking of 485 to ensure signature obtained prior to billing 29 Claims Submission Pre-billing audits for RAP: Verbal Start of Care order on file 1 st visit and initial assessment completed The RAP contains one HIPPS code From and Through dates match the date of first service Verify episode timing (check Common Working File) Pre-Billing audits for claim: Signed and dated Plan of Care on file Signed and dated interim orders on file OASIS has been electronically transmitted to the appropriate site (MAC or state agency) Clinical documentation for each visit on file Claim has same HIPPS code as RAP Claim includes line item details From date is same as RAP; Through date is discharge date or day

11 Claims Submission For RAPs and claims submitted electronically, review the RTP (Return to Provider) file daily, or when received Timely resubmission needed for RAPs Errors identified should be tracked and corrected Repeated errors could result in False Claims Act violation Unpaid claims can be reviewed in the Medicare Common Working File to check status 31 Charge Capture and Billing How are services charged? Old method- DAL (daily activities log); most agencies now use EMR with process flow. Documentation of services provided Reconciliation of charges submitted to charges billed Method of billing to third party payers: Frequency Charge entry Paper or electronic Identifying and monitoring of unbilled accounts Unbilled because Plan of Care not signed? Denials 32 Discontinuation of Medicare Coverage Medicare requires 48-hours notification of the client when Medicare Home Care coverage will end Includes discontinuation due to non-skilled level of care, lack of homebound status, or exhaustion of benefits Not required if service ends due to an emergent situation Notice must include reason for discontinuation, effective date, and appeal process Notification should include client signature; proof of attempt to deliver notification when signature not obtainable may be acceptable 33 11

12 34 Co-Pays As of July 1, 2008 Medicare still does not require a co-pay for traditional Medicare patients for home care services. Most Medicare Advantage programs do require a co-pay. Risks: Identify need to collect (payer type) Identify appropriate amount Obtain co-pay Write-offs when not obtained (documented proof of attempt to collect) 35 Cash Receipts and Collections Method of receiving payment- electronic, mail, lockbox, etc Receipt Logs security, oversight, and use Reconciliation of cash receipts and cash deposits Bank reconciliation Use of collection agencies Procedures for charity care and bad debt write-offs Reserves for doubtful accounts and contractual write-offs Discounts applied that are not contractual 36 12

13 Accounts Receivable Verify credit balances and reconcile to the appropriate ledger Compare timeliness of posting RAP and final claim Investigate if recurring delay in the billing and posting cycle time Review aging of accounts receivable balances to verify timely procedures 40 to 60 Days is preferred range Percentage older than 120 days should be no greater than 10% (< 5% preferred) Percentage of PEP adjustments should be less than 2% 37 System Security Use of laptops Electronic access (single use password) Location used- client home, caregiver home, agency office Physical security Client home, caregiver home, caregiver vehicle, agency office System backup Protected Health Information (PHI) Copy of Plan of Care, patient education left in home; who can access it? What policy/procedures are in place should there be a breech of privacy/security? 38 Additional Risks Some additional areas to consider in auditing: Background checks for new hires/oig screening Proposed Home Health Aide mandated screening Software glitches CMS errors with 5 th HIPPS character- default to letter (S- X) rather than number, which indicates non-routine supplies USED 39 13

14 HOME CARE AUDITING Auditing Audit Cartoon by Dave Harbaugh 40 References CMS Home Care website: CMS Home Health Agency Center (links to numerous CMS home care-related sites) p Medicare Benefit Policy Manual, Publication , Chapter 7, Home Health Services Medicare Claims Processing Manual, Publication , Chapter 10, Home Health Agency Billing 41 References continued OASIS Implementation Manual, January then select User Manual Code of Federal Regulations for Home Care- 42 CFR Section 484. Table of Contents found at _07.html 42 14

15 Catherine Niland, RN, BS, CHC, CHCQM Organizational Integrity Manager, Trinity Health Novi, MI

16 Medicare Home Care PPS HIPPS Code Calculation for Episodes Starting 1/1/08 or later 1/28/2008 Clinical Severity Level: (by point scores- Pseudocode Appendix Table 5) Functional Severity Level: (by point scores- Pseudocode Appendix Table 5) Services Utilization Level: (by number of therapy visits) NRS-Supplies Severity Level: (by NRS point scores- Pseudocode Appendix Table 7) Definitions of Severity Levels by Grouping Step: HIPPS Code 1st & 2nd Episodes 3rd+ Episodes All Episodes 0 to to 19 0 to to therapy therapy therapy therapy therapy visits For this In HIPPS visits visits visits visits level Enter this value: position: (grouping step): 1 to to 4 0 to 6 0 to 2 0 to 8 0 to 7 C1 A 5 to 8 7 to 14 3 to 5 9 to 16 8 to 14 C2 B C3 C 0 to 5 0 to 6 0 to 8 0 to 7 0 to 6 F1 F F2 G F3 H 0 to 5 14 to 15 0 to 5 14 to S1 K (one group) 6 16 to to 17 S2 7 to 9 18 to 19 7 to 9 18 to 19 S S4 11 to to 13 S5 NRS Points 0 1 to to to to L M N P NRS no NRS provided provided NRS-1 S 1 NRS-2 T 2 NRS-3 U 3 NRS-4 V 4 NRS-5 W 5 NRS-6 X 6 4 5

17 HHA PPS Grouper 0202 Logic January 28, 2008 Pseudocode APPENDIX TABLES Table 7: Nonroutine Medical Supplies (NRS): Case-Mix Adjustment Variables and Point Scores (Table taken from Table 10A of Final Rule CMS-1541-FC) (1) (2) (3) ROW VARIABLE DESCRIPTION Points SELECTED SKIN CONDITIONS: 1 Primary diagnosis = Anal fissure, fistula and abscess 15 2 Other diagnosis = Anal fissure, fistula and abscess 13 3 Primary diagnosis = Cellulitis and abscess 14 4 Other diagnosis = Cellulitis and abscess 8 5 Primary diagnosis = Diabetic ulcers [* SEE NOTE] 20 6 Primary diagnosis = Gangrene 11 7 Other diagnosis = Gangrene 8 8 Primary diagnosis = Malignant neoplasms of skin 15 9 Other diagnosis = Malignant neoplasms of skin 4 10 Primary or Other diagnosis = Non-pressure and non-stasis ulcers[* SEE NOTE] Primary diagnosis = Other infections of skin and subcutaneous tissue Other diagnosis = Other infections of skin and subcutaneous tissue 7 13 Primary diagnosis = Post-operative Complications Other diagnosis = Post-operative Complications Primary diagnosis = Traumatic Wounds and Burns Other diagnosis = Traumatic Wounds and Burns 8 17 Primary or other diagnosis = V code, Cystostomy care Primary or other diagnosis = V code, Tracheostomy care Primary or other diagnosis = V code, Urostomy care OASIS M0450 = 1 or 2 pressure ulcers, stage OASIS M0450 = 3+ pressure ulcers, stage OASIS M0450 = 1 pressure ulcer, stage OASIS M0450 = 2 pressure ulcers, stage OASIS M0450 = 3 pressure ulcers, stage OASIS M0450 = 4+ pressure ulcers, stage OASIS M0450 = 1 pressure ulcer, stage OASIS M0450 = 2 pressure ulcers, stage OASIS M0450 = 3 pressure ulcers, stage OASIS M0450 = 4+ pressure ulcers, stage OASIS M0450 = 1 pressure ulcer, stage OASIS M0450 = 2 pressure ulcers, stage OASIS M0450 = 3+ pressure ulcers, stage OASIS M0450e = 1(unobserved pressure ulcer(s)) OASIS M0470 = 2 (2 stasis ulcers) 6 35 OASIS M0470 = 3 (3 stasis ulcers) OASIS M0470 = 4 (4+ stasis ulcers) OASIS M0474 = 1 (unobservable stasis ulcers) 9 38 OASIS M0476 = 1 (status of most problematic stasis ulcer: fully granulating) 6 39 OASIS M0476 = 2 (status of most problematic stasis ulcer: early/partial granulation) OASIS M0476 = 3 (status of most problematic stasis ulcer: not healing) OASIS M0488 = 2 (status of most problematic surgical wound: early/partial granulation) 4 42 OASIS M0488 = 3 (status of most problematic surgical wound: not healing) 14 OTHER CLINICAL FACTORS: 43 OASIS M0550=1(ostomy not related to inpt stay/no regimen change) OASIS M0550=2 (ostomy related to inpt stay/regimen change) Any `Selected Skin Conditions` (rows 1-42 above) AND M0550=1(ostomy not related to inpt stay/no regimen change) Any `Selected Skin Conditions` (rows 1-42 above) AND M0550=2(ostomy related to inpt stay/ regimen change) OASIS M0250 (Therapy at home) =1 (IV/Infusion) 5 48 OASIS M0520 = 2 (patient requires urinary catheter) 9 49 OASIS M0540 = 4 or 5 (bowel incontinence, daily or >daily) 10 NOTE: * If episode receives points for diabetic ulcers, it cannot also receive points for Non-pressure and non-stasis ulcers. Abt Associates Inc. Questions: <grouper0202@homehealthgrouper.info> 1 Table 7 NRS Casemx Adj Variabls