Fast Pace of Healthcare Change

1. Fast Pace of Healthcare Change An Introduction to Home Healthcare and Hospice Coding System, Regulations, and Continuum of Patient Care. (C) Daymarck 2014

2. Objectives • Discuss the Home Healthcare (HHC) and Hospice coding background. • Information on the Federal Regulations and the impact on Home Healthcare (HHC) and Hospice coding. • Discussion of the transition from coding off the physician documentation to the assessment documentation. • Discussion on how documentation plays a crucial role from other facilities to (HHC) and Hospice for coding. • How can all Health Information Managers assist in the documentation quality and flow to support ICD-10 coding across all facilities. (C) Daymarck 2014

3. Fast pace of healthcare change Proactive approach vs. Reactive approach (C) Daymarck 2014

4. Examples of Poor Reactions • Hemiplegia • Vision codes (C) Daymarck 2014

5. What is Home Healthcare/ Hospice? • High technology care in homecare and hospice. • Patients do want to stay home. • Cost effective care. • These healthcare and hospice settings are one of the only settings where the clinicians’ documentation directly affects outcomes.

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7. Introduction • With the challenges of converting from ICD-9-CM to ICD-10-CM in October 2014, there come many opportunities. • One of these opportunities is for homecare agencies to take a proactive approach in changing how their clinicians culturally think and document their comprehensive assessment. • Most agency documentation training has been focused on scoring of the OASIS assessment during the past decade. • This has led to gaps in proper documentation standards of the comprehensive assessment. This in turn, supports the OASIS assessment, leading to financial and quality outcomes. DELAY (C) Daymarck 2014

8. Background on OASIS • The Centers for Medicare and Medicaid Services, Department of Human Services regulate the Code of Federal Regulations. Title 42- Public Health, section § 484.55, where a comprehensive assessment of the patient must be completed and an OASIS. • OASIS “Outcome and Assessment Information Set” Data elements. • It is used to collect the diagnoses. • These diagnoses are in turn, are used to group for payment methods HHRGs or Home Health Resource Groups. • Each facility will also be given a category of case mix (weighted scale) with the HHRG will determine the payment to the facility. (C) Daymarck 2014

9. What is OASIS? • A tool home healthcare uses for: • Data collection and patient goals. • For quality and process measuring and reporting. • For reimbursement. • The top 6 diagnoses are collected in OASIS. • Certain diagnoses can affect reimbursement. (C) Daymarck 2014

10. OASIS Example (C) Daymarck 2014

12. Overview Billing/Coding Cycle Home Healthcare Coding Patient Diagnosis Collected on OASIS ( SOC and Recert. Which allows for continued Patient care Creates HHRG (Grouping Payment Method Equates Payment Calculates Case Mix Score (C) Daymarck 2014

13. An Example of How Correct Coding Affects Payment

14. Narrative for the Last Example • Coding of Myocardial Infarctions (MI) as unspecified (410.90) in the home health setting loses 6 case mix points in the clinical dimension. If the patient has experienced a recent MI, treated in an acute care facility, the Coding Guidelines instruct the coder to code the inpatient diagnosis as 410.90 or more specifically 410.91and the home health diagnosis as 410.92, subsequent encounter. Note only the 5th digit, which denotes episode of care, is different in these examples but it is the 5th digit in this case that renders the payment. Home health is paid under the 5th digit (xxx.x2), subsequent episode of care. Coding an MI as unspecified in this example could cost the home health agency approximately $900.00. • So do we have the documentation for the coder to assign the correct code? We must keep in mind, ICD-10 will require even more specificity. Are we up for that challenge? (C) Daymarck 2014

15. Federal Regulations • Hospice final rule 08/07/13 • Home Healthcare 12/02/2013 • Both implement ICD-10 • The impacts are vast. (C) Daymarck 2014

16. ICD-10 Delay Impact on Federal Regulations • Both the Home Health and the Hospice Regulations had ICD-10 written into them. • What this means for Home Health. • What does this mean for Hospice. • How can we all assist each other as HIM professionals during this transition phase, again? (C) Daymarck 2014

17. Coding Guidelines • Both the HHC and Hospice regulations; • CMS is reiterating the agencies to adhere to coding guidelines when assigning diagnosis codes which is required under HIPAA. • 3M conducted analysis of OASIS records and claims from CY 2011 and found that some HHAs were not complying with coding guidelines. • “use additional code”, “code first”, “in diseases classified elsewhere” or “in conditions classified elsewhere” (C) Daymarck 2014

18. Shift in Thought Process The Federal Regulations affecting both HHC and Hospice.. • Has a shift in the thought process on only accepting coding from the physician documentation versus using the clinician documentation. • Examples: • Clear cut: hemiplegia – non-dominate versus dominate side • Others: Not so clearly stated. Asthma. (C) Daymarck 2014

19. Federal Regulation Interpretation • “Elimination of codes for nonspecific conditions when the clinician should be able to identify a more specific diagnosis based on clinical assessment.” • The Registry states in areas where the Clinicians should be able to identify certain aspects of a diagnosis. • Thus, should we be able to code off the clinician documentation? • Remember the clinician is the only provider in direct contact with the patient in home health and hospice. (C) Daymarck 2014

20. Federal Regulations “To ensure additional compliance with ICD–10–CM Coding Guidelines, we will be adopting additional claims processing edits for all HHC claims effective October 1, 2014. HHC claims containing inappropriate principal or secondary diagnosis codes will be returned to the provider and will have to be corrected and resubmitted to be processed and paid.” (C) Daymarck 2014

21. Benefits/ Concerns and Examples • Benefits to coding from clinician documentation. • The clinician has first, hands-on experience with the patient. • Thus, they would be able to assess a clear and concise diagnosis during the home health or hospice visit. • Concerns: • The coding guidelines have always addressed the physician is the direct and final decision maker for diagnoses. • One example where clinicians already to make diagnosis decision is in the Pressure Ulcer Staging. • We are allowed to code the clinician stage per our Coding Guidelines already. See Chapter 12: Diseases of Skin a. 3) (C) Daymarck 2014

22. Examples by DiseaseImpact of ICD-10 • The Federal Rulings have stated that unspecified codes maybe returned. • For the Home Healthcare agency who is relying on other facilities to supply disease information, this can be a conundrum of sorts. • One example we can share is that of a traumatic fracture where the patient is being cared for in the home afterward. • Will the Home Healthcare clinician be able to documented the stage of healing (Type I to Type IIIC) consistently from the referral information? • If not, this could lead to the Home Healthcare claim being returned for a more specific code and thus lead to financial burdens. (C) Daymarck 2014

23. Fractures in Home Health and Hospice • Delay ICD-10, will give us the opportunity to open these channels of discussion with providers to facilitate what documentation is needed in HHC and Hospice now and in the future. • Even the aftercare fracture codes, will have a tremendous impact on HHC since they require the actual fracture location and routine healing process coming in ICD-10. (C) Daymarck 2014

24. Continuing Care Documentation.. • Take a look at V54.15 Aftercare for healing traumatic fracture of upper leg. • Currently, home health receives a diagnosis of “fracture upper leg or hip”. • As we progress into ICD-10, we are left to chose from a possible one hundred twenty codes. • Everything from S72.2XXD subsequent fracture displaced, right femur, subsequent encounter for closed fracture with routine healing • To S79.109D Salter-Harris Type I physeal fracture of upper end of unspecified femur, subsequent encounter for closed fracture with routine healing (C) Daymarck 2014

25. Even DM RetinopathyTakes on a New Challenge for Home Healthcare • While DM retinopathy in ICD-9 always included the following sub-terms, we can take this opportunity to educate all providers on the specificity of Retinopathy. • To capture if the retinopathy is : mild, moderate or severe • As well as the stages of diabetic retinopathy? • Mild Nonproliferative Retinopathy. • Moderate Nonproliferative Retinopathy.. • Severe Nonproliferative Retinopathy. • Proliferative Retinopathy. • Keeping in mind that now there is a possibility the Home Healthcare claims could be rejected when codes are not specific. (C) Daymarck 2014

26. More Diagnoses to Assist our External Agencies with.. • How about pneumonia? • When a patient is referred to an outside agency are we; • Giving the underlying disease (such as tuberculosis) to the pneumonia? • Or the location of the pneumonia (lobar, basilar or bronchial)? • Or the pathogen which is causing the pneumonia? • Again, as we approach ICD-10, these factors become more of an issue. In addition, agencies such as Home Health care are facing issues with Non Specific diagnoses on their claims with rejection. (C) Daymarck 2014

27. More Diagnoses to Assist our External Agencies with.. Asthma J45.9 Other and unspecified asthma   J45.90 Unspecified asthma Asthmatic bronchitis NOS Childhood asthma NOS Late onset asthma J45.901 Unspecified asthma with (acute) exacerbation J45.902 Unspecified asthma with status asthmaticus J45.909 Unspecified asthma, As HIM professionals, are we able to assist external agencies to avoid NOS or unspecified Asthma when we transfer documentation? (C) Daymarck 2014

28. What does this mean for all HIM? • We are all part of continued care. • We can make a difference for our patients. • Home health care and hospice needs our HIM community assistance. • Documentation such as radiology to support the fracture location will help support their codes which will assist them in possible rejection of claims in the future. (C) Daymarck 2014

29. Your Ideas? What are your ideas when it comes to transfer of care and coding? How can we all support each other? (C) Daymarck 2014

30. Preparing HHC Clinicians for ICD-10a Proactive Approach • Key solutions included are to: • Have clinical staff training on what documentation is needed. • Who might the clinician need to contact if the documentation is not there. • What information is acceptable. • Education of providers and HIM staff on what information is need to HHC and Hospice. • To foster valuable relationships. • To anticipate what clinicians will need. (C) Daymarck 2014

31. ICD-10 Coding How does ICD-10 play into our revenue cycle? Patient Diagnosis Collected on OASIS ( SOC and Recert. Which allows for continued Patient care Creates HHRG (Grouping Payment Method How will the proposed Federal Regulations effect our payment cycle? Equates Payment Calculates Case Mix Score Rejections • *Rejection of payment due to: • Unspecified codes • Initial encounter • Inappropriate principle and secondary dx (C) Daymarck 2014

32. We Can All Support Each Other • As the leaders of health information, we are bending your ear today to assist in this documentation flow. • Hospice agencies, for many years, have not had the regulations regarding coding like we will see in the near future. • Many HHC agencies feel they are not forwarded comprehensive documentation. • Thus, we ask for your help to assist in this. • This is the perfect time, with ICD-10 causing us to rise up together, to create a culture of all-encompassing documentation. • The culture where comprehensive documentation is accurate and specific from the beginning and is handed off to ensure our patients quality of care. (C) Daymarck 2014

33. Just for Fun (C) Daymarck 2014

34. Thank you for your timeand attention. • If there are any questions, please feel free to ask. Shawna.zastoupil@daymarck.com or nick@daymarck.com • Thank you for attending. • We hope the information we supplied will help with the new culture of all-encompassing documentation which YOU are a critical piece of! (C) Daymarck 2014