Best Options for Responding to the Home Health PPS 2011 Cuts *revised handouts
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1 Best Options for Responding to the Home Health PPS 2011 Cuts *revised handouts Improve Your Revenues with OASIS and Coding Presented By: Rhonda Marie Will, RN, BS, HCS-D, COS-C Melanie R. Duerr, RN, MS, ANP, HCS-D December 9, King Street, Suite 246 Northampton, MA fax:
2 Speaker Information Rhonda Will, RN, BS, COS-C, HCS-D is the Assistant Director of the OASIS Competency Institute for Fazzi Associates, Inc. As a registered nurse she has worked in home health care since 1979 in various clinical, administrative and management roles. Rhonda has extensive experience in staff and program development and as a consultant and trainer. Her areas of expertise include OASIS assessment and diagnosis selection and ICD-9-CM skill building, documentation, care planning and management, and regulatory compliance. With Fazzi Associates Rhonda has developed OASIS and clinical training programs, record audits for reimbursement and quality and ICD-9-CM Coding training. She presents educational programs on site and by audio/video conferencing for home health agencies, state and national home health associations and industry vendor sponsored meetings.. Rhonda provided clinical leadership for the M National OASIS Integrity Project and the 2009 National Best Practices OASIS C Project with Fazzi Associates. Recognized as an industry expert, she gave feedback on data items in the CMS draft OASIS C Guidance Manual and The Handbook of Home Health Standards: Quality, Documentation and Reimbursement (5th ed.) by Tina Marelli. Rhonda served on the Editorial Board for Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional from and conducts peer review for draft magazine articles. Melanie Duerr, RN, MS, ANP is a Partner and Senior Clinical Consultant for Fazzi Associates. Her experience in home care includes both certified home care and hospice as a Clinician, Clinical Director, Administrator, Vice President of Operations and as a Director of Financial and Clinical Operations. Melanie has worked in the profession as a Home Health Aide, Licensed Practical Nurse, Registered Nurse, and Nurse Practitioner. Melanie is also the co-developer of OASIS NP, developed in partnership with the National Association of Homecare & Hospice. She has been a speaker in over 30 states on strategies for OASIS accuracy and success at the clinician practice level.
3 Nurses Only: Directions to receive contact hours for the training. 1. Each participant must complete an evaluation in order to receive contact hours. Click on the following link in order to access the online evaluation form: *Please allow four weeks for processing.
4 Key Indicators For Medical Necessity Yes No Fazzi Quick Sweep Checklist Notes/Comments SOC/ROC Homebound Status Easily Identified Medical Necessity: Clearly Defined Patient Problems/Deficits/Knowledge Deficits Clearly Identified Skilled Need at SOC Unique Patient Goals Consistency Between Functional M Item Response and M2200 Therapy Utilization Service Plan for each Discipline Reasonable for the Problems Identified and the Assessments and Evaluations Conducted/Provided Acute Condition Prior to Home Care Clearly/Completely Identified in M1010, M1012, M1016 Primary Diagnosis Accurately Selected Considering all Services M1022 Diagnoses Adequately Describe Patient and are Pertinent to the POC V Codes Not Overused Diagnoses Supported in the Record by Physician (e.g. History/Physical, Direct Communication, Clinical Notes) End of Episode Clearly Identified Skilled Need Every Visit Evidence that 1 st Six Diagnoses from POC were Pertinent to the Plan of Care and did not Become of Mere Historical Interest Remained Homebound Patient Response to Intervention and Progress Towards Goals Evident Fazzi Associates, Inc.
5 Best Options for Responding to the Home Health PPS 2011 Cuts: Improve Your Revenues with OASIS and Coding December 9, 2010 Rhonda Will, RN, BS, COS-C, HCS-D Melanie R. Duerr, RN, MS, ANP, HCS-D Fazzi Associates, Inc. Objectives Discuss the impact of errors in OASIS assessments and coding on home health agencies quality scores and profitability Identify specific OASIS assessment items that are most frequently inaccurate, and what you can do about them Receive proven best practice strategies for improving OASIS assessment accuracy in your agency 2011 Reality: Therapy Requirements New Assessment required visits 13 and 19 1
6 2011 Reality: Reduced Revenue LUPA 2% reduction when not submitting quality data! Coding changes HTM out? - Now it s back in but being closely tracked 2011 Reality: Face-To-Face Physician must have a face to face contact with the patient within 90 days of the SOC or within 30 days after Reality: Face-To-Face Documentation must certify clinical findings that support HH - Not a random visit! it! 2
7 Face-To-Face (FTF) Encounters for Home Health Certification And Then there s the OIG 2011 Work Plan RAC Issues 3
8 Overpayments Collected by Error Type 74.3 Million no/insufficient documentation - 8% $160.2 Million other - 17% $133.8 Million incorrectly coded - 35% $391.3 Million medically unnecessary 40% 2011 Reality Let s say that you're a Certified Agency in Buffalo, New York. Your average CMW in 2010 is 1.28, you have 2,500 Medicare episodes a year with a LUPA rate of 10%... Please select your CBSA Name Buffalo Niagra Falls, NY CBSA Code: Enter your actual Case Mix Weight Enter your number of Medicare Episodes 2,500 Enter the LUPA% 10% Enter the Average Number of Visits per LUPA 3.00 Please enter comparison Case Mix Weight Pretty Good! 2011 Reality Please select your CBSA Name Buffalo Niagra Falls, NY The wage index in CBSA Code: Buffalo Niagara Falls, NY has decreased by 2.15% Enter your actual Case Mix Weight Enter your number of Medicare Episodes 2,500 Enter the LUPA% 10% Enter the Average Number of Visits per LUPA 3.00 Going Down? Please enter comparison Case Mix Weight
9 2011 Reality Please select your CBSA Name Alaska CBSA Code: Enter your actual Case Mix Weight The wage index in Alaska has increased by 8.27% Enter your number of Medicare Episodes 2,500 Enter the LUPA% 10% Enter the Average Number of Visits per LUPA 3.00 Or Going Up? Please enter comparison Case Mix Weight Reality Nothing changes Change Wage Index: (0.0209) National Standardized 60 Day Episode Payment Rate: $2, $2, ($120.87) Case Mix and Adjusted Payment Rate without NRS: $2, $2, ($196.80) Reimbursement for 2,250 SOC's $6,527, $6,084, ($442,808.18) Wage Adjusted LUPA Rate per visit: $ $ ($3.45) Reimbursement for 250 LUPAs with 3 visits each, incl. LUPA Add on $106, $80, ($25,791.10) Total Reimbursement $6,633, $6,164, ($468,599.27) Status Quo: If, in 2011, your average Case Mix Weight remains at for 2,500 SOC's, total reimbursement will decrease by $442, or 6.78% due to the change in wage index and reimbursement rate. But there is $468,599 less reimbursement Rationale for Changes Patient acuity not as apparent as increased skills in data collection and diagnosis coding Behavior changes based on financial incentives It s all about documentation 5
10 Final Rule: November 17, 2010 Given the profit margins of HHA s that we and MedPAC are seeing in our analyses, we believe that the reductions of this final rule can be absorbed by the majority of HHAs, and that access to care will not be compromised. Federal Register P Reality: Reduced Revenue Impact: Decreased margins creating the need to do less with more Action: Confirm accuracy of OASIS completion Recommendations Increase revenue per episode Average CMW What is yours? 6
11 Case Mix Weight Episode Timing OASIS Response Selection Therapy visits PPS Scoring Variables Functional Other Clinical Diagnosis 51 variables 30 relate to diagnosis M1020/M1022/M1024 Primary, secondary or both (17) Interaction of 2 diagnoses (2) Interaction with other OASIS items (11) 15 additional clinical OASIS items 6 functional OASIS items 7
12 Most Frequently Missed M1342 Status of Surgical Wound M1400 When Dyspneic M1242 Frequency of Interfering Pain M1830 Bathing M1850 Bed Transferring M1860 Ambulation/Locomotion M1910 Multi-factor Falls Risk Assessment Conducted Extra Attention M1010 Inpatient Diagnosis M1012 Inpatient Procedure M1016 Diagnoses Requiring Medical or Treatment Regimen Change Attention! M1010 M1012 M1016 Recommendations Take the Quick Sweep Challenge: - Select 5 Medicare Assessments, - With multiple disciplines where the RAP has been dropped, - And the Assessment has been through your QA review process. Using tools available to you audit the records for the following: 8
13 See Fazzi Clean Sweep Tool Evaluate Data collection techniques Documentation of comprehensive assessment findings including OASIS items - Knowledge deficit - Documentation system Care planning - POC Episode Management Best Practice Strategy or Failure? Joint field visits or..validation field visits within 48hrs 100% OASIS review Regular and focused education sessions Care Management Clinical Pathways Do it right the first time 9
14 Episode Management OASIS Comprehensive Assessment Patient Plan of Care Patient Care Coordination fazzi.com
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