Harmony: Ensuring That Your Documentation, OASIS, and Coding Are Compatible Speaker(s): Arlynn Hansell, PT, HCS D, HCS O, COS C Cindy Krafft, PT, MS Session Type: Educational Sessions Session Level: Basic This information is the property of the author(s) and should not be copied or otherwise used without the express written permission of the author(s). www.homehealthsection.org Home Health Section of the American Physical Therapy Association Page 1 of 28 total pages
Harmony: Ensure your documentation, OASIS and coding are compatible Presented by: Cindy Krafft, MS, PT; CEO Kornetti & Krafft Health Care Solutions Arlynn Hansell, PT, HCS-D, HCS-O, COS-C, Owner, Therapy and More, LLC 1 Disclosure No relevant financial relationship exists for the speakers 2 distributed without permission. 1
The Presenters For the past 10 years, Cindy has been a nationally recognized educator in the areas of documentation, regulation, therapy utilization and OASIS. She has served in several national projects as well as an expert resource for OASIS Updates. Her focus is on providing the knowledge and tools to operationalize external requirements. Cindy has been involved at the senior leadership level for the Home Health Section of the American Physical Therapy Association and is the current President of that organization. She has been working with APTA and CMS to clarify regulatory expectations and address proposed payment methodologies to ensure the long term participation of therapy services in home health. She has written 2 books The How-to Guide to Therapy Documentation and An Interdisciplinary Approach to Home Care. 3 The Presenters Arlynn Hansell has been a Physical Therapist in the home health setting since October 1998, holding positions of field therapist, rehab manager, and quality/compliance assurance. As owner of Therapy and More, LLC, she assists agencies in achieving therapy documentation and practice excellence in order to better position themselves against auditors. Consulting services further consist of OASIS auditing and coding practice. She has developed the comprehensive electronic document, e Q&A, containing up-to-date guidance on OASIS Q&As. She remains current with certifications in HCS-D, HCS-O, and COS-C. Arlynn has been a member of the American Physical Therapy Association since 1995, where she currently serves on the Practice Committee of the Home Health Section. She will begin proudly serving her new term as Vice President of the HHS at CSM 2015. Arlynn is a member of the BMSC Home Health Advisory Panel, where she serves as Secretary. She is involved in the creation and editing of the HCS-D and HCS-O certification exams. With DecisionHealth, she has developed the online course ICD-10 Coding for Therapists, and is the technical editor of the Home Care Clinical Specialist OASIS C1 Certification Study Guide. 4 distributed without permission. 2
Session Objectives Prevent revenue loss and avoid fraud charges. Connect how proper in-depth documentation will enable comprehensive and correct coding and ensure correct OASIS reviews. Integrate OASIS instruction on common difficult M items with audit review commentary. Introduce changes coming in the ICD-10 code set that therapists need to be aware of. 5 Home Health Payment Methodology Being fiscally responsible is NOT the same as being financially driven. 6 distributed without permission. 3
Where Does the Money Come From? When the OASIS gets crunched, a CFS score is generated (e.g. C1F2S3), which becomes the HHRG score (e.g. 1.1244), and translates into the HIPPS (e.g. 1AGMS), which carries a monetary value. Certain M items within the OASIS contribute to the Clinical C score (see next slide) Certain diagnosis codes contribute case mix points as well toward the C score ADL items within the OASIS contribute toward the Functional F score, as well as potentially help toward combining with diagnosis codes to assist with C score points Therapy visits solely contribute toward the Service Utilization S score 7 $$$ OASIS Data Items that Impact Payment (HHRG) M0110 (Episode timing) M1020 (Primary diagnosis) M1022 (Secondary diagnoses) M1024 (Payment diagnoses) M1030 (Therapy at home) M1200 (Vision) M1242 (Pain) M1308 (Number pressure ulcers) M1324 (Most problematic stage) M1334 (Stasis ulcer status) M1342 (Surgical wound status) M1400 (Dyspnea) M1620 (Bowel incontinence) M1630 (Bowel ostomy) M2030 (Injectable medications) M1810 or M1820 (Dressing) M1830 (Bathing) M1840 (Toileting) M1850 (Transferring) M1860 (Ambulation) M2200 (Therapy need) 8 distributed without permission. 4
Case Mix Scoring Table Final Rule 2015 1 Dimension 0-13 Therapy Visits 1 st & 2 nd Episodes EARLY 14-19 Therapy Visits 0-13 Therapy Visits 3 rd + Episodes LATER 14-19 Therapy Visits All Episodes 20 + Therapy Visits Equation 1 2 3 4 (2 or 4) Clinical C1 0-1 0 0 0-3 0-3 (sum of C2 2-3 1-7 1 4-12 4-16 points) C3 4+ 8+ 2+ 13+ 17+ Functional (sum of points) F1 0-14 0-3 0-8 0 0-2 F2 15 4 12 9 1-7 3-4 F3 16+ 13+ 10+ 8+ 5+ Service Utilization (number of therapy visits) S1 0-5 14-15 0-5 14-15 20+ S2 6 16-17 6 16-17 S3 7-9 18-19 7-9 18-19 S4 10 10 S5 11-13 11-13 9 Effect of Missed visits PPS Amount - Beginning $4,878.15 PPS Amount Final $4,251.42 PPS Amount Change ($626.73) PPS Begin Casemix Weight 2.2716 PPS End Casemix Weight 1.9789 PPS Casemix Weight Change -0.2927 Beginning Svs Utilization S3 Ending Svs Utilization S1 PPS M2200 Therapy 18 PPS Therapy Utilization 15 PPS PT Vst Bill 9 PPS PT Vst Non Bill 2 PPS OT Vst Bill 6 PPS OT Vst Non Bill 1 Did we lose money?? 10 distributed without permission. 5
Chart Threats Recovery Auditors (RACs) employ a staff consisting of nurses, therapists, certified coders and a physician. 2 of the criteria they look for: 1. Improper payments under MCR Parts A and B for services that were not medically necessary 2. Improper payments for services where the documentation does not support the claim. 11 Claim-supported Documentation The claim (chart submitted for payment) should read like it is all the same patient. The Plan of Care (485) must be consistent with OASIS responses in the reporting of diagnoses, mental and functional status, order, goals, etc. In turn, the visit documentation by all disciplines should reflect the 485 and OASIS as well. Troubles begin for agencies when the documentation does not appear cohesive, and visits are performed that do not appear to be necessary for the patient. 12 distributed without permission. 6
Results of Analysis Data Concerns that coding, OASIS and therapy utilization data has been influenced by the payment model Cost Questionable accuracy of cost report data and completeness of reporting Correlation Cannot find clear correlation between utilization & patient characteristics/ need End Result Cannot accurately correlate payment to those patients who need greater resources ($) The Home Health Industry is either part of the problem or part of the solution Let s back up: Conditions of Participation Medicare Benefit Policy Manual 2, Chapter 7 holds the guidance for Home Health Services: Section 40.2.1 pertains to therapy services: Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy Defines skilled therapy service: The inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist. To be covered, the skilled services must also be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury. 14 distributed without permission. 7
Conditions for Coverage of Therapy Services Skills of a qualified therapist are needed to restore function Patient s condition requires a qualified therapist to design or establish a maintenance program Skills of a qualified therapist are required to perform maintenance therapy Restorative Maintenance Maintenance Medical Necessity Per the Conditions of Participation 2, the services must be consistent with: the nature and severity of the illness or injury, the patient's particular medical needs, the amount, frequency, and duration of the services must be reasonable; and. the services must be considered to be specific, safe, and effective treatment for the patient's condition, meeting the standards noted for the FA (Functional Assessment). 16 distributed without permission. 8
Defining Key Therapy Concepts Skill proficiency, facility, or dexterity that is acquired or developed through training or experience; an art, trade, or technique Reasonable governed by or being in accordance with reason or sound thinking; not excessive or extreme Necessary Exclusive to the therapist The amount makes sense The care is indispensible Absolutely essential; needed to achieve a certain result or effect; requisite Making the Connection OASIS Therapy Documentation 18 distributed without permission. 9
Does it All Make Sense? SOC ReAssess OASIS Visits Evals 19 Integrating the OASIS into practice One method to correlate documentation to items within the OASIS is by using OASIS item language within the evaluation documentation. 20 distributed without permission. 10
OASIS Instruction Standard method of teaching 21 What if this were taught as well? Clinicians should go beyond checking the box and document functionally what the patient is required to do in order to dress: The location of the clothing (dresser, closet, wardrobe) a.d. used for ambulation and any impact on how clothing is gathered from those locations Safety of the patient in gathering items alone (falls risk, mental impairments, etc.) Impairments impacting dressing abilities (limited ROM, endurance, mental limitations, etc.) 22 distributed without permission. 11
But don t stop there! Clinicians should also document what the patient is unable to perform during the activity and why: can t access the closet due to. difficulty with handling pants and walker simultaneously. required frequent vc for sequencing in the dressing activity required assistance with donning LE items due to right knee flexion limited to 15 degrees Remember, the ADL items are all about the patient s ability to SAFELY perform the task. Any of the above items will impact that safety, potentially showing the need for scores other than [0] independent. 23 OASIS and Care Planning With the added information, the documentation not only supports the OASIS score, but forms the platform for needed skilled intervention, helping to drive the plan of care. 24 distributed without permission. 12
ICF Model For the assessment of individuals: What is the person's level of functioning? What is the disability? For individual treatment planning: What treatments or interventions can maximize functioning? From gathering further information into why the patient was scored at a particular level, the criteria for functioning and disability are assessed, allowing the treatment plan to start formulating. 25 M1200 Vision Score [1] or [2] indicates some level of visual deficit. Are the therapists going to fix the vision problem? No. But don t assume then that it has no impact on your practice. Consider how the deficit is affecting visual functioning are there field cuts, a kyphotic posture limiting the visual field, decreased cervical ROM limiting the visual field? How is safety affected? Do compensatory strategies need to be taught? Do you regularly document any visual problems as well as any necessary intervention to adjust for the deficit? Arlynn Hansell and should not be distributed or 26 distributed without permission. 13
Assessing Pain 27 Defining Interfering Pain Pain interferes with activity when the pain results in the activity being performed less often than otherwise desired, requires the patient to have additional assistance in performing the activity, or causes the activity to take longer to complete. Include all activities (e.g., sleeping, recreational activities, watching television), not just ADLs. distributed without permission. 14
M1610 Urinary Incontinence Therapists need to investigate why this is occurring: Bladder issues RN Environmental issues OT, MSW Clothing management OT Cognitive implications OT/SLP Mobility PT/OT Is something happening in the home that causes it to be a night only/day only issue? 29 Any incontinence and Falls Number one site of falls in the home: the bathroom In a vain effort to avoid incontinence (bladder or bowel), the client hurries up and ultimately falls, as the increase in gait velocity has rendered them unsteady. PTs can address gait velocity to improve their safety for these situations. Ultimately, this may impact both the gait and transfer items within the OASIS. Is it a velocity issue? How easy was the sit to stand maneuver? Is their assistive device kept within reach? Discuss in the visit note the relationship between the incontinence and activity limitations/impairments 30 distributed without permission. 15
Depression Need to determine contributing factors Are they depressed because they are homebound? Are they tying their need for care to their self-esteem? Are their life roles changing (from CG to dependent)? Have they suffered a loss of recreational activities? Toss out the Theraband! Maybe they gave up baking or gardening because they didn t know how to modify it! Find out if they have stopped performing their normal recreational activities, and why. Are you even addressing depression in your evaluation (knowing they have a diagnosis of it)? This is important because if it is marked in M2250d that interventions will be provided, and it is coded, the criteria must be addressed at some point during the episode. If this is a therapyonly case, then it is the therapist s responsibility. 31 ADL items As therapists, it is here that we have the opportunity to capitalize on incorporating OASIS documentation into our evaluation and visit notes. Using the same language translates to an easy comparison of apples to apples, readily indicating support of the OASIS score. 32 distributed without permission. 16
Objective Measures Stating the assist level alone is not sufficient, as assistance levels are a subjective opinion, not an objective measure. Qualify it with a description of what the assistance entailed, why it was needed. B. TRANSFERS Assistive Device Used: Note documentation: Sit to Stand SBA Stand to Sit Stand / Pivot Toilet SBA SBA SBA What does this tell you? What else could have been added to the documentation? 33 Quality of Performance For example, how can PT indicate support for the SN that scored the bathing item M1830 as [2] Able to bathe with intermittent assistance? The PT can document: Patient requires verbal cues for walker placement during turns when ambulating, thus mandating assistance for safely accessing the shower. This supports the SOC clinician s choice of [2] for M1830, and helps to drive where treatment is needed. 34 distributed without permission. 17
Does that prior statement tell you more than this? Max assistance for what particular activity? What type of assistance? Will the next therapist going in to visit know what specifically needs to be addressed? Assist Level Training / Intervention Rolling L R Assistive Device Supine - max Ax1 Sit Sit - max Ax1 Supine 35 Charting Examples 36 distributed without permission. 18
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39 (M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. 0 - Able to independently transfer 1 - Able to transfer with minimal human assistance or with use of an assistive device 2 - Able to bear weight and pivot during the transfer process but unable to transfer self 3 - Unable to transfer self and is unable to bear weight or pivot when transferred by another person 4 - Bedfast, unable to transfer but is able to turn and position self in bed 5 - Bedfast, unable to transfer and is unable to turn and position self (M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. 0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device) 1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or withoutrailings 2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces 3 - Able to walk only with the supervision or assistance of another person at all times 40 distributed without permission. 20
Another example.. 41 D. GAIT / AMBULATION Assistive Device Used: Wt Bearing Status(Describe): Surface s Assis t Distanc e Assistiv e Device Surface s Assis t Distanc e Assistiv e Device FWB PWB WBA NWB TTWB Clear RLE RUE Level UA 0 FWW Stair s LLE LUE Clear Uneve n UA 0 FWW Ram p (M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. 0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device) 1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or withoutrailings 2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces 3 - Able to walk only with the supervision or assistance of another person at all times 42 distributed without permission. 21
B. TRANSFERS Assistive Device Used: Sit to Stand SBA Shower Tub Min A Stand to Sit SBA Fall Recovery Max A Stand / Pivot SBA Motor Vehicle Min A Toilet SBA Sliding Board N/A 43 ICD-10: documentation and the therapist 44 distributed without permission. 22
Guidance has not changed for the pending ICD-10 code set in that all of the top six diagnoses must be addressed in the POC through assessment/evaluation or treatment. When a chart is coded, what is listed should be only those diagnoses that 3 : will be monitored, evaluated, or treated by the agency, or those that will impact the treatment of the patient 45 Ensure all diagnoses are confirmed or validated by the physician. If a particular diagnosis is not originally stated in the medical record (referral, H&P, F2F, etc.), documentation must be included in the medical chart of query with confirmation. What shouldn t get coded: long-term conditions that are stable or have no direct impact on the POC (e.g., GERD, anemia). 46 distributed without permission. 23
In addition to greater attention to coding the true underlying condition, documentation of that condition needs to be enhanced in preparation for the greater specificity of ICD- 10. More detail will be required, and what that means for the therapist is deeper investigation of what happened to the patient, more detail about the comorbidities, and more specific documentation will be mandatory. For instance: Fractures need specific location, closed vs. open, displaced vs. nondisplaced Pressure ulcers need exact location (R vs. L) and stage Other ulcers need etiology per MD, clinician will need to stage it (depth of ulcer) 47 Documentation in ICD-9-CM Documentation in ICD-10-CM Was the fracture more involved? Hip fracture what part of the bone was involved Right versus Left open or closed displaced versus nondisplaced fx was the healing routine or delayed malunion versus nonunion Is the present condition actually a sequela from an earlier condition 48 distributed without permission. 24
Gait In ICD-9 4, gait has basically three options for coding 719.7 for Difficulty in Walking, 781.2 Abnormal Gait and 781.3 Ataxia. In ICD-10 5, the option has expanded to 6 categories, so descriptive documentation and correct verbiage is important so that the codes assigned are appropriate. 1. R26.0 Ataxic gait 2. R26.1 Paralytic gait 3. R26.2 Difficulty in walking, not elsewhere classified 4. R26.8 Other abnormalities of gait and mobility R26.81 Unsteadiness on feet R26.89 Other abnormalities of gait and mobility 5. R26.9 Unspecified abnormalities of gait and mobility 6. R27.0 Ataxia, unspecified 49 Description of gait codes The six gait categories are expanded on the next slide. Essentially, the coding guidelines state that clinicians should investigate the cause of the gait abnormality. If the gait abnormality is integral to the condition causing the abnormal gait, then code the condition and not the abnormal gait. 50 distributed without permission. 25
51 For patients needing gait training, the correct principal diagnosis code usually is the illness, especially if there is a disease code indicating gait problem as part of the illness. For example, abnormalities of gait and mobility category, (R26.-) is integral to a patient with hemiplegia due to a CVA, lower back pain, or when using aftercare following joint replacement (Z47.1) of the lower extremity. If the therapist or physician documents abnormal gait or unsteady gait, attempt to obtain the definitive diagnosis or a more specific description of the abnormal gait problem, such as R26.0 (ataxic gait), R26.1 (paralytic gait), R26.81 (unsteadiness on feet gait), R26.89 (other abnormalities of gait and mobility), or R26.9 (unspecified abnormalities of gait and mobility). If the patient has difficulty walking associated with a chronic condition of the bone or joint, R26.2 (difficulty in walking, not elsewhere classified) is the appropriate code to use. 52 distributed without permission. 26
REFERENCES 1. Federal Register. Vol.79 No. 215 Section 42 CFR. Nov.6, 2014. 2. CMS Medicare Benefit Policy Manual. Chapter 7. Section 40.2. Rev. 144, latest issue 05-05-11. 3. http://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/HomeHealthQualityInits/Downloads/HHQIAttachmentD.pdf. Accessed July 6, 2014. 4. ICD-9-CM Official Guidelines for Coding and Reporting, 2013. 5. ICD-10-CM Official Guidelines for Coding and Reporting, 2014. 53 distributed without permission. 27