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.

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ENSURING THERAPY SERVICES COMPLIANCE

Sheila Capitosti, RN-BC, NHA, MHSAMarigene Barrett, RN, MBA, CLNC, RAC-CT

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Florida Health Care Association2013 Annual Conference and Trade ShowAugust 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

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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 days3

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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 recommendations4

Compliance:Definition

The act of adhering to, and demonstrating adherence to, a standard or regulation

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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

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Regulations

• Licensure

– Clinical Practice Regulations• Federal

• State

– Facility Licensure Regulations• Federal

• State

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Guess Who Is Watching Us?

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EVERYONE IS WATCHING!!

–Additional Development Request

–Comprehensive Error Rate Testing

–Medicare Administrative Contractors

–Zone Program Integrity Contractors

–Recovery Audit Contractors

–Medicaid Integrity Program

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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

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What Are “They” Looking For?

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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)

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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

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Data Mining

• High volume

• High cost

• Dramatic changes

• Adverse impact on beneficiaries

• Problems which, if not addressed may escalate

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Outliers• Treatment/documentation patterns

– ICD-9 codes

– CPT codes

– Frequency

– Duration

– Automated documentation

UNIQUE PATIENT INDIVIDUALIZED PLAN OF CARE

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Outliers• Treatment/documentation patterns

– ICD-9 codes• Sepsis

• UTI

• Pneumonia

• CHF

• Myocardial Infarction

– CPT codes• Part B automatic exception codes

– Hospice/Palliative care16

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

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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

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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

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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

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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

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How Do We Minimize Our Risk?

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Minimizing Risk

• Documentation Practices

• Triple Check Audits

• Quality Improvement Initiatives

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Documentation Practices

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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

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Documentation Must Support…

• Technical Requirements

• Medical Necessity

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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 therapist27

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MDS Process Management

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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

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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

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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

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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

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TRIPLE CHECK BILLING AUDIT

MDS-VS-

UB-04-VS-

Medical Record

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Triple Check Audit Team

Minimum

• RNAC/MDS Coordinator

• Rehab Manager/Director

• Business Office Manager

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Verification and Cross-Check

• MDS–ARD

–Sections G and O (supported in Medical Record)

• Denial Notices issued appropriately

• MSP signed and completed on admission

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Verification and Cross-CheckMDS 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

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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

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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

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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 billed43

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

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Areas To Consider

• Therapy Documentation– Evaluation– Progress Notes– Daily Service Logs

• Nursing Documentation– ADL documentation– Progress Notes– Daily Skilled Charting

• Physician Documentation 45

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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

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Triple Check: Outcomes

• “Clean claims”

• Peer review

• Interdisciplinary process

• Reduce or eliminate denials

• Opportunity to determine support for claims

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Quality Improvement Initiatives

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Quality Improvement InitiativesIntegrate 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

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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

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Look for things that make an auditor go “hmmm”

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Tips For Success• Participate in Triple Check Audit Process

• Ensure "Sufficient" Documentation– Implement a Clinical Documentation

Improvement Program

• $$$ At Risk

• $$$ Missed

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Compliance = Confidence!

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Questions???

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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

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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

•

StandardReview Date

Met Met Met Met Met Met Met Met Met

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.

SS9. Discharge Planning active and documented

including barriers to d/c, if any.

Revised May 6, 2013

Revised May 6, 2013

IDT Signatures Review Dates

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

METice and Nursin”: p lace a N) check in the first column when the standard is

COMPLIANCE STANDARD 1. Admission date is correct

met. (X) or NOT MET SOURCE OR LOCATION OF

DOCUMENTATION Medical record

2. A signed & dated order is present to "admit to skilled Physician order/3008 care"

3. All orders are signed and dated by Physician or Medical record extender.

4. ARD falls within required timeframe MDS 5. Assessment type is correct MDS 6. Daily ADLs and skilled services supportive

documentation adequate.Medical record

7. Interim and Comprehensive Care Plan identifies problems requiring daily skilled care, measurable goals and interventions. Documentation identifies resident's progress toward goals.

Medical record

8. Diagnoses are appropriately coded and support services billed.

MDS/Rehab

9. RUGs & HIPPS / codes are correct MDS 10. Number of days billed for each assessment type are

correctDetailed Monthly Census/PCC

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 stayPharmacy Invoice

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

Orbits

Xrays/Lab/Equip. Etc.

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MET COMPLIANCE STANDARD SOURCE OR LOCATION OF DOCUMENTATION

16. Rehab RUG, PT, OT, ST charges are present and correct. Rehabilitation units/minutes accurate & consistent

U B04

17. Rehab Orders / Plan of Care / Updated plan of care are signed and dated by the physician Medical record

Business 0 ice and Rehab: Vace a (1 ) check in the first column when the standard is met (X) or NOT MET

Date Approved for Billing:

Signatures:

BOM Date

MDS Coordinator Date

Rehab Date

1 Updated 2/6/13 File: Word=> G: Business Office => => Triple CheckPage 2 of 2