Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #21 Compliance = Confidence! Tuesday, August 6 2:30 to 4:30 p.m. Diplomat 1 & 2 Upon completion of this presentation, the learner will be able to: identify Medicare requirements for skilled therapy services in a skilled nursing facility setting; demonstrate the impact of MDS 3.0 on quality measures; examine the documentation elements that will support medical necessity of therapy services provided in a skilled nursing facility setting; and describe a compliance process that includes both triple check audits and a peer audit review that can be utilized to ensure compliance of therapy services through integration with their quality improvement programs. Seminar Description: This session will provide a detailed discussion surrounding compliance as it relates to the provision of therapy services in a skilled nursing facility setting. This informative presentation will identify required documentation elements, review the relationship of documentation to MDS coding accuracy and explore strategies to ensure compliance with therapy services to integrate with the center s quality improvement initiatives. Presenter Bio(s): Marigene Barrett is President of MRH Professional Services, LLC. She has over 13 years of experience in the long term care field serving as an MDS Coordinator, Assistant Director of Nursing, Director of Nursing, Director of MDS and Division Director of Care Management for various long term care facilities and management companies before starting her own business. Her comprehensive knowledge and experience is concentrated in nursing home Resident Assessment Instrument (RAI) processes, clinical documentation education, quality assurance programs, Medicare and Medicaid reimbursement and the long term care survey and certification process. She has been a speaker at several corporate conferences and training sessions throughout her career and has been a contributor to articles on MDS 3.0 related subjects for MDSCentral at HCPro, Inc. Sheila Capitosti is Vice President of Clinical and Compliance Services for Functional Pathways. Her in-depth knowledge and experience is concentrated in all aspects of nursing home operations, clinical processes, quality improvement services and clinical program development, as well as the long term care survey and certification process and Medicare and Medicaid reimbursement. She is a frequent speaker at national, state and regional conferences and has authored numerous articles on subjects that include clinical practice applications, program development models and risk management applications.
ENSURING THERAPY SERVICES COMPLIANCE Sheila Capitosti, RN-BC, NHA, MHSA Marigene Barrett, RN, MBA, CLNC, RAC-CT Florida Health Care Association 2013 Annual Conference and Trade Show 1 August 6, 2013 Objectives Participants will be able to identify Medicare requirements for skilled therapy services in a skilled nursing facility setting Participants will be able to examine the documentation elements that will support medical necessity of therapy services provided in a skilled nursing facility setting Participants will be able to identify the relationship of documentation to accurate MDS coding Participants will be able to describe a compliance process that includes both triple check audits and a peer audit review that can be utilized to ensure compliance of therapy services through integration with their quality improvement programs 2 The News Is Not New BUT.. OIG Report on "Inappropriate" Medicare Payments to SNFs in 2009 identified: SNFs billed one-quarter of claims in error in 2009, resulting in $1.5 billion in inappropriate payments SNFs misreported information on the MDS for 47 percent of claims 30% therapy related minutes and days 3 1
OIG Report: November 2012 The OIG recommends the following: Increase and expand reviews of SNF claims Use its Fraud Prevention System to identify SNFs that are billing for higher-paying RUGs Monitor compliance with new therapy assessments (including through Medicare Administrative Contractor (MAC) and Recovery Audit Contractor (RAC) analysis and review) Change the methodology for determining how much therapy is needed Improve the accuracy of MDS items Follow up on the SNFs that billed in error CMS agreed with all six recommendations 4 Compliance: Definition The act of adhering to, and demonstrating adherence to, a standard or regulation 5 Regulations Medicare Part A Part B Managed Care Medicare Benefit Policy Manual Chapter 8 Section 30 Chapter 15 Section 220 National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Medicaid 6 2
Regulations Licensure Clinical Practice Regulations Federal State Facility Licensure Regulations Federal State 7 Guess Who Is Watching Us? 8 EVERYONE IS WATCHING!! Additional Development Request Comprehensive Error Rate Testing Medicare Administrative Contractors Zone Program Integrity Contractors Recovery Audit Contractors Medicaid Integrity Program 9 3
Whistleblowers Whistleblowers are becoming an increasingly powerful weapon against healthcare fraud HHS proposed rule calls for awards of up to 15% of the first $66 million in recovered funds, and HHS is seeking comments on whether the whistleblower payouts should be increased to the 30% range The proposed rule will be published in the Federal Register on April 29, and comments will be accepted through June 28 Florida, in particular, has had large success uncovering healthcare fraud with the help of whistleblowers, the Palm Beach Post reported in January 2013 Of the $162 million recovered, roughly $145 million stemmed from civil settlements including whistleblower cases 10 What Are They Looking For? 11 Medical Review Program Pay It Right Right Amount Right Provider Right Service Right Beneficiary Preventing improper payments through evaluation of vulnerabilities and action to prevent the identified vulnerabilities in the future (MAC/FI) Correcting of past improper payments through Medical Review (RAC) Measuring improper payments by service, provider, contractor (CERT) 12 4
Medical Record Selection Providers may be selected for review when Atypical billing patterns are identified Data Mining Looking for outliers A particular kind of problem is identified Errors in billing a specific service Evaluation of other information OIG work plan CERT error rate reports RAC vulnerabilities GAO reports 13 Data Mining High volume High cost Dramatic changes Adverse impact on beneficiaries Problems which, if not addressed may escalate 14 Outliers Treatment/documentation patterns ICD-9 codes CPT codes Frequency Duration Automated documentation UNIQUE PATIENT INDIVIDUALIZED PLAN OF CARE 15 5
Outliers Treatment/documentation patterns ICD-9 codes Sepsis UTI Pneumonia CHF Myocardial Infarction CPT codes Part B automatic exception codes Hospice/Palliative care 16 Outliers Frequency Ultra at 30 days Very at 60 days Ultra and Very High and ADL Index <5 RUA/RVA Part B: # units/day Trailblazers 60 units/month limit Trailblazers cert letter goal Reduce overall amount of utilization of RU and RV combined to 61% of all SNF rehab claims 17 Outliers Duration Medical diagnosis past 30 days Part B past 30-40 days Therapy services if BIMS Score <7 Rehab + Extensive Services Same RUG level for 3 successive periods 18 6
Outliers Utilization patterns higher than national/state averages Comparative Billing Reports Expect those receiving them will result in audit Automated documentation same drop-down responses Do FTEs reflect individual therapy or are there discrepancies 19 Outliers Medical necessity and need for institutional care do not match Section I coding instructions Who is assigning diagnosis codes should not be billing office Utilization increases but beneficiary characteristics remain unchanged Age Diagnosis Needs to be individualized V57.8 care involving other specified rehab procedure 20 If You Are An Outlier Recognize you might be an outlier There can be valid reasons Extra diligent in documentation If identified as an outlier and/or on probe review SUPER-EXTRA diligent in documentation ALL payment decisions are made based on the documentation and the documentation alone 21 7
How Do We Minimize Our Risk? 22 Minimizing Risk Documentation Practices Triple Check Audits Quality Improvement Initiatives 23 Documentation Practices 24 8
Documentation The paper IS the person If it is not documented, it did not occur! If it did not occur, it will not be paid! ALL payment decisions are made based on the documentation and the documentation alone 25 Documentation Must Support Technical Requirements Medical Necessity 26 Medical Necessity Medicare s benchmark for paying for services Further defined by Local Coverage Determinations (LCDs) Clinical component for payment Reasonable and necessary to the treatment of the individual s illness or injury Requires the skills of a licensed therapist 27 9
MDS Process Management 28 PPS Meetings Scheduled PPS meeting Daily or Weekly Goal is to ensure skilled criteria is met, appropriate MDS dates are set, documentation compliance, resident response to treatment, and discharge planning PPS Meeting Attendees Administrator Director of Nursing Unit Manager/Staff Nurse RNAC/MDS Coordinator Business Office/Billing Manager Therapy Manager/Director Social Services Director 10
MDS Assessment Scheduling Appropriate Assessment Reference Date (ARD) selection Within Federally mandated timeframes Scheduled PPS 5, 14, 30, 60, 90 day assessments Unscheduled PPS COT EOT EOT-R SOT (optional) MDS Documentation Documentation within MDS assessment reference observation period CNA ADL documentation Daily skilled nurses notes Therapy notes and weekly progress reports Document the resident s response to treatment and capture the most dependent level for the ADL documentation Therapy days/minutes match the therapy log ADL Documentation Document reflects what the resident actually did for that task not what they can do Must meet the rule of three: Three episodes of self-performance at most dependent level during observation period and one episode of staff support at highest level to be captured in Section G (ADLs) If three episodes at any one level are not documented during the observation period must code per RAI manual rules Chapter 3, Section G in RAI Manual 11
MDS Completion Completed accurately and timely Admission assessment by day 14 Includes Care Area Assessments (CAAs) Can be combined with the PPS 5 day or 14 day All other assessments must be completed within 14 days after ARD Transmitted to CMS within 14 days of completion Accepted by CMS as indicated by final validation report Triple Check Audits 35 Triple Check Defined Key to accurate reimbursement The triple-check system provides an internal audit of claims prior to submission in an effort to Decrease the chances of an audit Ensure successful results of an appeal if audited Improve cash flow to facility operations 36 12
TRIPLE CHECK BILLING AUDIT MDS -VS- UB-04 -VS- Medical Record 37 Triple Check Audit Team Minimum RNAC/MDS Coordinator Rehab Manager/Director Business Office Manager 38 Verification and Cross-Check MDS ARD Sections G and O (supported in Medical Record) Denial Notices issued appropriately MSP signed and completed on admission 39 13
Verification and Cross-Check MDS Matches UB-04 Matches MEDICAL RECORD Medicare Number and Resident Demographic Data Diagnosis for skilled service match and relate to hospital stay ICD-9 Diagnosis Codes accurate Admission Date correct Hospital Stay Dates Physician Orders for Skilled Services/SNF Stay Physician Certification Assessment Reference Dates within correct timeframe MDS Assessment Type correct RUGs & HIPPS codes correct 40 Triple Check Process Typically consists of a meeting during the month end close process After UB-04 claims are generated but prior to submission for payment Involve members of the interdisciplinary team Do not review your own work Not necessary to do all of the work during the meeting Do homework and come prepared 41 Triple Check Process Information is documented as an audit process Information from the audit is brought by the individual team members to the triple check meeting and reviewed Discuss any potential discrepancies during the meeting Make corrections (if possible) or decisions regarding billing status Assign responsibility (including deadlines) for any items needing follow up 42 14
Areas To Consider During Triple Check Qualifying hospital stay Watch for observational stays/days Benefit period Where has resident been in last 60 days Medicare Secondary Payer (MSP) May not be in Common Working File (CWF) RUG category accuracy MDS ARD (Service Date) Days billed 43 Areas To Consider ICD-9/Diagnosis Codes Medical diagnosis ICD-9 or V Code (related to hospital stay) Treatment diagnosis Section I coding Ancillary charges (therapy, labs, pharmacy, etc) Still listed even if part of consolidated billing Physician orders Did resident get the service Physician certification and recertification Timing/Completeness MUST DOCUMENT SKILLED SERVICE MDS submission and acceptance into the national database 44 Areas To Consider Therapy Documentation Evaluation Progress Notes Daily Service Logs Nursing Documentation ADL documentation Progress Notes Daily Skilled Charting Physician Documentation 45 15
Documentation Triple Check Audit Form Medicare Claims NOT SUBMITTED until Triple Check Completed AND Errors fixed Audit Team Sign-Off Error Rates Calculated Audits completed through Quality Assurance Committee 46 Triple Check: Outcomes Clean claims Peer review Interdisciplinary process Reduce or eliminate denials Opportunity to determine support for claims 47 Quality Improvement Initiatives 16
Quality Improvement Initiatives Integrate INTERNAL monitoring into ongoing quality assurance program and processes Focused chart audits Monitor trends Action plans for areas that represent opportunities for improvement Initiate Action Plans for areas of improvement 49 Focused Chart Audits Higher/lower than national average RUG utilization Higher/lower than national average LOS/Duration Industry trends Automatic denials RU at 60 day assessment Ultra at 30 day assessment (CHF-MI-UTI- Pneumonia) Accepted coding for medical necessity Part B exception codes Hospice/Palliative care Part B units/month Additional Development Requests Denials Local and national coverage determinations 50 Look for things that make an auditor go hmmm 17
Tips For Success Participate in Triple Check Audit Process Ensure "Sufficient" Documentation Implement a Clinical Documentation Improvement Program $$$ At Risk $$$ Missed 52 Compliance = Confidence! 53 Questions??? 54 18
Thank You! Questions or comments always welcomed! Sheila Capitosti, Vice President Clinical and Compliance services scapitosti@fprehab.com (865) 356-0256 cell Marigene Barrett, President, MRH Professional Services mbarrett@mrhpro.com (941) 350-7669 cell 55 19
SKILLED SERVICES MEDICAL RECORD REVIEW Resident Name: Admit Date: 3 = Standard Met. 0 = Standard not met and needs prompt follow up. New Admission STANDARD MET COMMENTS 1. Hospital Records of most recent hospital stay to support skilled care in chart 2. A signed Physician's Order to admit to skilled care is present. 3. Primary and Secondary Diagnoses listed on chart. 4. Nursing Admission Notes include assessment of resident's condition requiring skilled care. SNF Cert/Recert. Complete a New Cert/Recert each time resident is admitted/readmitted to skilled care. Time Frame Due Date Met (Physician Signed & Dated) Comments Admission: (On or before SNF admission) 15t Recert: (No later than 14 th day of SNF admission ) 2nd Recert :(No later than 30 days from previous recert date) 3 rd Recert :(No later than 30 days from previous recert date. Review Weekly During Medicare Part-A Stay Standard Review Date NSG. 1. Physician Orders/ Therapy Clarification Orders, T.O's are all signed and dated by physician. 2. Nursing Documentation supports skilled care. Nursing/Pt. Teaching, ADCs, Mood/progress 3. Assessments (ALL) identify skilled care. 4. Care plans are in place and address skilled care. 5. Evidence of physician visit every 30 days reflected on physician's progress notes. 6. Restorative Nursing Order and documentation (type, minutes, day's) are in place, if applicable. REHAB 7. Therapy Diagnoses, Clarification order's and Documentation support skilled rehab and include resident's progress toward goals. 8. Therapy Plan of Care signed and dated by Physician. SS 9. Discharge Planning active and documented including barriers to d/c, if any. Met Met Met Met Met Met Met Met Met Revised May 6, 2013
Review Dates IDT Signatures Revised May 6, 2013
Medicare Part-A Pre-Billing Triple Check Resident Name: Dates of Service: From Through Facility: Billing Month/Year: MET, - COMPLIANCE STANDARD 1. Beneficiary's name correct per CWF Screen SOURCE OR LOCATION OF DOCUMENTATION CWF 2. Birthday correct per CWF screen CWF 3. Sex correct per CWF CWF 4. Status Correct CWF 5. Provider number is correct. NPI number and doctor's name is correct UB04 6. Beneficiary's Medicare number is correct per CWF CWF 7. Qualifying hospital stay is correct Hospital record 8. Remarks for processing claim are present 9. All needed condition, occurrence and value codes are present/correct. UB04 UB04 10. Bill type is correct UB04 11. Dates of Service are correct UB04 12. Medicare Secondary Payor Form is complete. Medical record/financial File 13. ABN/NOMNC/Detailed Notices are issued and signed as applicable. Financial File Business 0 MET ice and Nursin : p lace a N) check in the first column when the standard is COMPLIANCE STANDARD met. (X) or NOT MET SOURCE OR LOCATION OF DOCUMENTATION Medical record 1. Admission date is correct 2. A signed & dated order is present to "admit to skilled care" 3. All orders are signed and dated by Physician or extender. 4. ARD falls within required timeframe MDS 5. Assessment type is correct MDS 6. Daily ADLs and skilled services supportive documentation adequate. 7. Interim and Comprehensive Care Plan identifies problems requiring daily skilled care, measurable goals and interventions. Documentation identifies resident's progress toward goals. Physician order/3008 Medical record Medical record Medical record 8. Diagnoses are appropriately coded and support MDS/Rehab services billed. 9. RUGs & HIPPS / codes are correct MDS 10. Number of days billed for each assessment type are Detailed Monthly Census/PCC correct 11. Cert/recert form is completed, signed and dated by Medical record Physician 12. Evidence of Physician visit every 30 days. Medical record 13. Pharmacy charges are only for legend meds used during the dates of Medicare stay 14. Med/surg charges are only for coverable items used during the dates of services billed 15. All billable ancillary charges have been applied and appear reasonable Pharmacy Invoice Orbits Xrays/Lab/Equip. Etc. Page 1 of 2
Business 0 ice and Rehab: Vace a (1 ) check in the first column when the standard is met (X) or NOT MET MET COMPLIANCE STANDARD 16. Rehab RUG, PT, OT, ST charges are present and correct. Rehabilitation units/minutes accurate & consistent 17. Rehab Orders / Plan of Care / Updated plan of care are signed and dated by the physician SOURCE OR LOCATION OF DOCUMENTATION U B04 Medical record Date Approved for Billing: Signatures: BOM Date MDS Coordinator Date Rehab Date 1 Updated 2/6/13 File: Word=> G: Business Office => => Triple Check Page 2 of 2