2-part article: Part 1 by Tim Rowan, editor and publisher of Home Care Technology Report; Part 2 by Darcy Treacone, RN
Part 1: Twenty-four months ago, before anyone had uttered “PDGM,” Tim experienced home health as a patient and provides details.
Rowan describes his long stint in healthcare at home being treated for a total knee replacement. Assistants included nurses and therapists
Though this experience took place before the implementation of PDGM, Rowan thought much on the planning that needed to take place. He notes, for one. “Medicare does not pay merely for visits, but documentation especially about patients’ progress is needed to be shown
Select Data CEO Ed Buckley has been analyzing data gathered from clients of his outsource coding service as well as industry-wide historical claims files. Rowan asked him what he foresees for next January, when clinicians start producing assessments for 60-day episodes of care broken into two 30-day payment episodes. Rowan wanted to know what preparations agencies would need to focus on in this final quarter prior to PDGM’s January launch.
Vigilance begins with intake, not with the assessment visit.
Documentation is still key.
“Documentation has always been, and will continue to be, a leading key to success for home health. Under PDGM. obOtaining the right physician documentation in a timely manner will become critical. And while home health documentation requirements will not change, complete and accurate patient information continues to carry significant weight to drive clinical and financial outcomes,” Buckley noted.
A key task that HH Staffpersons must underyake with physicians is encouraging them to cite diseases or conditions in the patients’ notes rather thsn simply symptoms (and which tasks are not reimbuseable by Medicare ymptoms. ENCOURAGING THEM TO CITE DISEASES OR CONDITIONS IN THEIR NOTES AND NOT ONLY RE LY ON DYMPTPMSHHAs must now under”Based on our auditing experience, approximately 38 percent of records include errors with the primary diagnosis,” Buckley saig. “If not corrected, that will definitely affect agency reimbursement next year. And, with the addition of non-payment codes or “questionable encounters” under PDGM, these errors can prove even more costly. In addition to the primary code, the co-morbidity adjustment with PDGM also has the potential to affect reimbursement, and greatly depends on complete documentation from the physician as well as reconciliation with agency documentation.”
“If they do not improve their clinical documentation and change their coding practices, yes, their revenue will take a hit,” he told us. “Payers and auditors are going to closely watch diagnoses, coding, and medical necessity. This is what CMS intended with PDGM. They have your data from the last 20 years of PPS and OASIS. PDGM is their attempt to make a better match between care and payment.”
Here is a synthesis of our lengthy conversations with Buckley and with Select Data’s Chief Strategy Officer, Ginger Voss.
New No No’s
There is language that referring physicians use fairly frequently today – CMS says about 15% of the time – that may not be used under PDGM. They are descriptions of symptoms rather than a diagnosis. Starting in January, there will longer be payment for symptom codes.
To adapt: To maximize success with PDGM, Buckley says HHAs need to take specific steps. Vigilance begins with intake, not with the assessment visit. The intake person who receives referrals from physicians absolutely must be on the lookout for any physician verbiage that describes a symptom rather than a disease or chronic condition. “Generalized muscle weakness,” for example, carries a symptom code, not a diagnosis code, and it will no longer generate a payment. Only the underlying diagnosis that causes the symptom belongs on the PDGM OASIS and care plan. If a physician referral document with words like those on it slips past your intake department, you will pay a nurse for an OASIS visit for which you will not be paid as it will result in a “questionable encounter.”
Educate referrers: To prevent symptom language before a referral even reaches the intake department, Select Data recommends to its clients that they develop a carefully planned physician education program.
Meet with your high-referring physicians and tell them, “You can’t do this anymore; I won’t get paid.”
Educate referrers on what codes are no longer eligible for payment with PDGM and why.
Produce educational documents that explain the new rules, using examples of what is no longer acceptable and what specifically will now be required.
Teach your intake personnel that such unacceptable referrals must be returned to the physician for more information about the diagnosis and the patient’s condition and less about the patient’s symptoms.
Questionable encounters start before the episode starts
With a solid diagnosis of a disease or condition from a referral source, the intake department can confidently forward the referral for scheduling, the assessment clinician can create a solid foundation for a coder, and the episode is far less likely to be deemed a questionable encounter. Clear, complete, accurate documentation is what helps a coder to be more specific. The coder will be able to accurately place the patient into the correct clinical category, assign the correct functional level, clinical category, and determine secondary codes that calculate a co-morbidity adjustment if appropriate. Specific, accurate coding, in turn, leads to more accurate payments and fewer payment denials.
The bottom line is that clinical documentation will become even more of a factor next year in determining whether an episode is vulnerable to payment denial. While inadequate clinical documentation is already the core driver of high-risk episodes today, its power to increase or decrease payment calculations will grow next year.
“Teamwork is the key,” Buckley concluded. “From physician cooperation to intake vigilance to clinician attention to assessment documentation to coding specificity, those involved in the early phases of an episode must work together.”
Part 2: PDGM Demands on Efficiency
Former CMS OASIS coordinator and Founding President of OperaCare, LLC Michael McGowan discussed with us how HHAs can thrive with PDGM
Michael McGowan is no CMS critic. As a former OASIS coordinator for Region IX, he views PDGM as a logical move to correct some ineffective or inefficient habits that have crept into home health agency practices over the years. Today, as we move into the 4th quarter, McGowan shares his observations on PDGM and why agencies are struggling to prepare for this payment reform.
What agencies need to realize is that the data they start to generate in January 2020 is the data that CMS will be evaluating for Value-Based Purchasing payments in 2022.
“What I’m seeing is a desperate need to cling to the legacy practices of the past twenty years, almost to a point of disbelief that change is going to occur and needs to occur in our payment model. Once we mentally move past the idea of change and analyze the components of what’s required in this new payment system, then agencies can start moving forward successfully.
“There is plenty of money in this payment system for agencies with high productivity and efficiency standards, not so much for those who lack in those areas. Agencies need to sit down and figure out if they have a static or dynamic census. A static census is not designed for successful entry into PDGM. A dynamic census, which is a hybrid of a little bit of static and a fair amount of unduplicated census, is what’s required to succeed.
“A static census, relying on patients who remain on service with minimal improvement, will provide just enough enough money to exist for the next 18 months under PDGM, but will not be rewarded in 2022 when Value Based Purchasing (VBP) begins. Under VBP, agencies will be penalized for a lack of positive outcomes with their patient populations. What agencies need to realize is that the data they start to generate in January 2020 is the data that CMS will be evaluating for VBP in 2022.”
Focus on payments? Or costs?
“My team is seeing a lot of scattered, haphazard approaches within agencies we speak with about PDGM preparedness. The primary approach to date is “How much will we get paid under PDGM?” Industry trade associations, consulting firms and vendors have done a fabulous job answering that question for agencies, but agencies also need to be making substantial changes to their productivity practices under this new payment model to prepare to thrive with VBP.
“We are only three months before the launch of PDGM and many agencies still have not educated their physicians on qualifying diagnoses, and they are still 12 to 15 days from SOC visit to care plan creation and RAP submission. Rapid cycle orders management and expedited clinical documentation that supports a plan of care, and data submitted to CMS to achieve positive outcomes, are challenges our industry has always faced but they will significantly exacerbate in the first two quarters of 2020.
“The process changes required under PDGM can be corrected in time if there is commitment at the agency level to do so. Eliminating after hours charting, working with intake on the referral process, and care planning are all key. One simple step, for example, is for agencies to pay attention to care planning and anticipate their patients’ needs over a 30 to 60-day period of time. This will help reduce the volume of addendum orders required for physician signature. When the care plan is complete, there should be an understanding of the patient’s potential needs while on your service and what outcomes, STAR and QAPI, are being affected.
A clear concern voiced in parts 1 and 2 of this article is: HHAs are not prepared for PDGM CLEAR COMCERN VOICED IN PARTS 1 AND 2 OF THIS ARTICLE IS:HHAS ARE NOT READY FOR pdgm yet.
Darcy Trescone’s focus is on CMS’s demanding preoccupation on effective outcomes .
She notes:”If you are not able to produce the completed OASIS packet and be RAP ready in 48 to 72 hours, you are already behind the PDGM 8 ball; plus, you have a significant potential of overwhelming your QA department and field staff. Sit down, take a deep breath and re-evaluate.
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
