Spring to Life with Critical Documentation for PDGM

Instructor:Claudia Baker, RN, MHA, HCS-D, HCS-O

Objectives

• Learn approaches to maximize both the quantity and quality of documentation from referral sources, physicians and facilities

• Establish strategies for capturing information at each billing period end

• Describe how to integrate team member collaboration into agency practices

• Improve communication and documentation techniques to succeed under PDGM

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PDGM Architecture

*CMS-ABT PDGM Model 2018

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PDGM Quick Refresher

• Affects ALL Home Health Care agencies

• Went into effect January 1, 2020

• Payment change from 60-day PPS episodes to 30-day PDGM periods of care

• Eliminated Therapy Thresholds

• LUPAs vary from 2-6 visits per period

• Increased secondary diagnoses documented to 24 on the claim

• RAPs will be paid at 20% for year 2020 and eliminated completely beginning 2021

• PTAs allowed to provide maintenance therapy

• Biggest change to Medicare since PPS implementation in 2000

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PDGM Key Operational Considerations

• Regulatory and compliance requirements don’t change, including Face to Face

• Cycle time must be reduced each step of the process:• Referral and intake• Admission and assessment• OASIS and Plan of Care completion• Documentation• Scheduling

• Accuracy must be improved

• Utilization must be carefully monitored

• Case Management and Coordination are key to achieving quality outcomes

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31-40Days

Orders Management (Follow-up on aging orders older than 2 days, every 2 days.)24 hours48 hours

PDGM-Critical Patient Interactions Time Intervals and Milestones - Referral to Discharge

4 hours

ReferralSOC/ROC

Scheduling

24 hours

OASIS Creation

OASIS Review &

Coding

OASIS/POCReturned

Coded/LockedSubmitted

POC sent to MDAuto-RAP

– Days 30-Day Interval

LUPA Management (Daily prospective analysis and prevention.)

Final Claim

Capture (Source, Timing, Dx, Ver.Payor, Cert. Physician, SOC order)

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Referral and Intake – Where It All Starts

• Accurate information begins here• Important to consider it from the “customer” point of view – intake

process must remain customer friendly• Centralize the intake process to a team with customer service training• Best practice is RN leadership in this area for decisions on complex

care and regulatory compliance• Determine Admission Source and Timing

• Facility liaisons and community engagement/sales should assist with this• If Hospital referral – determine if ER or Observation stay vs. inpatient

• Obtain F2F documentation and PCP to follow

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PDGM Impacts on Referral and Intake

• Referral accuracy important in determining reimbursement • Gather patient secondary diagnosis information for co-

morbidities• Implement scripting for intake staff• Make sure staff know what to do when the referral comes in

with a Questionable Encounter (QE) diagnosis

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PDGM Impacts on Referral and Intake

Develop a checklist of required items including:1. Home health diagnosis2. Physician Face to Face and supporting documentation3. Any other general diagnosis information4. Accurate referral source – if institutional determine if qualifying inpatient

stay5. Requested services, orders6. Supporting documentation from physician(s), facility, etc. supporting

home health

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Source Documents

• History and physicals

• Recent and past, if applicable, physician office notes• Certifying physician

• Primary care physician

• Specialists, if applicable

• Inpatient stay records• Acute care, SNF, IRF, etc.

• H & P – recent and past

• Discharge summary

• Assisted Living or non-skilled nursing facilities records – if not physician signed, get confirmation

• Patient/caregiver report important – but requires confirmation!

• Medication profile as reference – get confirmation

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Strategies for Gathering Information

• Develop relationships with facilities, physicians, referral sources• What is their preferred method of communication?

• Determine the best point of contact

• Learn the best approach for each source of information:• HIEs -Missouri Health Connection (MHC), SHINE of Missouri, Tiger Institute

Health Alliance (TIHA), Lewis and Clark Information Exchange (LACIE)

• EMR - Interoperability

• Fax

• Liaisons

• Clinicians – your front line for information!

• Utilize a simple, standard request for information • To a specific person where possible

• Be detailed, yet brief

• Give specific agency contact information11

PDGM Coding Considerations

• Use certified, knowledgeable coders

• Goal of 24-hour turnaround (no more than 72 hrs. w/weekend)

• Know the timeframe from clinician start to locked• OASIS completed by clinician?

• Coding completed?

• Clinician response time for corrections?

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PDGM Primary Diagnosis and Co-Morbidities

• Reminder that symptom and unspecified codes will cause a QE

• Maintain a list of common unacceptable codes and possible alternatives – but also individual to patient

• 24 additional diagnoses are allowed on the claim

• Only 1 co-morbidity adjustment is allowed per claim

• If primary diagnosis changes in first 30-day period, it should be indicated on the second 30-day period claim

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CMS Guidance

“Complete and comprehensive documentation of the patient’s diagnoses and other clinical conditions by the physician will help to ensure that such diagnoses support medical necessity and Medicare payment aligns with your patient’s home health resource needs.”

Clinical Impact on PDGM

Patient centered care management is essential under PDGM

• Clinical/comorbidity grouping

• Functional scoring

• LUPA rates

• Appropriate visit utilization over two 30-day payment periods

• Appropriate use of therapy services

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OASIS Review and POC Development

• OASIS accuracy is paramount

• OASIS certification and/or training for clinicians completing assessments is KEY

• Interdisciplinary collaboration critical in development of a comprehensive plan of care and OASIS-D

• Key Best Practice Considerations:• Functional items are completed thru observation by the clinician, not

thru interview• POC and visit plan is reviewed with Clinical Team Manager prior to

submission• When possible, assessments are completed by the Case Manager

responsible for ongoing care coordination• Use technology – secure texting, EMR, conference calls – to speed

communication where appropriate

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“One Clinician” Guidance

“The comprehensive assessment is a legal document and when signed by the assessing clinician, the signature serves as an attestation that to the best of his/her knowledge, the document, including OASIS responses, reflects the patient status as assessed, documented and/or supported in the patient’s clinical record.”

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Role of the Assessing Clinician

• Completes Start of Care/recertification documents

• Collaborates with physician, pharmacist and/or other agency staff

• Documents findings and communicate to case manager

• Responsible for the content on the OASIS

• Approves all changes to the OASIS

• Findings guide the primary diagnosis and focus of the plan of care

• Collaborates with physician and obtains verbal order for care

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Collaboration

• Information must be relayed among team members TIMELY

• One on one or smaller team/patient discussions

• Increased use of admission/recertification narratives

• Create a formal process for at least weekly team meetings, but encourage immediate communication among team members

• SOC handoff/driveway calls

• Clinicians need to know what is done during OASIS/POC review and they need to be doing it themselves

• Involve your utilization review experts in the meetings

• Learn what your software vendor has in place for team conferencing

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It Takes a TEAM!

• Best practice is to organize care into clinical teams geographically servicing 125 – 175 patients

• The clinical team is lead by a clinician – generally an RN

• All disciplines report into the Clinical Team Manager/Supervisor of the team

• Each team includes a dedicated Scheduler, who also assists with clerical duties and phone triage

Clinical Team Manager/Supervisor

125-175 patients

Scheduling

Care NavigatorClinical or Non-

clinical(Optional Position)

CliniciansRN, LPN, PT, PTA, OTR, COTA, SLP,

MSW, HHA

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Interdisciplinary Team Coordination

IDT/Care Conferences • Appropriate utilization of therapies• Succinct, directed “huddles” • Ensure appropriate skill mix• Capitalize on interdisciplinary skill sets and perspectives• Review plan of care at admission, day 21-25 check-in before 2nd

period, prior to recertification• Update diagnosis, functional information, and POC if necessary• Engage patient/caregiver as a member of the team

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2nd 30-Day Billing Considerations

Day 21-25 POC review coordination and collaboration:

• Know your agency’s policy/process for actions at this stage!• Is there a change in the patient’s focus of care? (Primary diagnosis

change, changes to the POC, SCIC)• Was that change communicated to billing for claim, if needed?• Was a SCIC done for significant, unanticipated change? How was that

communicated to billing, if needed

• Visit utilization – can we mitigate a LUPA in the next 30 days? • Appropriate mix of disciplines? • Case management model being followed?

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What About the Field?

Case Manager RNCare Pod/Team20-25 patients

Responsible for all Care Coordination of Assigned

Patients

Visit Nurses1-2 FT

RN and/or LPN

Clinicians PT, PTA, OTR,

COTA, SLP, MSW, HHA

Clinicians report to Case Manager for

coordination of care

• Best practice is the implementation of care coordination through Case Managers

• Generally an RN, however PT can case manage therapy only cases

• Case Manager is responsible for establishment of POC, goals, and coordination of care in conjunction with the patient/caregiver

• Whenever possible, Case Managers should conduct the admission visit, or at least complete the comprehensive assessment

• Case Manager productivity should be lower than visit clinicians to allow for OASIS events, coordination, and communication

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Responsibilities:

• Establishes, monitors and modifies plan of care• Admission visit if possible and all OASIS visits• Verify POC with MD/Orders for F/U needs• Confirm query diagnosis•Oversight that plan is being followed, updated, etc.• Determines hand-off to visit clinicians

• Ensures continuity of care•Works within the care team to ensure minimal different staff are visiting patient

• Care coordination among all involved disciplines

• Visit and resource management• Review visit frequency and length of time patient is on service•Use of supplies• Reviews profit/loss report with Clinical Manager

• Clinical outcome management•Works to ensure POC achieving desired outcomes

Case Management Model

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Use the Right Staff at the Right Time

• Registered Nurses, Physical Therapists, Occupational Therapists• Work to the top of their license• Case Manage• Conduct visits on the most complex patients• Coordinate care

• Visit RNs, PTs, OTs, MSWs, SLPs, HHAs• Follow up visits• Coordinate with Case Manager and follow established care plan

• Don’t forget LPNs, PTAs, COTAs!• Perform task orientated visits on less complex patients• Can be eyes and ears for Case Manager

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Don’t Forget Telemonitoring

• The cost of telemonitoring can be included on the cost report under PDGM

• Ideas:• Use wound care pictures for WOCN to evaluate remotely –

stretching a scarce resource and improving care• Tablets can be used with therapy to “watch” patients perform care

between visits, or to demonstrate exercises• Telemonitoring can help reduce nursing visits by providing real

time, monitored data at the same time aide in preventing re-hospitalizations

• What other ways can you use technology to improve care and manage PDGM?

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Getting Physician Orders Signed

Everything under PDGM needs to happen faster –with the same quality and regulations –including MD orders!

Educate your physician partner. Enlist your community engagement/ sales team to carry the message

Who follows up on MD orders and Plans of Care in your agency?

Best practice will be following up on orders not signed after 2 days, and then follow up every 2 days until received

Use Technology! Physician Portals, e-Signature, EMR’s.

Find out the best way to communicate with your MD partners

Escalate to leadership as needed for delinquent orders

Enlist your Medical Director to help carry the message

Regulations haven’t changed – all orders need to be back signed prior to dropping the claim

Review the MD orders your clinicians are creating now

Are they necessary, or would a case communication suffice?

Can you consolidate orders to reduce volume?

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Resources

• ICD-10-CM Coding Guidelines• https://www.cdc.gov/nchs/icd/icd10cm.htm

• OASIS Guidance Manual• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/HomeHealthQualityInits/Downloads/draft-OASIS-D-Guidance-Manual-7-2-2018.pdf

• Home Health Conditions of Participation • https://www.federalregister.gov/documents/2017/01/13/2017-00283/medicare-

and-medicaid-program-conditions-of-participation-for-home-health-agencies

• MLN Matters Number SE19027: • https://www.cms.gov/files/document/se19027.pdf

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800.949.0388 | Simione.com

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4130 Whitney Avenue

Hamden, CT 06518

California Office

50 Professional Center Drive, Suite 200

Rohnert Park, CA 94928

Massachusetts Office

54 Main Street, Unit 3

Sturbridge, MA 01566

Claudia Baker, RN, MHA, HCS-D, HCS-O cbaker@simione.com (203) 287-9288

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