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12/02/2022

Termination for Poor Performance is Often a Management Failure- Part 1

Supervising an employee’s work and coaching improvement are hard to accomplish on a consistent basis, but they’re critical to an organization’s operations and even its survival. And frankly, we owe it to our staff members to periodically assess their work and provide feedback that lets them know how they’re doing and gives them an opportunity to finetune their performance. The last place for an employee to learn of any deficiencies is on an annual evaluation or, perish the thought, at the point of termination. That’s just poor management, in our opinion.

While you may agree with this, you might be wondering how you can possibly add another – albeit important – task to your already full schedule. It may not be easy, but it does need to be a line item on your to-do list. You might begin by analyzing your work day as a manager: on what do you spend your time? What interruptions occur? Do you ever encounter mistakes and just fix them because it’s easier than working with the employee who made the error?

When bogged down with periods of intense work but seemingly little accomplishment, our consultants will track their activities on a given day. It’s tedious, for sure, and probably imperfect, but a few days of this will start to reveal patterns. So, we suggest you start there. Once you can see the things that occupy your time, you can determine if these are tasks that you, personally, have to do. While they may be “easy” and “don’t take a lot of time,” if they’re not managerial tasks, you’re squandering your brain-power and time. We’ve also seen managers hide from facing big things because they’re busy on minutiae that other staff members can do. Make sure this isn’t you….but what if it is?

If you find that you’re doing things others can do, develop a plan to transition those responsibilities to others. Maybe you can split them up and redistribute one task to each of several people. You’re not doing this to sit in your office and play video games, but to be more effective in your primary role as a manager and to develop others on your team. And lest you think everyone else is “too busy” to take on one more thing, give it a try and let the worker come up with a plan to get things done. The same way that paperwork expands to fill the empty parts of our desk (say it isn’t just me LOL), you may find that the amount of time it takes to complete work expands to fill the time allotted. Maybe others can learn to be more efficient in performing their tasks if you give them additional responsibilities.

What will you do with the extra time?

Join us for the second half of this two-part series where we’ll answer that question and also tackle the topic of staff interruptions and remediation.

*Picture taken from: blog.vantagecircle.com

11/01/2022

Top Home Health Agency Survey Deficiencies: Medication Review

In Part 1 of this blog series on ACHC’s top home health agency survey deficiencies, we looked at the Plan of Care. In the second installment of this weighty topic, let’s discuss medications. CMS – and by extension, accrediting organizations – require a comprehensive assessment and regulations detail the aspects of this evaluation. A review of medications is a critical component. During the assessment and on a regular basis, agencies must review all of the medications, prescription and non-prescription, the patient is taking. The review begins with making sure all the medications (as defined above) are listed on a medication profile, including the correct medication name, dose and frequency. Next, the registered nurse must assess:

Potential adverse effects and drug reactions, including ineffective drug therapy;
Significant side effects;
Toxic effects;
Drug and/or food allergies, in addition to allergic reactions;
Immediate desired effects;
Unusual and unexpected effects including those which may rapidly endanger the patient’s life or well-being;
Significant drug interactions;
Duplicate drug therapy;
Noncompliance with drug therapy;
Changes in the patient’s condition that contraindicate continued administration of the medication.
For therapy-only cases, the therapist can compile a list all of the medications and forward the listing to the RN to review. As with all things medical, documentation is the key so the therapist must, of course, date the medication listing and sign it with his/her credentials and make a notation that the listing was forwarded to a named individual. The reviewing nurse will do the same: document the review and sign off as having reviewed the medications.

Medications that are taken PRN, or as needed, must include parameters or indications (e.g., for pain, when systolic pressure is > X). Additionally, oxygen must be listed on the medication profile, including method of administration (nasal cannula, mask), frequency, flow rate and parameters for its use. Finally, the patient’s medical provider must be notified when there is a medication discrepancy, any side effect, problem or reaction to a prescribed medication. All reported issues, conversations with and orders from the provider must be documented in the record.

Because medications may change during the episode of care, make sure the medication profile is an important part of your agency’s quality assurance activities so you can minimize the likelihood for adverse patient care situations and survey deficiencies.

*Picture taken from: mcmasteroptimalaging.org

10/13/2022

Top Home Health Agency Survey Deficiencies: The POC

In this blog series, we’ll explore the most common survey deficiencies of skilled home health agencies as reported by the Accreditation Commission for Health Care (ACHC), one of three accrediting organizations for home health agencies (among others) with deemed status from CMS to assure compliance. As we all know, health care is highly regulated and agencies are subject to Florida laws as well as CMS regulations.

One of the top deficiencies reported is about the Plan of Care (POC), specifically, that there is a written POC for each patient accepted to services. Once the agency conducts the comprehensive assessment, the information obtained – in addition to orders from the medical practitioner, which must be received before care is provided to the patient – must be incorporated into the POC. The POC will contain specific treatment orders and measurable goals and objectives for the care that is to be provided with the purpose of the patient’s eventual discharge back to community-based care.

Honestly, we’ve never seen an agency that doesn’t have a POC for each patient. We have, though, seen issues with the quality of the information on the POC. Remember that it all has to tie together from the orders and assessment. Some issues we’ve encountered are missing frequencies for the services. The standard is that duration, frequency and amount of service has to be spelled out in the POC. Therapy services, in particular, must include the specific modalities and procedures that will be used. When your therapist completes his/her therapy assessment, make sure those modalities are explained so that you can include them in the POC.

Another issue concerns medications. First, they must all be listed and also, must match the medications on a medication profile. For the most part, agencies using electronic systems enter info into a medication section that then populates a med profile and POC, but we’ve seen differing doses and medication names so employ your eagle-eye to avoid any problems. PRN medications and treatments need parameters or indications (e.g., for pain, when systolic pressure is > X).

POCs are not one-size-fits-all documents although, admittedly, a good bit of templated language may be contained in each plan. However, this language must be appropriate for the conditions being treated and the care ordered by the provider. For example, many diabetic patients may have similar goals: to keep their blood sugars within a specified range, to adhere to a diabetic diet, to be able to administer their own insulin, etc.

The quality assurance aspect of reviewing admission documents can’t be overemphasized. Spend time on the front-end, reviewing admission information and making sure your POC is a good blueprint for the care that will be provided and that it meets all accrediting standards and CMS regulations.

*Picture taken from: forbes.com

09/27/2022

ICD-10 CM Adds 1468 Codes for 2023

Every year, we’re curious to learn about the changes to ICD-10-CM codes that become effective on October 1st, and this year, there are many interesting additions. Of course, our company looks at codes primarily through the risk adjusted payment lens, so for a more complete summary of the changes in all code categories, we suggest you consult the CMS website directly.

As an overview, 1,790 code changes were announced, which includes 1,468 new ICD-10-CM codes, 251 deleted codes, 35 revisions and 36 codes that were converted to parent codes; this last one means they were tapped to head up a new series of codes, which entails the availability of greater coding specificity.

Von Willebrand disease is an inherited bleeding disorder that, currently, has one ICD-10-CM code (D68.0). The Washington Manual of Medical Therapeutics calls it the most common inherited bleeding disorder. There are several types of the disease and each of them will have its own code, spawning D68.00 through D68.09.
D75.82 Heparin induced thrombocytopenia (HIT) is also expanding to allow for distinction among immune-mediated, non-immune and other HIT. See codes D75.821 through D75.829.
Considerable changes are affecting the dementia category of codes (F01.- vascular dementia, F02.-dementia in diseases classified elsewhere, and F03.- unspecified dementia). These diagnoses currently have two codes available: with or without behavioral disturbance. Shortly, however, providers will be able to better specify any disturbance (e.g., with agitation, with psychotic disturbance, with mood disturbance, with anxiety, with other behavioral disturbance) and also assign a severity (e.g., mild, moderate or severe) to the condition. In short, 29 ICD-10-CM codes will exist for each of the three dementia categories. In a subsequent blog, we’ll explain the criteria for categorizing a dementia as mild, moderate or severe.
Right now, substance disorders have codes for use with intoxication, withdrawal and induced disorders. The updated ICD-10-CM adds unspecified use, uncomplicated for alcohol (F10.90), and unspecified use in remission (F1-.91) for alcohol, cannabis, sedatives, co***ne, other stimulants, hallucinogens, inhalants and other psychoactive substances.
To all the atherosclerotic heart disease types in I25, a code for with refractory angina pectoris (I25.7–) will be added.
ICD-10 is expanding the lonely ventricular tachycardia (I47.2) to include a little more specificity, and the world of aneurysms is being shaken up to provide specificity about their location. While current ICD-10 codes allow for general aneurysm locations (I71.-), with/without rupture (e.g., thoracic aorta, abdominal aorta, etc), these codes will expand to include a more specific site, such as the ascending aorta, descending aorta and aortic arch.
The last section for discussion is additions to Z-codes, which are used to report statuses, histories and other factors influencing health. Of note are Z79.63 Long term (current) use of chemotherapeutic agent (along with codes for more specific agents) and Z79.85 Long-term (current) use of injectable non-insulin antidiabetic drugs. Z91.1- Patient’s noncompliance is expanding to identify factors relevant to social determinants of health, such as due to financial hardship, other reason and unspecified reason. And a whole new code series (Z91.A) allows providers to detail reasons for a caregiver’s noncompliance with the patient’s medical treatment and regimen.
As a reminder, ICD-10-CM code changes become mandatory for use on October 1, 2022 through September 30, 2023. Make sure that your EMR or billing system will automatically update the code-set and make it available on October 1st. Old codes should be flagged so your billers can distinguish the correct code based on the date of service being billed. Check with your EMR and billing company so your practice doesn’t experience payment interruptions due to incorrect ICD-10-CM codes. There is no grace period for implementing the ICD-10 changes.

*Picture taken from: en.wikipedia.org

09/22/2022

Fractures & Coding the 7th Character

ICD-10-CM turned coding on its head when implemented in October 2015. The coding convention was so unlike the mostly numeric, five-character codes we were accustomed to in ICD-9. Now I wonder how we ever got along without the coding upgrade! If anything, the number of potential codes is staggering, which can lead to errors if providers and coders don’t fully read and apply coding guidelines. One area where we see mistakes is in orthopedic coding.

To clarify, the majority of our clients are primary care providers who operate under risk adjusted payment paradigms. Their ortho coding is mostly limited to back pain (and its more specific causation), arthritis and the occasional fracture. Most ortho codes seen in primary care do not risk adjust, but some fractures do, such as pelvic and hip breaks. We thought it prudent to review the seventh character in ortho ICD-10 codes to dispel any myths.

Here is the list of seventh characters for fracture of the femur, which coding guidelines say should be added to all codes from category S72:

A – initial encounter for closed fracture
B – initial encounter for open fracture type I or II, initial encounter for open fracture NOS
C – initial encounter for open fracture type IIIA, IIIB, or IIIC
D – subsequent encounter for closed fracture with routine healing
E – subsequent encounter for open fracture type I or II with routine healing
F – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
G – subsequent encounter for closed fracture with delayed healing
H – subsequent encounter for open fracture type I or II with delayed healing
J – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
K – subsequent encounter for closed fracture with nonunion
M – subsequent encounter for open fracture type I or II with nonunion
N – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
P – subsequent encounter for closed fracture with malunion
Q – subsequent encounter for open fracture type I or II with malunion
R – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
S – sequela
The most important for our conversation is the initial encounter. We can all agree that a patient with a hip fracture is not generally seen in an outpatient setting for the initial encounter. He or she is seen in follow up after the fracture is surgically repaired by whatever means. The initial encounter character relates to the initial encounter for the condition, not the provider. This means that the initial encounter occurs in an emergency room, for the most part. Yet time and again, we see P*Ps coding initial encounters for these fractures because it’s the first time the P*P is seeing the patient for the condition. Incorrect.

Moreover, only the initial encounter codes are risk adjusted, which means that P*Ps who report this code during their visits are inflating their coding under the CMS-HCC model. And finally, notice the wording: “for ___ fracture.” Remember that providers report diagnoses they actually assess at the visit. Is the P*P seeing the patient for a fracture? Doubtful. Coding a condition whose care is deferred to another provider, in this case the orthopedist, is not proper because the P*P isn’t treating it. Using the M-E-A-T acronym as our documentation standard, the P*P can and should assess at the visit any other aspects of the fracture that persist beyond the initial encounter, such as pain, immobility, etc. By that point, the fracture – to use some coding humor – is history. Literally. (Z87.81)

*Picture taken from: climb.pcc.edu

08/26/2022

Pitfalls in Chart Reviews: It's not only about the Bottom Line

In this last blog in our four-part series on pitfalls, we thought we’d discuss the culture of your MRA department and how it guides the work. Our almost-20 years in this field have brought us into contact with practices and reviewers who span a long continuum. On one side is the practice whose directive is to increase MRA scores at all costs; reviewers who constantly identify new conditions are lauded. This, however, can be a slippery slope. We’ve lost track of the “creative” conditions suggested by some coders and how they strain credulity or are downright incorrect.

In addition, misunderstandings about the actual criteria of medical conditions can abound. We mean no disrespect when we say that sometimes that misunderstanding comes from providers themselves. They follow guidance from the coder in reporting diagnoses they are not convinced are valid. (Don’t scoff… we’ve seen and heard it first-hand!) One condition making its way around coding circles – to the future financial peril of medical practices – is the substance induced disorder. Scenario: the patient has insomnia. The patient drinks coffee. Coffee is a stimulant. Hence, the insomnia is due to the coffee drinking. Uhhhhh not so fast…. Read this blog on how that diagnosis category really works.

On the other end of the MRA department continuum is the team of reviewers that look for the basics: chronic conditions reported last year that are missing this year. That’s really just the bottom of the barrel in MRA work. There must be a balance between assuring long-standing, stable conditions are assessed and reported, and mining new documents to catch new conditions as they’re diagnosed.

Our company has occupied the risk adjustment space since 2004, its very early days, and we completely understand the financial implications of leaving money behind. We also know the pain of CMS recoveries that strip years of funding from a practice that reported unfounded conditions. The best philosophy for your MRA department is to identify all the conditions that are clinically indicated for your MA plan member and to assure that every risk adjusted condition you report is valid and properly documented. This is quite different from the objective of increasing MRA scores that has been management’s directive to more than one coder.

Increasing MRA scores is a finite exercise because although more than 10,000 codes are risk adjusted, the number of chronic conditions found in primary care is not ever-growing. Report all you know to be valid and make sure it’s well defended by the provider, both clinically and coding-wise. That’s the true key to success in MRA!

*Picture taken from: bcmj.org

08/17/2022

Pitfalls in Chart Reviews: Specialist Notes

In this four-part series, we’ve explored so far, the use of suspect reports and issues related to prior medical records. In this installment, we’ll look at what can make specialist notes a little challenging to the chart reviewer.

Although the scope of primary care is broad, it’s obviously not as deep as that for a provider who receives additional training in a subspecialty, resulting in greater expertise. Of course, P*Ps diagnose conditions that fall under subspecialties like cardiology, pulmonary and gastroenterology, all the time, but in some cases, the standard of primary care includes referral to a specialist.

Specialist reports can contain a wealth of MRA information that is helpful to the reviewer. However, over the years, we’ve learned to take those notes with a grain of salt for the reasons below.

Sometimes providers list diagnoses that are differential – meaning they’re not yet confirmed – as the justification for ordering and/or performing tests. It’s important for the reviewer to carefully read the specialist’s note and evaluate whether the “breadcrumbs” for the diagnosis are spelled out in the note. An example that we encounter with great regularity is the diagnosis of angina. When a cardiologist diagnoses this condition in the absence of any documented findings from the HPI, ROS or exam, it’s suspect for us. In addition, if the only things documented in the plan are orders for testing, this is usually not a valid diagnosis. We can’t take a specialist’s note at face value without reading for the context to assure the condition is valid and active. As non-coders, clinicians may not be cognizant of the differences between inpatient and outpatient coding, and report working diagnoses in error.

Another example is the oncologist visit where the provider codes a cancer diagnosis. However, the rest of the note goes into great length about the treatment the patient received in the past, often a decade earlier, and mentions there’s been no recurrence. Sometimes, the oncologist also writes “no evidence of disease” yet he or she does not use the personal history of cancer code. Again, these are red flags that just because a specialist said it in a note doesn’t make it code-able.

The last example is the specialist who lists conditions that are not under his/her medical specialty. An example is the gastroenterologist who lists in the assessment Crohn’s disease (a GI condition) along with heart failure and COPD, which are not under the GI specialty. It would be incorrect to use the GI note as evidence of heart failure and COPD. The reviewer must look for other proof – especially from a specialist in that field – to corroborate the condition.

Join us for the final installment of this four-part series where we’ll discuss the bottom line.

*Picture taken from: freepik.com

07/29/2022

Pitfalls in Chart Reviews: Prior P*P Records

In Part 2 of this series on the challenges encountered in chart reviewing for risk adjusted conditions, we’ll discuss the prior P*P. Every single primary care practice has a mechanism for requesting and obtaining records from the patient’s prior primary care provider. Of course, there is great variability in the processes, follow through and success in obtaining records.

Additionally, every practice has different guidelines for what it will release. Some P*P offices release only their created medical visit notes, while others release P*P notes and labs. Still others release the whole chart, or every document for the last two years. You really don’t know what you’ll receive although your medical records request form should state what you want (which should be all documents for X period of time).

When receiving prior P*P records, it’s important to review them with a critical eye. We’ve blogged before about providers who report conditions that have no evidence to support them and so, incorporating a condition into your new patient’s chart because “the prior P*P said so” is a recipe for recoupments.

To be honest, when we review charts, we take a cautious approach with old P*P notes, relying on them only to provide clues that will be validated elsewhere in the record. For example, the prior P*P says the patient has pulmonary hypertension and cites an echo result. We use that to track down the actual echocardiogram report and would never suggest the condition to our client based on only hearsay. Some might take that as evidence, but what if the P*P did not adhere to the proper medical criteria for diagnosing this condition? Or what if the P*P’s note contains a typographical error? You would be perpetuating erroneous information for your company. If you’re lucky enough to receive lab and imaging reports, you’re close to a goldmine of information that can bolster your work as an MRA reviewer.

In Part 3 of this series, we’ll explore specialists’ notes. If you missed Part 1 of this series on suspect reports, here’s the link.

*Picture taken from: hopkinsmedicine.org

07/20/2022

Pitfalls in Chart Reviews: Suspect Reports

Our company began working with risk adjusted payments in 2004, shortly after the CMS-HCC model was implemented, and as you can imagine, we’ve reviewed thousands of medical charts. Over the years, as providers from all specialties have become more versed in medical coding and MRA, we’ve seen an evolution in the pitfalls that reviewers can encounter when auditing charts. This series will explore four common issues and our suggestions for avoiding mistakes. In Part 1, we’ll discuss suspect reports.

Suspect reports are lists of risk adjusted medical conditions that health plans believe may apply to specific patients. The plans provide these lists to provider offices and request the staff “work” the lists. This means chart reviewers should determine whether the suspected conditions are valid (e.g., there is evidence to support them) and then suggest that providers assess and report them at the next visit. At first blush, this sounds like a great help to provider offices in making sure no valid conditions are being overlooked. Reality, however, doesn’t bear this out. (Our health plan colleagues will probably cringe, but we’ve got to share our honest perspective with you.)

Suspected conditions are pulled from many sources: hospitalizations, lab and other provider data, medication use and even plan algorithms that supposedly can pinpoint possible medical conditions. What results is, essentially, a wild goose chase, assuming the practice has a process for reviewing documents from any provider who sees the member and determining whether there are new conditions to assess. Suspect reports rarely contain the name of the provider source or date of service, which makes this an even more frustrating and time-consuming exercise with little return on investment.

In addition, let’s not forget that hospitals, for example, are subject to different coding rules than medical professionals in outpatient settings. Inpatient claims may contain codes for differential diagnoses or rule-out conditions that can ultimately find their way into suspect reports. Consequently, taking them at face value can result in errors for the practice.

A better source of potential conditions is a report of claims paid on behalf of your patients, if it’s possible to obtain that from your plan. A claims report will provide a date of service and ICD-10-CM codes reported for your patient. The practice can then request specific records from the provider source and determine whether the conditions are valid for the patient. It may be valuable to work both types of reports and track success rates in validating new conditions. This will give you data with which to reassure your MA plan rep that you’re doing the work, just a little differently.

In the next installment of this blog series, we’ll discuss the value and hazard of prior P*P records.
-HCC

*Picture taken from: bcmj.org

07/14/2022

Principal Care Management

Although chronic care management has been a CMS-covered care model for managing patients with multiple chronic conditions, this year, codes for a similar program were created. Principal care management (PCM) is a “sister” model – if you will – geared to patients with only one chronic medical condition. The goal of this program is two-fold: improving the patient’s quality of life & medical status, and avoiding costly decompensations in the patient’s health.

PCM is for patients who have had a recent hospitalization, an acute risk of death, exacerbation or functional decline, or require management that’s unusually complex due to comorbidities.

The first step is for the provider to create a disease-specific care plan. As the provider implements the plan, adjustments may be necessary in order to stabilize the patient’s condition. This medical dance involves not only the medical provider but clinical staff members who continue the program by communicating regularly with the patient to monitor his/her condition and coordinate additional care.

It’s important to keep in mind these parameters in order to incorporate PCM successfully into your practice:

PCM is for patients with a complex chronic condition that is expected to last at least three months.
It’s for patients at high risk for hospitalization, exacerbation, decline or death.
The condition requires a specific care plan that is often subject to revision or tweaking.
The condition requires frequent adjustments in medication, or the complexity of care is complicated by the patient’s comorbidities.
At least 30 minutes of care per month must be provided by the medical practitioner (CPT code 99424; use 99425 for each additional 30 mins of provider time). Staff may also provide services as they implement and manage the patient’s care plan (CPT code 99436 for the first 30 mins; use 99427 for each additional 30 mins of staff time as directed by the medical provider).

*Picture taken from: throughcare.net

07/05/2022

The 2022 Hurricane Season is Here!

Hurricane Season started June 1st. Our first tropical weather system crossed South Florida on June 4th and 5th. The National Oceanic and Atmospheric Administration predicts an average of 14 named storms and seven hurricanes for the Atlantic hurricane season. The average for major hurricanes is three. NOAA is calling this year’s season “above-normal” with 14-21 named storms expected.” Although most of us Floridians have been lucky through the past several hurricane seasons, trusting that luck is not a good plan.

The first part of a plan is to assess the risk most likely to affect your region. As with the first topical weather system that crossed South Florida earlier this month, wind was not the worst threat or eventuality; flooding was the issue. When dispatching caregivers to clients’ and patients’ homes, Administrators need to be aware of the conditions surrounding a client’s residence and avoid sending workers into dangerous areas. FloridaDisaster.org provides resources to identify flood-prone areas. By identifying, in advance, where your clients or patients reside, you can be much more efficient in evaluating whether it is safe to send a worker to a particular location. Further, this process will be necessary while assisting your clients and patients in developing their individual disaster plans.

During the development of your patients’ and your organization’s emergency management plans, consideration must be given to evacuation. Again, FloridaDisaster.org provides maps and other information for Evacuation zones where the likelihood of storm surge and flooding is the highest.

Finally, as we’ve written in past blog posts on this topic, initial preparation should include the following:

1. Survey your direct care staff to determine their plans to remain available for work or whether they will evacuate. Plans always change, but having people think about it may solidify your staffing levels. Make an analysis of the number of confirmed staff who indicate they will remain available for patient assignments compared with the number of clients/patients who will continue to need care. Categorize the patients according to acuity of their medical condition and needs relative to your skilled providers.

2. Contact your mutual assistance partners – organizations with which you may have understanding regarding assisting one another in an emergency – to determine their continued availability to assist with staffing, etc. if needed.

3. Re-assess your clients’ or patients’ plans to evacuate or remain in their homes because their plans, too, are subject to re-evaluation as personal circumstances change. If they will evacuate, be sure to obtain the contact information for their destination and confirm Special Needs Registry patients have the most updated medication, supplies and equipment list. If they do not, make arrangements to get the updated list to them

If you spend some time right now, working through these steps – while you can do so thoughtfully and carefully – you will be better able to keep your patients served and staff safe when a hurricane is on the radar, aiming at your area!

*Picture taken from: 13newsnow.com

Coleman Consulting Group

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