Acorn’s End Blog

HIPPA Code Changes: Discharging when Client Hospitalized
Effective July 1, 2010, if a patient resumes services prior to the 60th day of the episode, the agency must resume services under the same HIPPS code established by the start of care assessment. If the patient does not resume services by the end of the 60th day, the agency can discharge him or her and start a new episode upon return home.

CMS Publication 100-4, Chapter 10 reports that if an agency chooses to discharge, based on an expectation that the beneficiary will not return, the agency should recognize that if the beneficiary does return to them in the same 60-day period, the discharge is not recognized for Medicare payment purposes. All the home health services provided in the complete 60-day episode, both before and after the inpatient stay, should be billed on one claim.

Below is an exerpt from the CMS transmittal. To view the entire transmittal, go to: http://www.cms.gov/transmittals/downloads/R1904CP.pdf

Pub 100-04 Medicare Claims Processing Transmittal 1904
30.9 - Coordination of HH PPS Claims Episodes With Inpatient Claim Types

(Rev.1904, Issued: 02-05-10, Effective: 07-01-10, Implementation: 07-06-10)

Claims for institutional inpatient services, that is inpatient hospital and skilled nursing facility (SNF) services, will continue to have priority over claims for home health services under HH PPS. Beneficiaries cannot be institutionalized and receive home care simultaneously. Thus, if an HH PPS claim is received, and CWF finds dates of service on the HH claims that fall within the dates of an inpatient or SNF claim (not including the dates of admission and discharge), Medicare systems will reject the HH claim. This would still be the case even if the HH PPS claim were received first and the SNF or inpatient hospital claims came in later, but contained dates of service duplicating dates of service within the HH PPS episode period.

A beneficiary does not have to be discharged from home care because of an inpatient admission. If an agency chooses not to discharge and the patient returns to the agency in the same 60-day period, the same episode continues. However, if an agency chooses to discharge, based on an expectation that the beneficiary will not return, the agency should recognize that if the beneficiary does return to them in the same 60-day period, the discharge is not recognized for Medicare payment purposes. All the HH services provided in the complete 60-day episode, both before and after the inpatient stay, should be billed on one claim.

The ICD-9 proposed codes for 2011 have been released – and they take effect Oct. 1, 2010, without a grace period. There are 122 new codes that all reflect CMS’s continued drive for greater specificity in diagnosis coding. The 122 new codes are accompanied by 11 deleted and nine revised diagnoses codes – and 54 of the 122 new codes are V codes. You can download a list of the proposed 2011 codes at the following web site: https://www.cms.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage

Is an abscess that has been incised and drained a surgical wound in M1340?

Maybe! A typical I&D procedure does not result in a surgical wound. This is reported as an abscess, not a surgical wound. However, if a drain was inserted after the I&D, then “yes” it is reported as a surgical wound.

CMS posted the Process-based Quality Improvement (PBQI) Manual on the Home Health Quality Initiative (HHQI) website. This manual describes the Process Quality Measure Report and discusses its use for quality monitoring purposes and survey. Download the manual at — http://www.cms.gov/HomeHealthQualityInits/Downloads/HHQIOASIS-PBQI.pdf.

CMS is updating the Outcome-based Quality Improvement (OBQI) and Outcome-based Quality Monitoring (OBQM) manuals to address the impact of OASIS-C and will post those on the HHQI website some time in the future.

Many agencies have incorporated the TUG, Tinetti, or frontal reach exams into their fall risk assessment to create a standardized tool. How should we respond to M1910 if the patient is unable to perform or complete any of these tests because the patient: a) cannot complete the test safely, or b) is bedfast?

According to CMS:
In order to say “Yes” in M1910, the multi-factor falls risk assessment must consist of or include a standardized tool that 1) has been scientifically tested on a population of community dwelling elders and shown to be effective in identifying people at risk for falls; and 2) includes a standard response scale. If you can not identify a test where the patient can be assessed safely, then you would have to answer “No”, and explain the circumstance in your documentation

From: NAHC, Regulatory Affairs
There has been some confusion among providers regarding the implementation dates for several of the HIPAA privacy and security provisions contained in the Health Information Technology for Economic and Clinical Health (HITECH) Act. NAHC has confirmed with the Office of Civil Rights (OCR) that the only provisions currently in effect are the breech notification requirements and enforcement of HIPAA violations. Guidance on compliance and the effective dates with the provisions that address business associate liability; new limitations on the sale of protected health information, marketing, and fundraising communications; and stronger individual rights to access electronic medical records and restrict the disclosure of certain information, will be issued through the notice of proposed and final rule making process.

Although agencies can anticipate the need to revise their patient privacy notices, there is no requirement at this time to make those changes. NAHC will continue to follow rule making on the HITECH provisions that affect home health and hospice providers and update our members as we become aware of the changes.
The OCR has posted the following information regarding the privacy provisions of HITECH on their web site at:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechblurb.html

From: NAHC, Regulatory Affairs

The Centers for Medicare & Medicaid Services (CMS) requested that NAHC post a reminder to home health agencies that CAHPS requirements must be met during 2010 in order to receive a full market basket update in 2012. Meeting CAHPS requirements entails selecting a CMS approved vendor to conduct patient perception of care surveys, completing testing with that vendor during the 3rd quarter of 2010, and conducting formal patient surveys by the 4th quarter of 2010. Certain small agencies are exempted from CAHPS. Details about the survey instrument and process, CMS approved vendors, and the exception process can be found at the web site link below:

For all Medicare-Certified Home Health Agencies: HHCAHPS Requirements

Have you heard about HHCAHPS (Consumer Assessment of Health of Healthcare Providers and Systems) but need to know more about how to start it? Go to www.homehealthcahps.org to learn all about it. If you are a very small HHA with less than 60 HHCAHPS eligible patients annually, by June 16, 2010, you will need to submit the Exemption Form on https://homehealthcahps.org/ForHHAs/ParticipationExemptionRequestForm.aspx with your patient count. If you have 60 or more HHCAHPS eligible patients annually, then you will need to do a dry run in the third quarter 2010 (July, August, and/or September), and you need to contract with an HHCAHPS survey vendor listed on www.homehealthcahps.org. All Aboard for the HHCAHPS Survey in 2010!

What are the guidelines you use for answering surgical wound status? I had a QA nurse before tell me that up to 30 days post op was considered early/partial granulation and then 30-60 days was fully granulating.

A surgical site closed by primary intention is considered a current surgical wound until re-epithelialization has been present for approximately 30 days. After 30 days, it is generally described as a scar/lesion and not included in this item unless signs and symptoms of infection are present or it dehisces.

If a clinically significant problem is resolved before completion of comprehensive assessment, do you need to report the problem in M2000 (drug regiment review)?

The problem does not need to be reported in M2000.

Timeframes for Reports
Home health quality measures are on hold for awhile as OASIS-C data is collected and risk models are being developed. Enough numbers of patient episodes are needed in order to report measures based on new OASIS-C data. Once sufficient OASIS-C data have been collected and submitted to the national repository, CMS will begin producing new reports based on OASIS-C.

On March 15, 2010, providers will be able to access OBQI and OBQM reports containing data through December 2009. This will be the last month for which OBQI and OBQM data is calculated for OASIS B1.

OASIS C Process, Outcome and Potentially Avoidable Measures will be transitioned between September 2010 and May 2011. Specific details regarding these reports will be available closer to implementation date of the Process Measures scheduled for September 2010.

Home Health Compare will be updated in April 2010 with OASIS B1 data for a time period of January 2009 through December 2009.

Providers can access OBQI reports through CASPER (Certification and Survey Provider Enhanced Report). Only those process measures endorsed by the National Quality Forum (NQF) will be reported on the Home Health Compare Web site.

OBQI will report on 47 process measures. The majority of the process measures will have one measure on the report. However, all of the measures related to implementation of plan of care interventions (diabetic foot care, pressure ulcer treatment) will generate three reports, including: 1) Short-term episodes (60 days or less from start or resumption of care through transfer or discharge - no recertification assessment done); 2) Long-term episodes involving at least one recertification of care; 3) All episodes combining short-term and long-term episodes. Home Health Compare will report only five implementation process measures: treatment of pain, heart failure, and pressure ulcer; diabetic foot care, and medication education.

Download the two-year transition reporting matrix at: http://www.cms.gov/HomeHealthQualityInits/Downloads/HHQIOASISB-1ToOASIS-CTransitionReportingMatrix031710.pdf

Watch for updates on the Home Health Quality Measures Web site at:
http://www.cms.gov/HomeHealthQualityInits/10_HHQIQualityMeasures.asp#TopOfPage

Background
Patient outcome measures are calculated based on a completed episode of care that begins with admission (SOC) to a home health agency (or a resumption of care [ROC] following an inpatient facility stay) and ends with discharge or transfer to inpatient facility. This is different than a Home Health Prospective Payment episode of 60 days.

There are two types of outcomes; 1) utilization outcomes and 2) end-result outcomes.
Utilization Outcomes: Discharged to Community, Acute Care Hospitalization, Any Emergent Care.

End-Result Outcomes

Improvement in Grooming
Stabilization in Grooming
Improvement in Upper Body Dressing
Improvement in Lower Body Dressing
Improvement in Bathing
Stabilization in Bathing
Improvement in Toileting
Improvement in Transferring
Stabilization in Transferring
Improvement in Ambulation/Locomotion
Improvement in Eating
Improvement in Light Meal Preparation
Stabilization in Light Meal Preparation
Improvement in Laundry
Stabilization in Laundry
Improvement in Housekeeping
Stabilization in Housekeeping
Improvement in Shopping
Stabilization in Shopping
Improvement in Phone Use
Stabilization in Phone Use
Improvement in Management of Oral Medications
Stabilization in Management of Oral Medications
Improvement in Dyspnea
Improvement in Urinary Tract Infection
Improvement in Urinary Incontinence
Improvement in Bowel Incontinence
Improvement in Pain Interfering with Activity
Improvement in Number of Surgical Wounds
Improvement in Status of Surgical Wounds
Improvement in Speech and Language
Stabilization in Speech and Language
Improvement in Confusion Frequency
Improvement in Cognitive Functioning
Stabilization in Cognitive Functioning
Improvement in Anxiety Level
Stabilization in Anxiety Level
Improvement in Behavior Problem Frequency