The software that powers post-acute care kinnser.com MEDICAL REVIEW SURVIVAL GUIDE What the CMS Probe & Educate Initiative Means for Your Agency Success Tactics for High Performing Home Health Agencies by Sharon Harder, President of C3 Advisors
About the author Sharon S. Harder has over three decades of executive management experience in the healthcare industry. She has served in financial and operational leadership roles in a variety of healthcare organizations ranging from a major healthcare professional association to large post-acute healthcare providers. As President of C3 Advisors, LLC, Sharon engages with clients to develop and implement the strategic vision required to improve their profitability and competitive position in the rapidly transforming healthcare market place. Her demonstrated expertise extends to regulatory compliance, financial management and business improvement solutions for achieving growth and long term success. Sharon frequently speaks on a range of industry topics, has led research projects on industry trends and authored numerous articles. Learn more at C3Advisors.com. 2
Overview Late in 2015, the Centers for Medicare and Medicaid Services announced its directive that Medicare Administrative Contractors (MACs) conduct Probe and Educate reviews of every Medicare certified home health agency during the first three quarters of 2016. The purpose, in general, is to assess the degree to which agencies understand and are complying with the 2015 Face-to-Face Encounter rules. Five unpaid claims submitted for service dates after August 1, 2015 will be selected for review. While the Probe and Educate initiative is supposed to measure compliance with Face-to-Face instructions, each record will be subjected to a full medical review. Clean claims will be paid and those that do not meet one or more conditions of payment will be partially adjusted or denied altogether. In announcing the Probe and Educate initiative in SE 1524, CMS made it clear that agencies receiving two or more denials for the first five claims to be reviewed will have the option of oneon-one telephone calls to better understand the reasons for the denials and obtain educational guidance. Those agencies will also be subjected to a repeat review of another five claims. What SE 1524 is silent about is what happens if, after the second round of reviews, an agency still has an error rate in excess of 20%. Unfortunately, the published review results so far are producing an error rate of just over 91% and very few clean claims. Compared to the estimate from the Office of the Inspector General in 20121 that 22% of home health claims contained errors, it is clear the trend is moving in the wrong direction for home health agencies. This paper reviews the basics of responding to Additional Development Requests (ADRs) and explores how each agency s billing and clinical team should evaluate its documentation before billing to produce the desired payment. 1 Documentation of Coverage Requirements for Home Health Claims, March 2012, Office of the Inspector General, OEI-01-08-00390 3
Additional Development Requests (ADRs): The Basics Many agencies haven t had to deal with large numbers of ADRs. Sometimes agencies tell us they haven t dealt with them at all not because they haven t received requests, but because they ve ignored the requests that have come through. They simply allow the claims in question to be denied. This isn t a good strategy for several reasons, including Chapter 3 of the Medicare Program Integrity Manual which states that providers/suppliers who show a pattern of failing to comply with requests for additional supporting documentation for any claims submitted to CMS may be subject to complex medical review for all claims. The language of Section 3.7, Corrective Actions, goes on to state that for purposes of this paragraph, a pattern is two or more ADRs that have gone unanswered. According to Cahaba Government Services, in its early review rounds, 30% of the ADRs sent out were ignored, which is not a good sign, particularly for agencies that did not respond in time. Instead of waiting for your agency to be subjected to additional reviews, let s look at how to construct your agency s responses, beginning with the documentation likely to be requested. Based on our contacts with a number of agencies, the ADRs associated with the Probe and Educate initiative are exactly like the ADRs that have been sent out for recent service and provider specific reviews. The following list shows the top 10 items needed in a submission of information for a Medicare episode without therapy services. The Top Ten ADR Documentation Requirements DOCUMENTATION REQUEST 1. OASIS Assessment used to generate the HIPPS Code for the episode. 2. Initial (SOC) Certification and Plan of Care regardless of dates of service billed. 3. The Face-to-Face Encounter documentation related to the episode under review. NOTES This is a condition for payment. If the OASIS is not in the national repository the claim will be subject to denial because the HIPPS code will not be verifiable. The agency should not only submit the OASIS, but also the submission validation in the ADR response. The Start Of Care (SOC) date on the Plan of Care will be compared to the SOC date on the claim. This document will also be used to validate the Face-to-Face in terms of the identity of the physician who provided the encounter and the encounter timing. The agency should be sure the physician s identity is clear, with credentials included, and that the document has been timely signed and appropriately dated prior to billing for services. Remember, stamped dates are not permitted. This means the Face-to-Face Certification and the underlying encounter record from the physician or facility for the episode that comprised the Start of Care. Even if the episode being reviewed is a second or subsequent episode, the Face-to-Face Certification and encounter record must be submitted if the series of episodes began on or after Jan 1, 2015. Each should be signed and dated, and the encounter record from the physician should support the elements of the 2015 Face-to-Face requirement (see Face-to- Face Issues). 4
The Top Ten ADR Documentation Requirements (continued) DOCUMENTATION REQUEST 4. The Recertification and Plan of Care to cover the period under review (if this is a second or subsequent episode). NOTES The Plan of Care that applies to the episode under review will be used to establish and review the focus of care, initial orders and visit frequencies as well as medical necessity and patient homebound status. As with all other orders, this document should be appropriately signed and dated by the referenced physician prior to billing for services. 5. All Supplemental Orders. This includes the written, verbal and telephone orders for starts of care/recertifications, all visit discipline and/or frequency changes, additions or deletions to the Plan of Care, new and changed medications, blood draws, labs etc. These documents will be used to ascertain that care provided was performed under a valid order. They should be appropriately signed and dated prior to billing for services. 6. Visit notes for each visit by each discipline. 7. Other pertinent documentation that supports medical necessity. 8. If there were daily, or more frequent, nursing visits for the period under review, a statement from the physician as to the endpoint of daily visits. Visit notes will be used to measure skilled care against the services/interventions that were ordered for the patient as well as Aide services, if ordered. Each note should contain a narrative of the skilled care that was provided and the patient s response to that care. Visit notes should address ordered interventions and should be specific and as non-repetitive as possible with respect to disease process and medication teaching. Each should have the time in and out as well as the clinician s (electronic or handwritten) signature and date of signature. This can be virtually any other element of documentation that supports the skilled need for home health services and/or the patient s homebound status as a prelude to that need and medical necessity. This is reasonably rare, but if the circumstance applies, be sure the statement is included. Otherwise, the Medicare Policy Manual specifically limits daily service to a maximum of 21 days. 9. Signature logs & attestations as to the veracity of signatures, if applicable, as well as documentation of the process for authenticating electronic signatures and dates. 10. As applicable, the physician s statement and estimate of how much longer skilled services will be needed. If there is any doubt about the legibility of physician signatures, err on the side of getting the signature log to include in the ADR response. Now required for all recertifications either as an order or as part of the Recertification Plan of Care for every recert period. 5
Clearly, therapy services are under intense scrutiny and have been the subject of several service specific probes over the last few years. Episodes with Therapy For those episodes with therapy services, the list will get a little longer and will include: 1. The initial therapy evaluation if the episode under review is a Recertification. It doesn t matter how long ago the initial therapy assessment was done as long as it was for the SOC episode in the series. 2. Therapy reassessments for the prior billing period as well as those for the dates of service in question. 3. Documentation of timely assessments, functional measurement comparisons and therapy effectiveness. Clearly, therapy services are under intense scrutiny and have been the subject of several service specific probes over the last few years. Nothing has changed, and it will be the agency s responsibility to ensure therapy services delivered are shown to be appropriate in terms of overall utilization as well as medically necessary and demonstrated improvement toward long- and short-term goals. Other Documentation to Include Other items the agency will want to submit are labs and values, Aide Care Plans, as applicable, itemized supplies, copies of Advance Beneficiary Notices that were provided to the patient, documentation of SN and Aide hours where on a combined basis the visits span more than two hours in a day, and documentation that responds to applicable Local Coverage Determinations (LCDs). Regarding LCDs, Palmetto is the MAC with the largest library of LCDs covering Physical Therapy, Occupational Therapy, Speech Language Pathology, Glucose Monitoring (A1C), Falls at Home, Treatment of Dysphagia, Alzheimer s Disease and Behavioral Disturbances Teaching and Training and Home Health Psychiatric Care. Medical reviews conducted by Palmetto for any episode involving any one or more of these care topics will be reviewed in conjunction with the guidance in the applicable LCD. Agencies should consider the requirements in an applicable LCD as a necessity for payment. Document Submission Hierarchy There is no hard and fast rule regarding the order in which documents should be organized for submission, but the following method facilitates flow and overall organization. 1. A copy of the ADR and/or FISS screen shot with the ADR information. This should be the first document and will give the MAC s reviewers information as to which ADR is being processed. 2. A cover letter that responds to the ADR request. The cover letter can serve as a guide to the information the agency is providing. 3. Signed and dated initial (SOC) Plan of Care if the episode under review is the second or subsequent episode. 4. The Face-to-Face Certification and physician encounter record for the episode that formed the SOC. Both should be signed and dated by the physician who performed or supervised the encounter. 5. OASIS and submission information. 6. Signed and dated Plan of Care for the current episode. 7. All signed and dated Supplemental Orders. 8. Signature logs and/or signature attestations, if required. 9. Additional documentation, if any, that supports homebound status and/or medical necessity. 10. Visit notes by date and discipline, signed and dated by each clinician who performed the visit. Discipline order is generally SN, PT, OT, SLP, MSW, HHA. 11. Initial therapy evaluations, as applicable. 12. Therapy reassessments for the prior billing period and the billing period under review. 13. Aide Care Plans and other requested or applicable documentation. 6
ADR packets can be submitted several ways. They can be scanned and sent via the MAC s web portal. They can be scanned as a pdf document to a DVD/CD and mailed. They can be mailed as a paper submission. Or, they can be faxed. Once an ADR response is received, the MAC will review the response using a specific, hierarchical approach. Generally, submitted documentation is first reviewed to ensure that the technical requirements have been satisfied. The technical requirements relate to everything about the record that is not medical documentation such as Face-to-Face encounter documentation, presence of a valid (signed and dated) Plan of Care, etc. This technical review is followed by a medical review. If, at any time during the review process, required documentation is found to be insufficient, incomplete or missing altogether, the review process stops and the claim is denied. The MAC has 30 days from the date it receives your agency s documentation to make its payment determination. If your claim is denied for payment, it will be updated in the FISS system as having been denied due to insufficiency of the submitted documentation. At that point your agency cannot resubmit the claim for payment and the decision must be appealed. ADR TIPS 1 Once the ADR packet is arranged, proofed and in order, clearly number the pages. 2 Don t use highlighters to draw attention to information in a segment of the record. If it is that important, refer to it in the cover letter. Highlighted information may become less visible when scanned. 3 Don t bind or staple documents together if you are submitting paper documentation. 4 Don t use sticky notes or other means to call attention to information or documents in the packet. This includes avoiding the temptation to write on various records. 5 Send each ADR packet separately and retain proof of submission, such as a certified mail receipt. 6 Get it in on time. Claims will be denied if the MAC has not received and logged your response by the 45th day following notification. Postmarking the package on the 45th day won t be sufficient. Aim for a 30-day turnaround. 7 Don t use FedEx or other overnight carriers to send information as it may not get to the right place. Remember, most of the addresses are Post Office Boxes that are specific to ADRs. 7
Documentation that Makes the Grade Now that we understand the ADR process, let s look at what is needed to make sure your agency s documentation meets the standard. For years, inadequate Face-to-Face documentation has been the biggest single contributor to ADR denials. Why? General opinion blamed the physician narrative. However, the current denial rates for Face-to-Face reasons clearly exceed those from physician narratives. The Face-to-Face documentation process now is more complicated than ever, and most providers are unsure about what their Face-to-Face documentation should look like. Face-to-Face Encounters Every Start of Care after January 1, 2015, must have a Face-to-Face Encounter certification from a qualified physician who either performed the encounter himself/herself or who supervised the encounter performed by a qualified non-physician practitioner. In addition to being a physician, the person certifying the Face-to-Face Encounter must either be the patient s primary care physician who will be following the patient s post-discharge home health care regimen or a physician who saw the patient in an inpatient setting immediately before the patient was discharged to home health. In the case of the latter inpatient encounter, the physician who will be following the patient for home health services must generally be identified on the encounter certification. What agencies need to have in hand to bill and what is required to qualify for payment and/or keep the money following a post-payment review are really two different things. This is the reason many are confused. To bill for services, the agency must have a signed and dated certification from the physician who performed or supervised the encounter, and the certification must include the date upon which the timely encounter occurred. This document should be clearly designated as the Face-to-Face Encounter Certification. A timely encounter is 8
one that is either within 90 days prior to the Start of Care or within 30 days following the Start of Care. Be aware that if the encounter occurs after the Start of Care, it should precede the signature date on the Plan of Care; the theory is that the certification of the encounter related to the reasons for home health services should happen before the Plan of Care is signed by the physician. While a bit of a chicken and egg problem, this is the way that the reviewer would evaluate the record. What agencies need to have in hand to bill and what is required to qualify for payment and/or keep the money following a postpayment review are really two different things. To respond to any ADR, the agency will need the basic Face-to-Face Encounter Certification described above, as well as the underlying encounter record from the physician who performed or supervised the encounter. The actual encounter record (the physician s progress note or inpatient discharge summary or other clinical record) must be attached to and made a part of the Face-to-Face Encounter Certification as described above. And, that underlying progress note or discharge summary must satisfy the elements of the Face-to-Face requirement: 1. The encounter record must be timely (of even date with the Face-to-Face Encounter Certification), signed and dated. 2. The encounter must have been related to the primary reason the patient required home health services. 3. The encounter must establish the need for skilled home health services. 4. The encounter also must confirm the patient s homebound status. Both the Medicare Policy Manual, Chapter 7, and the Medicare Program Integrity Manual, Chapter 6, provide for augmentation of the physician s record with information from the agency s record, if necessary. This can be useful if elements of the physician record isn t adequate on some of the requirements. This is often most useful in confirming a homebound status or skilled home health need. There are additional requirements, though, that must be met if the agency wants to add to the physician s record to round out the basic Face-to- Face requirements. First, the information offered by the agency must corroborate the information in the physician record. Second, the physician must sign off on the information to be included in his/her record for the patient. Third, that must occur prior to billing for the added information to be considered upon review. Timing is everything. Also helpful is SE 1219, A Physician s Guide to Medicare s Home Health Certification as updated on August 15, 2015. SE 1219 addresses the issue of a physician in an inpatient setting performing the Face-to-Face Encounter and informing the certifying physician of his/her findings. SE 1219 specifically states that if the certifying physician chooses to use the encounter documentation from the informing [inpatient] physician as his or her documentation of the Face-to-Face encounter, the certifying physician must sign and date the documentation, demonstrating that the certifying physician received that information from the [inpatient] physician who performed the faceto-face encounter, and that the certifying physician is using that discharge summary or documentation as his or her documentation of the face-to-face encounter. One physician signature, from the certifying physician, suffices if the face-to-face encounter documentation is co-located with the physician s certification of eligibility. Otherwise, if the face-to-face documentation is attached as an addendum to the certification (a separate document), the face-to-face documentation and certification each requires a signature from the certifying physician. 9
If the Face-to-Face Encounter documentation is found to be insufficient in any way if it fails to satisfy even one of the requirements the claim will fail. This language suggests that if the patient is coming from an inpatient setting and the inpatient physician has not identified the physician who will be following the patient s home health care regimen, the certifying physician (in this case, the person signing the Plan of Care) can incorporate the record from the inpatient physician into his/her record and use it to satisfy the requirement. One last word about the Face-to-Face requirement in the context of medical reviews. This is considered a technical requirement and, as a result, it is among the very first things that will be reviewed, particularly in the Probe and Educate initiative. If the Faceto-Face Encounter documentation is found to be insufficient in any way - meaning that it fails to satisfy even one of the requirements - the claim will fail. Because this seems to be happening frequently, it is critical for agencies to get this element of the record right from the start. Process Tip: When reviewing physician or facility encounter information to ensure that it satisfies the requirement of addressing the reason for home health, the presence of skilled need and homebound status, consider including a separate entry (such as a communication note) in the agency s file that identifies the elements of the record that the agency believes contribute to fulfilling the requirements. This approach is better than marking up or highlighting the record itself and can be very useful to defend homebound status. While many physician and/or facility records don t specifically indicate that a patient is homebound, they are very likely to include information that can be used to defend homebound status, such as observations about weight bearing status, confusion, pain, ambulation limitations, etc. This type of information can be demonstrative of a patient s limited ability to leave home. Remember, a medical reviewer may not interpret a record exactly as you would, or they may even miss a key, pertinent fact buried deep in a long discharge summary or inpatient encounter. Thus, a guide to how the agency is interpreting the record can be useful, particularly months after a case is accepted and an ADR is received. Including a guide will not guarantee success, but at least a reviewer will have the benefit of knowing what the agency s process was at the time a case was opened. Establishing Homebound Status This, too, is a challenge for many agencies. Relying on available checkboxes to establish the two tiered requirement is fine, but in this particular area a little more is definitely a lot better. Consider augmenting those handy checkboxes with some information that further explains homebound status based on the patient s overall OASIS findings and diagnoses. The answers to the following questions, and others like them, could go a long way toward strengthening homebound status. Agencies will always be well served to include specifics in their homebound status narratives on the Plan of Care and in visit notes. In addition to having the checkboxes that indicate the patient is homebound, you ll also have the important reason(s) why. The following is not an exhaustive list, but it will prompt thinking about the specific reasons your patient is homebound: Is this a patient with a cardiovascular or other condition that causes poor endurance and shortness of breath even at rest? Is this a patient who is only able to ambulate a short distance before experiencing shortness of breath or angina? Is the patient oxygen dependent? Is the patient blind? Does the patient have lower extremity edema that impairs or limits ambulation? Are there weight bearing status restrictions due to peripheral vascular disease or other conditions? Does the patient have cardiac post CABG restrictions (x the number of vessels) or postoperative pain and weakness? Does the patient have right/left hemi paresis/ paralysis due to CVA? Does the patient require significant assistance 10
with activities of daily living including safe ambulation and transferring using an assistive device such as a cane, walker or wheelchair? Does the patient have partial or non-weight bearing status, unsteady gait or poor balance that makes it difficult and unsafe to leave home? Does the patient have a respiratory condition that produces breathing difficulty with minimal activity or has the patient recently had the flu such that he/she may be at risk for further respiratory infection? Does the patient have post-operative restrictions due to risk of infection? Is the patient unable to safely leave home due to confusion, deteriorating mental status or impaired decision making? Is the patient at significant risk for falls due to unsteady gait, dizziness or syncope? Does the patient have one or more open wounds with significant drainage or for which a risk of infection is a consideration? A little common sense is also always a good thing when documenting and considering each patient s continuing homebound status. For example, if your patient is taking ballroom dancing lessons twice a week or if he was arrested for driving 90 miles an hour in a school zone and fleeing the arresting officer on foot, that patient is probably not homebound and should be discharged. And, yes, there is documentation of both and even more. Medical Necessity According to most published reports, medical necessity is generally established for most episodes up to a point. But it is becoming more of a concern for regulators, particularly regarding multiple Recertifications. This is why the physician s estimate of how much longer care will be needed is now a required element of every Recertified episode. And, if you have a recertification without that estimate, the agency s claim for payment will be denied. In addition, any one of the following factors can contribute to a finding that medical necessity is lacking for an episode: 1. No demonstrated skilled care during one or more visits. When this happens, most often there is no clinical narrative describing the visit and the patient s/caregiver s response. Or, the narrative is there but includes only nonskilled services such as filling a med planner or helping the patient with unordered, unskilled services like changing kitty litter, taking out the trash or burying a plastic bag full of cash in the back yard to hide it from the patient s unruly extended family (yes, all of these things have been documented). 2. Repetitive teaching, particularly when it is ongoing through multiple episodes. Ask yourself whether it really should take nine episodes to educate a patient who has had diabetes for the last 20 years about diabetic nutrition and a compliant diet. This is what happens when Plans of Care are simply copied from one episode to the next; redundant interventions can t help but raise questions. 3. Copied Plans of Care that have nothing to do with the services delivered to the patient during the episode. This often happens when a patient is admitted for one problem that ends up being resolved only to be followed by another that is the focus of additional care. If the Plan of Care does not order the new interventions that are performed, the episode will stand a good chance of being denied for failure to follow the orders that were given or for lack of medical necessity because the focus of the ordered interventions was already resolved. 4. Non-specific teaching of disease process or medications will always be an area of risk. Without specificity, the reviewer has no idea which disease process(es) or medications were taught or how often. Without specificity, there is a high likelihood of a finding of lack of medical necessity for a given visit or series of visits. 11
5. Therapy that goes on and on without adequate documentation of prior functional measurements and subsequent, progressive measured improvement and achievement of short- and long-term therapy goals. If your agency s therapists are not documenting measured progress and the effectiveness of therapy services, your claims for therapy services will be in jeopardy. Signatures and Dates Here is the rule of thumb: If a document is required as a condition of payment and it is authored by a physician or a clinician who is providing service to your agency s patients, it must be appropriately signed and dated. It should also be legible. If you are accepting Supplemental Orders from more than one physician who is treating a patient, your Plan of Care must reference that fact either with respect to the individual identities of physicians able to provide orders or through a blanket statement in the Plan of Care that all consulting physicians may provide orders. If signatures are not legible, get a signature log or qualify them with an attestation from the physician. Otherwise, their validity could be challenged. If your agency uses electronic signatures and dates, you must be able to confirm the authentication methodology as well as your processes for ensuring that such documents are signed by the person(s) indicated and not someone else. You need to be able to include that information with your ADR response. Four things that often kick out or invalidate orders are: 1. The Plan of Care or Supplemental Order is not signed by the physician for whom it was intended. Most often, this happens when someone in the physician s office or an associate signs an order on the physician s behalf. to qualify it. Otherwise, a signed but undated order is invalid. Remember, a late entry can be used to cure a problem with documentation that already exists, but that late entry must be acquired prior to billing for the services; otherwise, it will not be considered timely. 3. There is no order or entry in the record that confirms the Plan of Care while a signature is pending. Even with a date in Locator 23 of the 485, it is necessary to have a confirmation in the record that the Plan of Care was, in fact, confirmed with the ordering physician. 4. Supplemental orders that change visit frequencies after the fact. PREPARE FOR SUCCESS The Probe and Educate initiative will be trying, and perhaps expensive, for many agencies that are not prepared and that suffer a first round denial rate that moves them into phase two with another round of claim reviews. With respect to the medical review process, the best defense is a good offense. Now is the time for all agencies to strengthen their pre-billing medical record reviews to meet and exceed the minimum records standards to ensure payment. While ramifications are unknown for a moderate to high risk finding for both rounds of the Probe and Educate ADRs, there is certainly the potential for corrective action aimed at agencies that either ignore the ADRs directed to them or that are unable to demonstrate compliance with the conditions of payment. High-performing home health agencies are the ones who instead prepare for success. 2. The order is signed but not dated. If there is no date, the agency should obtain an attestation as to the date that the physician signed the order 12
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