Harmony Healthcare's Medicare Minute - Length of Stay

Harmony Healthcare's Medicare Minute - Length of Stay

Introducing Harmony Healthcare's "Medicare Minute" Video Blog!

Harmony Healthcare's Medicare Minute

Capturing Mood Disorders On The MDS 3.0

For MDS 3.0, the importance of coding accuracy for Mood indicators continues to be significant, as well as relevant to quality care, care planning, and reimbursement. One of the goals of MDS 3.0 was to provide residents in SNFs with the opportunity to have a "voice", thus contributing to their overall plan and quality of care in a very individualized way. This is accomplished via the PHQ-9 ©, a questionnaire designed to identify indicators that could possibly predict the presence of depression, and based on the scores, the severity of the symptoms as well. The results are beneficial for the purpose of referral to the physician and/or the appropriate mental health professional, as well as to promote optimal care planning to provide for the resident's personal needs. Mood distress is often under diagnosed and under treated in the long term care setting, yet it is associated with significant morbidity. The presence of depression often correlates with weight loss due to refusals to eat, decline in ADL independence, decline in social skills and peer, staff, and family interaction, as well as overall reduced quality of life.

 

Mood is accessed via the Resident's Mood Interview process, with parameters identified to promote the resident's comfort level with the process. These include privacy, assuring the resident is able to see, hear, and understand the interviewer, segmenting the prescribed questions at times to elicit a response, detangling responses once provided to screen out extraneous information, and echoing, where the interviewer reframes what the patient has said in order to validate what is being communicated. Interviews conducted outside of these parameters may be less successful and therefore less accurate, leading to inaccurate care planning and missed opportunity to capture the possible presence of this treatable condition.

 

In addition to the importance of Section D accuracy for proper identification, referral, care planning, and treatment, it is also significantly related to reimbursement. The presumption is that depressed patients exhibiting the symptoms described lead to overall reduced physical functioning, indicating the need for increased labor expenditure on the part of staff to care for them. Therefore, reimbursement may be influenced by the presence or absence of mood indicators. Based on the qualifiers for MDS 3.0, this is achieved by "end splits" that recognize mood indicators or their absence for the Special Care and Clinically Complex RUG categories. Not properly identifying mood indicators and depression has significant financial impact for facility reimbursement that varies by geographical location. This creates an elevated importance to carefully scrutinize assessment and information gathering processes to ensure that they allow for the capture of this essential clinical information.

 

Overall, assessment, MDS, and care plan accuracy have significant impact on state survey outcomes, quality measures reporting, and reimbursement. In order to achieve success in this process, staff should have ongoing education and the opportunity to conduct the PHQ-9 © appropriately to ensure residents' comfort level and privacy to voice their feelings. Successful identification, care planning, and treatment if indicated are vital to improved quality of life and the best possible outcomes for the SNF population.

 

Harmony experts will continue to explore this process as well as many other key aspects of MDS 3.0 coding during the upcoming course MDS 3.0 Basics and Beyond.  Click Below for more info!

Harmony Healthcare Launching Therachirps Blog!

 

 

 

 

Harmony Healthcare is Launching Therachirps Blog!

Therachirps will be Guiding Therapy Professionals Working in the LTC Industry. Chirping Your Comments, Thoughts, Opinions and Insights to Unlock the Mysteries of Medicare and Medicaid Reimbursement, the Challenge of Clinical Complexities and Facilitate Therapy Operations in Long Term Care...

Coming Soon!

 

 

MDS 3.0 Data Included in QCLI Dictionary

In late October, CMS announced and posted a revised Quality of Care and Life Indicator (QCLI) Dictionary which includes 28 MDS 3.0-based QCLI as well as 84 from other sources. Used in the Quality Indicator Survey (QIS), QCLIs are resident-centered outcome and process indicators which are calculations comprised of MDS data as well as data collected by the surveyors during their on-site Stage I activities (i.e., staff, family and resident interviews, resident observations and medical record reviews). After completion of Stage I, the facility's QCLIs are compared with predetermined norms (called thresholds) to determine what areas will be focused on in Stage II of the QIS.

 

Like the proposed Quality Measures (QMs), the MDS 3.0-based QCLIs include prevalence and incidence measures. A prevalence measure is simply reporting the number of residents that have the condition on their most recent OBRA or PPS MDS. An important difference between prevalence measures in the Quality Measure (QM) data specifications and those in the QCLIs is that those in the QCLIs do not exclude Admission assessments. One example is Prevalence of Indwelling Catheter which is simply a measure of how many residents had an indwelling catheter recorded on their most recent MDS. If greater than 14.8 percent of residents have an indwelling catheter, this area would be flagged for investigation in Stage II. Other QCLIs measure incidence (or change between two points in time); one example is Incidence of Decline of Range of Motion. This QCLI is comparing range of motion (ROM) on the most recent assessment to the ROM on the prior assessment. If there is a decline noted between the two assessments, the resident will be counted into the numerator for this QCLI. If greater than 18.1 percent of the residents meet the definition, there will be an investigation of the care and services related to Range of Motion in the Stage II. There are several pairs of assessments that will be used to calculate the incidence QCLIs. For instance (like the ROM measure discussed above) some will use the previous and most recent assessments; some (like Increase in Rejection of Care) will compare the resident's status between admission and approximately one quarter later and another (Lack of Transferring Rehabilitation Status) will compare PPS 5-day and 30-day assessments for a given resident.

 

It is important to note that exceeding the threshold for a QCLI does not mean there is a deficient practice; compliance is not determined until Stage II investigation occurs. When a QCLI is exceeded, the particular area will be investigated fully in Stage II. When using the QCLI information in continuous quality improvement (CQI) activities in the facility, it is critical that facilities investigate residents who potentially meet the definition whether or not the facility exceeds the threshold for the QCLI. Certainly those areas where a threshold is at or near zero should take precedence for being aggressively addressed but all of the QCLIs represent an opportunity to examine care practices and outcomes. The QCLI Dictionary is available at www.QTSO.com along with the all of the QIS tools. It is imperative that providers familiarize themselves with the tools. All staff (including direct-care staff) must be aware of the survey process changes that will accompany QIS. Facility staff should be aware that frontline nursing management (e.g., unit charge nurses) will have a tremendous amount of interaction with the surveyors during a QIS. Their preparedness through education and training is critical to your QIS success!

 

 

MDS 3.0 and Care Area Assessments; A Decision Facilitator

Harmony often receives questions during seminars, calls and emails wondering how to improve the CAA documentation in the SNF.

 

CMS has not set forth distinct mandates regarding the process for how nursing home staff uses the CAAs. For MDS 3.0 there are no specific tools mandated as long as the tools are current and founded on evidence-based or expert-endorsed research, clinical practice guidelines, and resources.    The RAI process involves the completion of the MDS, the CAA's, and the development of a comprehensive care plan.

  

The CAA process functions as a decision facilitator on whether or not to proceed to care plan as well as to assess the resident in the areas that have been triggered with the use of evidence-based resources. The CAAs guide the assessor in determining the nature of the issue or condition and understanding the causes specific to the resident.

  

Documentation for each triggered CAA should describe:

• The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). What is the problem for this resident?
• Causes and contributing factors.
• Complications affecting or caused by the care area for this resident.
• Risk factors that arise because of the presence of the condition that affect the staff's decision to proceed to care planning.
• Factors that must be considered in developing individualized care plan interventions, including documentation to justify the decision to plan care or not to plan care for the individual resident.
• Need for referrals or further evaluation by appropriate health professionals.
• What research, resource, or assessment tools were used in performing the CAA. A source need only be cited if it is not already cited as the standard source used for this CAA by facility policy.
• Completion of Section V CAA Summary.

New Final Rule FY 2012 Therapy Documentation Requirements

In the Final Rule FY2012, CMS provided clarification on therapy documentation and expectations in regards to changes in therapy treatment plans.  Harmony recommends facilities are vigilant when documenting on patients that have a change in intensity resulting in increased reimbursement for the facility.  Changes to the mode and/or intensity of therapy must be justified by the changes in the beneficiary's underlying health condition.  In order to demonstrate that such changes are medically necessary, the provider should clearly describe in the plan of care the reasons for deviating from the original plan.  The following statements are examples of documentation that would assist in justifying an increase in therapy intensity:

• Coordination of patient's pain medication and Physical Therapy treatment times has enabled the patient to tolerate BID sessions versus QD. 
• Patient is showing decreased signs and symptoms of depression now that she has regained the ability to ambulate a few steps.  Improved motivation with desire to participate in more therapy in an effort to return home.
• Patient had a follow up orthopedic appointment resulting in increased weight bearing status.  Patient's treatment program has been expanded to include stair training in preparation to return home to a 2-level home. 
• Respiratory status has improved, patient is now able to tolerate increased exercise and length of treatment sessions without complaints of shortness of breath or fatigue.

Telling the story of the patient from medical and functional perspective will support the need for daily skilled care as well as meet the practical matter criteria that the patient could only have received care at the SNF level. Supportive skilled documentation involves education regarding skilled care criteria and practice. Training should be provided on an ongoing basis for both nursing and therapy team members.

 

CMS Newsflash!!  

HIPPS Master Code List Updated

http://www.cms.gov/ProspMedicareFeeSvcPmtGen/02_HIPPSCodes.asp

 

For a complete list of the upcoming Harmony University Seminars and Webinars Please Click Below!!

 

 

Medicare Part A verified by Mobile Medical Review for NY and CT!

 

National Government Services (NGS) published information on its October 14, 2011 list-serve that they have launched a new “Mobile Medical Review” program.

The NGS announcement stated:

The Mobile Medical Review team will provide on-site medical review of processed claims to verify that Part A Medicare payments were issued appropriately. The team will provide immediate feedback to the provider during the review regarding any deficiencies noted in the medical documentation, and the rationale for any determination that the claim should not have been paid as billed.

Selected providers will receive a letter notifying them of an upcoming on-site review. Included in this letter will be a list of the claims that will be reviewed during the visit. Providers will be asked to:

• Prepare the medical documentation necessary to support the billed services
• Participate in the on-site review by attending an entrance and exit conference and being available for questions throughout the review

Once the review is complete, a written summary will be issued to the provider with the review findings. The summary will include a list of all claims reviewed along with the team’s determinations. It will identify denials and include an explanation of why the provider is responsible for any overpayments, an estimate of over or underpayment, and a description of any follow-up actions to be instituted by either the provider or National Government Services. 

If the on-site review reveals any significant issues with the claims reviewed, the provider will receive a letter notifying them of a follow-up on-site review. The follow-up visit will be scheduled approximately four to six weeks following the initial visit. During this visit, the team will review records for claims billed after the initial site visit, to ensure that the facility is utilizing the feedback and references previously provided.

Click Here to View the NGS Announcement!

 

ADL Skills: Addressing Posture and Positioning in the SNF

Poor sitting posture is a common problem in long-term care and has an effect on function and performance of ADL skills. Skilled Nursing Facilities strive for a restraint free environment, no recorded falls and eliminating the occurrence of skin breakdown at the facility level.  Committee meetings, QA teams and active walking rounds are a part of the daily operations in the SNF aimed at minimizing and eliminating the above listed clinical barriers to function.

 

The resident's ability to function in their environment is improved through good body alignment.  The primary goals of a positioning program include improving body alignment, preventing or mitigating of the effects of pressure on existing pressure ulcers and improve in ADL participation.  Example: A patient was admitted with multiple pressure ulcers (6) stage II and (2) stage IV.  A brief period of skilled therapy intervention was appropriate to determine the best seating system including cushions, lateral supports etc., and tolerance of the system.  Goals included identifying the most appropriate system, successful follow through by staff and maximum time recommended that the patient should be in a specific position to reduce risk factors. 

 

It is as important for caregivers to understand the unique situation of the identified patient at risk.  For example, one patient may tolerate sitting for 2 hours without skin compromise while another should be limited to 45 minutes out of bed. 

 

 

There are many factors to take into consideration when addressing positioning needs:

• Is there abnormal tone contributing to poor posture and can it be normalized through treatment?
• Is there muscle weakness contributing to poor posture and body alignment and can it be improved through treatment?
• Can the patient improve strength in upper and lower extremities?
• Are there contractures contributing to positioning problems?
• Can the contractures be reduced?
• Is there any skin breakdown?
• Is there adequate support of the extremities in the current seating system?
• Does the patient have pain?
• Does the patient have circulatory compromise?
• Does the patient's position in the seating system vary throughout the course of the day or during specific tasks?

Evaluation and treatment of the above concerns are areas of specialty for a therapist.  This intervention meets the skilled criteria by definition and qualifies for coverage under Medicare Part A and B. Specialized positioning evaluations should be available to the therapy team to assist with individualized programing and goal setting for successful seating systems. 

Harmony Healthcare is leading the way in Education and Training in the Long Term Care Industry.  Click below to find a Seminar near you or to register for one of our informative Webinars today!

Managing Medicare Part A Length of Stay

Surviving the Medicare adjustments in FY2012 has been a major topic of discussion and debate in most SNF's throughout the US. To maintain a viable Medicare program in the SNF you must analyze the admission and discharge process for the Medicare Part A caseload. A component of this analysis critical to successful clinical outcomes and preserving the integrity of the program is the clinically anticipated Medicare length of stay. Case management by the Rehab professional is one of the primary factors affecting length of stay. Generally, when a patient is admitted for short term rehab their underlying medical conditions stabilizes before they have met their functional potential. Therefore, it is very likely that the Rehabilitation Department is the driving force behind the patient's discharge plan.

 

Medicare supports providing rehabilitation services to help the patient achieve their prior level of function. This should be thoroughly investigated and considered when discussing the patient's potential discharge. The following is a brief list of questions to consider before discontinuing therapy services:

• Is the patient going home with an assistive device they did not previously use? Does the patient have the potential to progress to a less restrictive device?
• Are we asking caregivers to assist the patient with any of their BADL or IADL tasks that the patient was able to do before? Does the patient have the potential to do these tasks on their own with further training?
• Is the patient able to resume their prior leisure activities? Would further therapeutic interventions allow the patient to resume these activities?
• If the patient is returning to an assisted living facility, did the patient utilize all of their services before or will they be using services that they previously did not? Do they have the potential to resume their prior routine?
• Even though the patient has assistance available (ALF, spouse, etc.) do they want to rely on their caregiver or are there activities the patient would like to be able to do on their own?
• Does the patient enjoy making their bed every morning?
• Would the patient prefer if other people did not wash their undergarments?
• Does the patient like to make their own afternoon tea?

If yes is the answer to any of these questions it is clinically appropriate to continue the therapy program and further progress the patient to their highest functional ability. It is important to update the therapy plan of care to include new goals specific to these higher functioning tasks and ensure that it is documented that these goals directly relate to the patient's prior level of function.

Daily and weekly meetings conducted by facility managers, direct care nurses and therapists should spur discussion to reveal the patients community living situation and allow for further customized treatment planning.  

 

Billers, MDS Coordinators, Rehab Managers and Nursing Managers  Please click the link below and  Join Us........   

FY 2012 Medicare Billing for SNFs

Topsfield, MA
 NOVEMBER 2, 2011, 9:00AM - 1:00PM