How to Survive Audits By Accurately Documenting Medical Necessity Presented by Jennifer Warfield, BSN, HCS-D, COS-C Education Director, PPS Plus
How to Survive Audits By Accurately Documenting Medical Necessity CGS Top Reasons January - March 2017 Rank Code 1 5HN18 2 5HC01 Description # of Claims % of Claims Skilled nursing services were not medically necessary 125 23% The physician certification was invalid since the required F2F encounter was 110 20% missing/incomplete/untimely 3 56900 Requested documentation not received/received untimely 97 18% 4 5HY01 The documentation did not show that therapy services were reasonable and 41 8% necessary The initial certification was missing/ 5 5HC09 incomplete/invalid, therefore 30 6% recertification episode is denied PGBA Top Reasons January - March 2017 Rank Code Description # of Claims % of Claims 1 56900 Auto denial - Requested records not submitted 3,671 44.3% 2 5FF2F F2F encounter requirements not met 1,538 18.6% 3 5CHG3 HIPPS code change due to partial denial of therapy 872 10.5% 4 5F023 No plan of care or certification 644 7.8% 5 5A301 Info provided does not support the 287 3.5% medical necessity for therapy services 6 5FNOA Unable to determine medical necessity of 283 3.4% HIPPS code billed as app Oasis not submitted NGS Top Reasons October - December 2016 Rank Code Description 1 55H2B Documentation submitted does not support homebound status 2 55H2C Medical necessity not supported as OASIS not submitted 3 55H3A Skilled observation was not needed from the SOC 4 55H3V Skilled nursing services were not medically necessary 5 56900 Requested documentation not received/received untimely Top Reasons 5CHG1 Medical Review HIPPS Code Change/Documentation Contradicts M Item(s) OASIS data conflicts with what was billed 5AMVN/5FMVN More Visits than Reasonable & Necessary SN visits not covered because documentation indicated more visits were provided than were reasonable and necessary. Visits may be denied that do not affect payment but will affect the overall charge denial rate. Each visit note for all disciplines must stand alone. 1
5F023/5T023 No Plan of Care or Certification No POC established and approved by a physician. All pages MUST be included. Care plans are omitted from ADRs and/or the wrong POC may be submitted because agencies are working against a deadline. 5ANOA/5FNOA Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted HHA did not submit the OASIS for the HIPPS code billed on the claim OASIS not submitted for ADR All pages of OASIS not submitted 5F012/5T012 Physician s Plan of Care and/or Certification Present Signed but not Dated Documentation submitted did not include the physician s signed certifi cation or recertifi cation Electronic signatures ensure compliance with this standard All pages of POC not signed 5A301/5F301 Info Provided Does Not Support Medical Necessity for Therapy Services Clinical documentation did not support the medical necessity of the skilled services from start of care. Therapy evaluation MUST be complete. Ensure that therapy complies to coverage determination. Ensure that # of visits is supported by OASIS assessment. Consider who does the OASIS in SN and therapy cases. 5FF2F/5TF2F Face-to-Face Encounter Requirements Not Met F2F documentation not submitted with ADR Homebound status is not adequate Reason for skilled services not adequate Clinical data not found in patients acute/post acute records 5A041/5F041 Info Provided Does Not Support the Medical Necessity for this Service Clinical documentation submitted for review did not support the medical necessity of the skilled services billed. See Medicare Benefits Manual - Chapter 7, Section 40 for what constitutes skilled services for each discipline. 56900 Auto Deny - Requested Records Not Submitted Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity. 21.5% of claims denied. Administrative Focus Review your claims through DDE or other revenue management tool to make sure they are not in ADR. Have a process in place to review End of Episodes so they will be clean for billing. Review and discuss utilization data. Is therapy handling med and HF issues? Mandatory Multidisciplinary Case conference before recertification. Provide education during orientation and annually on coverage guidelines. 2
Look for late paperwork. Notes that are completed long after the visit are rarely accurate. Review medications in the computer to look for clues for incorrect or incomplete diagnosis coding. Who's Looking at Your Documentation? RAC Recovery Audit Contract All MCR FFS Looking specifically for incorrect payments, non-covered services, duplicate services and medical necessity 3 years period of time On-going process especially if problems found initially ZPIC Zone Program Integrity Contractors Focus on detecting and preventing MCR fraud & abuse Seven jurisdictions All healthcare providers Compare data from Medicare & Medicaid RHHI Regional Home Health Intermediary per HH Regions Per HH regions: - Palmetto GBA - CGS - NGS Subject to do probe or focus audits Focus is that services provided meet requirements for reasonable & necessary visits Documenting Medical Necessity Clinical notes should include the following for every discipline: Assessment specific to the day of each visit Skilled services performed at each visit Patient s response to treatment rendered Plan for next visit (if there is no plan is a next visit necessary?) Avoid Vague Terms Patient sitting up. Alert & oriented Patient with no new complaints Wound care performed Instructed on disease management and medication teaching Will continue POC Be Specific Pain level since last visit has decreased from 8/10 to 5/10 Observed patient demonstration of insulin administration Patient reports coughing up thick green stuff Wound edges well approximating, no drainage noted 3
Diagnoses Code to the highest specificity. Avoid unspecified codes whenever possible. Keep in mind that home health codes will not always match physician codes. The condition requiring the most care or the focus of care given should be coded as primary, followed by the other diagnoses for which the agency will be performing interventions. Add co-morbid diagnoses that may affect the plan of care. Be sure that diagnoses are sequenced properly, and that each of the top 6 payer diagnoses are addressed in the plan of care. Medicare wants to know what you are going to do about these diagnoses, as well as how you are going to keep the patient out of a hospital and get the patient to an independent or supported independent status by discharge. Show that you have a plan, what the plan is, and how you are going to execute this plan. Query physician when documentation is illegible, conflicting, incomplete, or ambiguous; when clinical indicators of a diagnosis (are noted) but no documentation of the condition is available. If enough information is not available to code to a specific diagnosis, ask the physician and clinician for more information, so that you can code correctly and appropriately. POC Specifics POC must be precise and patient centered. Avoid cookie cutter interventions and goals Example: instead of writing, SN to teach on cardiac diet, write, SN to instruct patient on rationale for following a cardiac diet, and foods allowed and not allowed on this cardiac diet. Example: instead of writing patient will understand the effects of Furosemide, write, SN to instruct patient on S&S of hyper or hypokalemia and when to report to health provider Frequencies Red Flag! Majority of your POCs say SN 1wk9. Frequencies should be patient specific, and should indicate that you are planning to discharge the patient. Focus on what services are needed, not availability of care Upon discharge from hospital, when patient has a knowledge deficit, or has an unstable status, it is difficult to justify a 1w9. Front load visits when necessary. Documentation Supporting Therapy Orders to justify at least the evaluation Documentation of orders beyond initial visit Number of visits projected Patient s current functional status Objective tests and measurements A review of relevant systems Progress towards goals Revision of interventions and goals when necessary 4
Therapy Specifics When adding therapies, be sure that documentation demonstrates why the care is indicated. Give them guidance on reason for evaluation. Instead of order for PT TO EVAL AND TREAT, use, PT to EVAL AND TREAT due to left hemi paresis with poor understanding of need to use walker and increased fall risk. Be sure the therapy plan of care is also comprehensive, specific, and documentation supports the interventions and goals as planned. Red Flags Previous episodes of care for same issues Compliance or concerns on SOC No new diagnoses or issues since previous OASIS Recerting patient with same chronic conditions No exacerbation of old issues No definitive documentation progress being made Caregiver involvement early in episode Care not reasonable and necessary Numerous canceled or missed visits Skilled Needs The general principles governing reasonable and necessary skilled nursing care include: 1. Service must be provided by a registered nurse or a licensed practical nurse under the supervision of a registered nurse to be safe and effective. 2. To determine if the service requires the skills of a nurse, consider: - The inherent complexities of the service - The condition of the patient - Accepted standards of medical and nursing practice 3. Some services may be skilled based on complexity alone if it was reasonable and necessary: - Intravenous injections - Intramuscular injections - Insertions of catheters 4. In some cases, the service that ordinarily is considered unskilled will be considered skilled if the patient s condition is such that the service can only be safely and effectively provided by a nurse Skilled Needs Not every skill preformed by a licensed professional is considered medically necessary for payment. Become familiar with what is a covered services as listed in Medicare Benefit Policy Manual Chapter 7, Section 40. Even if a skill is covered, document efforts to educate patient/cg especially if skill will be ongoing (Ex: attention to PEG or colostomy) Observation & Assessment Observations and assessment of the patient s condition when only the specialized skills of a medical professional can determine patient s status include: 1. Observation and assessment are reasonable and necessary skilled services when the likelihood of change in a patient s condition requires skilled nursing personnel to identify and evaluate the patient s need for: - Possible modification of treatment - Possible initiation of additional medical procedures 5
2. Observation and assessment are reasonable and necessary only until the patient s treatment regimen is stabilized 3. Must be a reasonable potential of a complication or further acute episode 4. Services covered for three weeks or so as long as there remains a reasonable potential for such a complication or further acute episode 5. For the patient where services are extended beyond the 3-week period, the medical record must support likelihood of a future complication or acute episode 6. There are other indications that observation and assessment are reasonable and necessary when it is likely they will result in changes to the treatment of the patient. 7. Observation and assessment is not reasonable and necessary when these indicators are part of a long standing pattern and there is no attempt to change the treatment to resolve them Homebound or Not? Medicare Benefit Policy Manual definition. Homebound status should be documented on every visit. Are assistive devices or assistance of another person needed to leave home safely? Don t assume that every patient that was homebound on admission is still homebound. Question all frequent absences or missed visits. Absences must not indicate that the patient has the capacity to obtain healthcare outside rather than in the residence without a taxing effort. The elderly person who does not leave due to feebleness or insecurity must meet Medicare requirements to be homebound. Reassessment according to the new 2011 regulations (RFA #5) Goals reset if more visits are projected. Plans for discharge. Plans for continued in home program if discharge is eminent. Patient /Caregiver documentation and reception of over all plan. Multidisciplinary case-conference Conference with physician regarding new plans Conference with patient and/or caregiver Reassess current POC Make revisions Assess more often Early discharge if compliance not met or no progression to goals Review every record thoroughly upon discharge Use a documentation check sheet Don t assume anything. Remember the old adage, if you didn t chart it, you didn t do it Every visit note for every discipline must stand alone (HIPPS code down-coded because reviewer decides more visits were done that what was medically necessary) 6
Responding to ADR Assign someone to monitor DDE daily (notification methods) Do not ignore Use a checklist to be sure all required documentation is added Include copy of ADR letter Use a cover sheet and an index page Hand number all pages Do not use post-it notes or highlighters Include a clean copy of POC Get attestations and addendums from physicians and clinicians when needed Include signature logs when needed Assure everything is signed and dated Put everything in chronological order Send everything at once and be sure everything is legible Finally... Wait for responses. Take note of all correspondence and use as an educational opportunity. Develop Plan of Correction (whether directed to do so or not). Reinforce orientation to include lessons learned. 7
Thanks for Attending! Feel free to contact us with any questions. Jennifer Warfield, BSN, HCS-D, COS-C jennifer@ppsplus.com 1-888-897-9136 Join the PPS Plus Conversation!