harmony: ensuring that your documentation, oasis, … · toward the c score – adl items within...

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

of 28 total pages

Harmony February 7, 2015

Property of Krafft and Hansell, not to be distributed without permission. 1

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

This information is the property of Cindy Krafft and Arlynn Hansell and should not be distributed or

otherwise used without express written permission of the authors.

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Disclosure

• No relevant financial relationship exists for the speakers



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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.



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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.



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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.



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Home HealthPayment Methodology

Being fiscally responsible is NOT the same as being financially

driven.



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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



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$$$ 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)

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Case Mix Scoring Table Final Rule 20151

Dimension 1st & 2nd Episodes

EARLY

3rd + Episodes

LATER

All Episodes

0-13

Therapy

Visits

14-19

Therapy Visits

0-13

Therapy

Visits

14-19

Therapy

Visits

20 + Therapy Visits

Equation 1 2 3 4 (2 or 4)

Clinical

(sum of

points)

C1 0 - 1 0 0 0 - 3 0 - 3

C2 2 - 3 1 - 7 1 4 - 12 4 - 16

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



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PPS Amount - Beginning $4,878.15PPS Amount Final $4,251.42PPS Amount Change ($626.73)

PPS Begin Casemix Weight 2.2716PPS End Casemix Weight 1.9789PPS Casemix Weight Change -0.2927

Beginning Svs Utilization S3Ending Svs Utilization S1

PPS M2200 Therapy 18PPS Therapy Utilization 15PPS PT Vst Bill 9PPS PT Vst Non Bill 2PPS OT Vst Bill 6PPS OT Vst Non Bill 1

Did we “lose” money??

Effect of Missed visits



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.



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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.



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Results of Analysis

Dat

aD

ata Concerns that

coding, OASIS and therapy utilization data has been influenced by the payment model

Concerns that coding, OASIS and therapy utilization data has been influenced by the payment model

Cos

tC

ost Questionable

accuracy of cost report data and completeness of reporting

Questionable accuracy of cost report data and completeness of reporting

Cor

rela

tion

Cor

rela

tion Cannot find

clear correlation between utilization & patient character-istics/ need

Cannot find clear correlation between utilization & patient character-istics/ need

End

Res

ult

End

Res

ult Cannot

accurately correlate payment to those patients who need greater resources ($)

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 Manual2, 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.



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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 Participation2, 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).



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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• Absolutely essential; needed to achieve a certain result or

effect; requisite

Exclusive to the therapist

The amount makes sense

The care is indispensible

Making the Connection

Therapy Documentation

Therapy Documentation

OASISOASIS



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Does it All Make Sense?

SOCSOC

OASISOASIS

EvalsEvalsVisitsVisits

ReAssessReAssess



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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.



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OASIS Instruction – “Standard” method of teaching



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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.)



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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.



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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.



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ICF Model



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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.

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?

This information is the property of Cindy Krafft and Arlynn Hansell and should not be distributed or otherwise used without express written permission of the authors.

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Assessing Pain



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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.



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?



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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 incontinenceand activity limitations/impairments



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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 therapy-only case, then it is the therapist’s responsibility.



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ADL items



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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.



Objective Measures



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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.

Note documentation:B. TRANSFERS Assistive Device Used:

Sit to Stand S B A

Stand to Sit S B A

Stand / Pivot S B A

Toilet S B A

What does this tell you? What else could have been added to the documentation?

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.

Quality of Performance



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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 -Sit

max Ax1

Sit -Supine

max Ax1

Charting Examples



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(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 transfer1 - Able to transfer with minimal human assistance or with use of an assistive device2 - Able to bear weight and pivot during the transfer process but unable to transfer self3 - Unable to transfer self and is unable to bear weight or pivot when transferred by another person4 - Bedfast, unable to transfer but is able to turn and position self in bed5 - 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 unevensurfaces 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 assistanceto negotiate stairs or steps or uneven surfaces

3 - Able to walk only with the supervision or assistance of another person at all times



Another example…..



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D. GAIT / AMBULATION Assistive Device Used:

Wt Bearing Status(Describe):

Surfaces

Assist

Distance

Assistive Device

Surfaces

Assist

Distance

Assistive Device

FWB PWB

WBA NWB TTWB Clear

RLE RUE

LLE LUE Clear

Level UA

0

FWW

Stairs

Uneven

UA

0

FWW

Ramp

(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





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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

ICD-10: documentation and the therapist



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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 that3:

will be monitored,

evaluated, or

treated by the agency, or

those that will impact the treatment of the patient



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• 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).





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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. non-displacedPressure ulcers – need exact location (R vs. L) and stageOther ulcers – need etiology per MD, clinician will need to stage it (depth of ulcer)

Documentation in ICD-9-CM Documentation in ICD-10-CM Was the fracture more involved?

Hip fracture what part of the bone was involved

malunion versus non-union

Right versus Left Is the present condition actually a sequela from an earlier condition

open or closed

displaced versus non-displaced fx

was the healing routine or delayed



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Gait• In ICD-94, gait has basically three options for coding – 719.7 for

Difficulty in Walking, 781.2 Abnormal Gait and 781.3 Ataxia.

• In ICD-105, 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 gait2.R26.1 Paralytic gait3.R26.2 Difficulty in walking, not elsewhere classified4.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 mobility6.R27.0 Ataxia, unspecified



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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.



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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.



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.



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harmony: ensuring that your documentation, oasis, … · toward the c score – adl items within...

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