4/24/2012. Cake Walk for a Successful National Government Services Medical Review Process. Today s Presenter. Disclaimer. Sally Rosiello, BSN

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1 Cake Walk for a Successful National Government Services Medical Review Process 2012 Today s Presenter Sally Rosiello, BSN 2 Disclaimer has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at 3 1

2 Acronyms Acronym ADL ADR BP CAP CERT CHF Cm DPS HEP HH Term Activities of daily living Additional documentation request Blood pressure Corrective Action Plan Comprehensive Error Rate Testing Congestive heart failure Centimeter Director Patient Services Home exercise program Home health 4 Acronyms Acronym LOF LPN Mg Nsg OT OTC P POC PT PTA Term Level of function Licensed practical nurse Milligram Nursing Occupational therapy/therapist Over the counter Pulse Plan of care Physical therapy/therapist Physical therapy assistant 5 Acronyms Acronym R RN ROM SLP SOB SPC THR WBAT Term Respiration Registered nurse Range of motion Speech-language pathology/pathologist Shortness of breath Single point cane Total hip replacement Weight bearing as tolerated 6 2

3 Agenda Documentation Face-to-Face Encounter Homebound Status Nursing Therapy Medical Review CAP CERT Program 7 Objectives Understand what auditors are looking for and what you can do to tighten up your documentation and justify every visit Understand how to develop a Correction Action Plan 8 Documentation 3

4 Face-to-Face Encounter Date 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 THR Certification statement Signature: Dr. Jack Doe Date: 12/18/ Face-to-Face Encounter Date of face-to-face encounter: January 4, 2012 Homebound status: SOB Services needed: NSG Reasons patient requires services: CHF and emphysema Certification statement Signature: Dr. W. Right Date: 1/4/ Homebound Status Main issue is how often the patient leaves home for reasons other than for medical care Day care Attendance at state licensed or certified day care can be acceptable. Documentation submitted for review should include this information. 12 4

5 Homebound Status Nurse 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. Is the visit billable to Medicare? 13 Homebound Status No. The patient is not homebound so the patient is not eligible for services under the home health benefit. The visit should not be billed. 14 Homebound Status Patient 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? 15 5

6 Homebound Status We 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 an accredited day care program providing therapeutic, medical or psychosocial treatment of the patient. Without documentation showing it is a day care program, services would be denied. 16 Skilled Nursing Wound care daily for 3 months needed. First POC indicates daily nursing visits for 3 months. Second episode POC says daily for 1 month and then reduced frequency after that. Visit notes show progress in healing or changes made to the wound treatment provided. 17 Nursing Documentation Why does this person need skilled nursing now? Recent diagnosis, exacerbation, or hospitalization Change in treatment regimen 18 6

7 Observation & Assessment Every visit has to be medically necessary When condition stabilizes, additional visits no longer necessary 19 Observation & Assessment Patient discharged from hospital with CHF. Plan to visit 2 times a week for 3 weeks 2/7/12 Admission assessment: BP 148/74, P 86-regular, 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 RN 20 Observation & Assessment 2/10/12 BP 152/92 P 98 regular R 24 Oxygen saturation 92%, breath sounds rales in bases, coughing more than last visit-nonproductive, 1+ pedal edema. Feels tired-not sleeping well d/t cough and sleeping in chair. Called Dr. Smith. Additional furosemide 40 mg po ordered for today and increase dose to 40 daily. Patient and daughter notified. N. Nurse RN 21 7

8 Observation & Assessment 2/14/12 BP 136/80 P 80-regular R 20 Oxygen saturation 95%, breath sounds clear, coughing intermittently-nonproductive, 2+ pedal edema, feels better, no SOB. N. Nurse RN 22 Observation & Assessment 2/17/12 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 23 Observation & Assessment 2/20/12 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 24 8

9 Wound Care 6/1/11 Right lower leg 4.0 x 3.4 x 1.7 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. T. Nurse RN 25 Wound Care 6/4/11 Right lower leg moderate yellow drainage. Wound bed has small amount pink and rest yellow slough. Daughter expresses no concern with performing wound care. Pain level 5/10. N. Nurse RN 26 Wound Care 6/8/11 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. N. Nurse RN 6/12/11 Right lower leg wound is 2/3 pink, 1/3 yellow with minimum drainage. Pain 4/10. N. Nurse RN 27 9

10 Wound Care 6/15/11 Right lower leg 3.3 x 2.5 x 0.5 Minimal yellow drainage. Wound bed ¼ yellow, ¾ pink. Pain 3/10. N. Nurse RN 6/19/11 right lower leg. Minimal light yellow drainage. Wound bed ¾ pink, ¼ yellow. Pain 4/10. N. Nurse RN 28 Wound Care 6/22/11 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 29 Wound Care 6/26/11 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 30 10

11 Teaching Medically 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. 31 Teaching Diabetes not controlled with diet and maximum oral hypoglycemics. Starting on insulin coverage. 4/2/12 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. T. Nurse RN 32 Teaching 4/4/12 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. T. Nurse RN 33 11

12 Teaching 4/6/12 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. T. Nurse 34 Therapy Evaluation Why 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 35 Therapy Evaluation Prior 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 36 12

13 Evaluation Example Date-1/6/12 Current complaint-difficulty ambulating due to osteoarthritis No new illness or diagnosis. Continues to take OTC medication for hip pain of 3/10. Daughter noticed decline ~4 weeks ago. States balance is poorer. 37 Evaluation Example Prior level of function-ambulated independently with 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. 38 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 39 13

14 Evaluation Example Current LOF-Again having gait instability. Had 1 fall last week. 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 ADLs due to poor balance. 40 Evaluation Example ROM Hip flex L 100 R 90 Hip extend L 10 R 10 Knee flex L 90 R 85 Knee extend L WNL R WNL Balance Timed Up and Go 1 minute Static balance 20 seconds 41 Evaluation Example Goals Safe performance of ADLs as evidence by Timed Up and Go less than 20 seconds. Patient able to stand safely for 2 minutes

15 Evaluation Explanation No therapy for 8 months but no new illness or injury. Has had a fall and gait is definitely unstable. Has been doing HEP with help of caregiver. Reasonable to do some therapy visits to update HEP and additional gait training for safety 43 Therapy Notes Date Services performed Skilled treatment Observations, judgments, cues, instructions given Progress towards goals When patient becomes independent with an exercise, transition it to home plan No longer skilled Therapist Signature 44 Therapy Notes Transfer training-chair to commode times 5 Better: 1/10/12 Transfer training-chair to commode times 5. Cued regarding correct weight shift. Performed with no loss of balance today. T. Therapist PT 45 15

16 Therapy Notes Gait training-ambulated 25 feet with rolling walker times 2 Better: 1/3/12 Gait training-ambulated 25 feet with rolling walker times 2. Verbal cues regarding correct hand placement, upright posture, and stride length. Needed frequent reminders. T. Therapist PT 46 Therapy Notes Exercises: 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 47 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 stairs Signed B. Brown PT 1/27/

17 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 Signed T. Therapist PT 49 Medical Review Corrective Action Plan Plan to correct identified deficiencies Begin with each denial reason and develop plan to correct each issue Timeline to solve each problem Staff involved 51 17

18 Corrective Action Plan Problem identified Action plan to correct each problem Timeline for implementation of each action How the corrective action will be monitored Name of the person responsible for carrying out each action of the plan The date you will implement the plan 52 Corrective Action Plan Therapy not reasonable and necessary National Government Services educational webinar on 3/12/12 mandatory for all therapists and assistants M. Jones, Director of Rehab, is assessing 20% of all therapy records to ensure patients meet guidelines and documentation is adequate beginning 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. 53 Corrective Action Plan Nursing services not reasonable & necessary National Government Services educational webinar on 3/12/12 mandatory for all RNs and LPNs N. Nurse DPS is reviewing 40% of assessments for patients admitted for nursing services effective 4/13/12 Nursing Supervisors are meeting weekly to peer review nursing documentation and each follows up with nursing staff regarding suggestions. They report to DPS on specific findings. Effective 4/20/

19 CERT Results 2011 Report (Home Health WI workload) 150 claims reviewed 13 claims denied 8% Payment Error Rate Good! 55 Identified Issues Insufficient documents submitted Not medically necessary Incorrectly coded Documentation not legible Signatures did not meet requirements 56 Submission of Records Submit the records with the ADR on top Double check records to be sure records are: For the correct patient For the correct episode A visit note is included for each visit 57 19

20 Submission of Records Records should be returned within 30 days of the date of the ADR We allow an additional 15 days Allows extra time for mail issues & scanning Upon receipt of records the claim is moved to status S M5REC Claim will deny if not moved Extension can be requested by fax (414) Electronic Records National Government Services accepts electronic records on a compact disc Include a cover letter (a form is available on the Web site) Home Health & Hospice > Resources > Tools & Materials > Coverage & Documentation > Submitting Electronic Medical Records Department that is the intended recipient Claim information 59 Electronic Medical Records Currently unable to accept HH record electronically through the health information handler 60 20

21 Resources Provider Contact Center Michigan, Minnesota, New York, New Jersey, Wisconsin, Puerto Rico, U.S. Virgin Islands IVR: Toll free number: Resources Defensible Documentation for Patient/Client Management CMS Web site Type/Home-Health-Agency-HHA-Center 62 Resources National Government Services Web site Computer based trainings RHH-C-0001-Home Health Agency Overview RHH-C-0010-Home Health Scenarios RHH-C-0012-Home Health Orders and Certification RHH-C-0013-Home Health Coverage Guidelines and Documentation Requirements 63 21

22 References CMS IOM Publication , Benefit Policy Manual, Chapter 7, Home Health Manual CMS IOM Publication , Benefit Policy Manual, Chapter 15 Sections 220 & Guidance/Guidance/Manuals/index.html 64 Medicare University Medicare University Interactive online system available 24/7 Educational opportunities available Computer-based training courses Teleconferences, Webinars, live seminars/face-to-face training Self-report attendance 66 22

23 Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at Topic = Cake Walk for a Successful National Government Services Medical Review Process Medicare University Credits (MUCs) = 1 Catalog Number = to be provided Course Code = to be provided For step-by-step instructions on self-reporting please visit > Medicare University > Accessing the Self-Reporting Tool 67 Thank You! 23