by Tim Rowan (part 1) and Darcey Trescone (part 2)
Part 1: Twenty-four months ago, before anyone had uttered "PDGM," Tim experienced home health as a patient.
My experience was typical. Like thousands of others, I went under the knife for a total knee replacement and came home the next day. I received 11 in-home therapy visits over a little more than three weeks: PT at admission and discharge, OT on day two, and eight from an extraordinary PT assistant in the middle. After discharge, I continued with out-patient physical therapy for another two months. Medicare paid for nearly all of it.
The more I study PDGM, the more I understand just how different next year's typical home health patient's experience will be from mine. More importantly, the home health agencies that create the patient experience, and expect to be paid for it, will behave differently as well. Staff writer Darcey Trescone and I have been spending this year talking to experts to learn exactly what those differences will look like. This week, we focus on HHA behavior around physician referrals, initial assessments, coding, care planning and utilization.
Select Data CEO Ed Buckley has been analyzing data gathered from clients of his outsource coding service as well as industry-wide historical claims files. I asked him what he foresees for next January, when clinicians start producing assessments for 60-day episodes of care broken into two 30-day payment episodes. I wanted to know what preparations agencies would need to focus on in this final quarter prior to PDGM's January launch.
"Documentation has always been, and will continue to be, a leading key to success for home health. Under PDGM, obtaining the right physician documentation in a timely manner will become critical. And while home health documentation requirements will not change, complete and accurate patient information continues to carry significant weight to drive clinical and financial outcomes," he told us.
"Based on our auditing experience, approximately 38 percent of records include errors with the primary diagnosis," Buckley continued. "If not corrected, that will definitely affect agency reimbursement next year. And, with the addition of non-payment codes or "questionable encounters" under PDGM, these errors can prove even more costly. In addition to the primary code, the co-morbidity adjustment with PDGM also has the potential to affect reimbursement, and greatly depends on complete documentation from the physician as well as reconciliation with agency documentation."
"If they do not improve their clinical documentation and change their coding practices, yes, their revenue will take a hit," he told us. "Payers and auditors are going to closely watch diagnoses, coding, and medical necessity. This is what CMS intended with PDGM. They have your data from the last 20 years of PPS and OASIS. PDGM is their attempt to make a better match between care and payment."
Here is a synthesis of our lengthy conversations with Buckley and with Select Data's Chief Strategy Officer, Ginger Voss.
There is language that referring physicians use fairly frequently today – CMS says about 15% of the time – that may not be used under PDGM. They are descriptions of symptoms rather than a diagnosis. Starting in January, there will longer be payment for symptom codes.
To adapt: To maximize success with PDGM, Buckley says HHAs need to take specific steps. Vigilance begins with intake, not with the assessment visit. The intake person who receives referrals from physicians absolutely must be on the lookout for any physician verbiage that describes a symptom rather than a disease or chronic condition. "Generalized muscle weakness," for example, carries a symptom code, not a diagnosis code, and it will no longer generate a payment. Only the underlying diagnosis that causes the symptom belongs on the PDGM OASIS and care plan. If a physician referral document with words like those on it slips past your intake department, you will pay a nurse for an OASIS visit for which you will not be paid as it will result in a "questionable encounter."
Educate referrers: To prevent symptom language before a referral even reaches the intake department, Select Data recommends to its clients that they develop a carefully planned physician education program.
With a solid diagnosis of a disease or condition from a referral source, the intake department can confidently forward the referral for scheduling, the assessment clinician can create a solid foundation for a coder, and the episode is far less likely to be deemed a questionable encounter. Clear, complete, accurate documentation is what helps a coder to be more specific. The coder will be able to accurately place the patient into the correct clinical category, assign the correct functional level, clinical category, and determine secondary codes that calculate a co-morbidity adjustment if appropriate. Specific, accurate coding, in turn, leads to more accurate payments and fewer payment denials.
The bottom line is that clinical documentation will become even more of a factor next year in determining whether an episode is vulnerable to payment denial. While inadequate clinical documentation is already the core driver of high-risk episodes today, its power to increase or decrease payment calculations will grow next year.
"Teamwork is the key," Buckley concluded. "From physician cooperation to intake vigilance to clinician attention to assessment documentation to coding specificity, those involved in the early phases of an episode must work together."
Former CMS OASIS coordinator and Founding President of OperaCare, LLC Michael McGowan discussed with us how HHAs can thrive with PDGM
Michael McGowan is no CMS critic. As a former OASIS coordinator for Region IX, he views PDGM as a logical move to correct some ineffective or inefficient habits that have crept into home health agency practices over the years. Today, as we move into the 4th quarter, McGowan shares his observations on PDGM and why agencies are struggling to prepare for this payment reform.
"What I'm seeing is a desperate need to cling to the legacy practices of the past twenty years, almost to a point of disbelief that change is going to occur and needs to occur in our payment model. Once we mentally move past the idea of change and analyze the components of what's required in this new payment system, then agencies can start moving forward successfully.
"There is plenty of money in this payment system for agencies with high productivity and efficiency standards, not so much for those who lack in those areas. Agencies need to sit down and figure out if they have a static or dynamic census. A static census is not designed for successful entry into PDGM. A dynamic census, which is a hybrid of a little bit of static and a fair amount of unduplicated census, is what's required to succeed.
"A static census, relying on patients who remain on service with minimal improvement, will provide just enough enough money to exist for the next 18 months under PDGM, but will not be rewarded in 2022 when Value Based Purchasing (VBP) begins. Under VBP, agencies will be penalized for a lack of positive outcomes with their patient populations. What agencies need to realize is that the data they start to generate in January 2020 is the data that CMS will be evaluating for VBP in 2022."
Focus on payments? Or costs?
"My team is seeing a lot of scattered, haphazard approaches within agencies we speak with about PDGM preparedness. The primary approach to date is "How much will we get paid under PDGM?" Industry trade associations, consulting firms and vendors have done a fabulous job answering that question for agencies, but agencies also need to be making substantial changes to their productivity practices under this new payment model to prepare to thrive with VBP.
"We are only three months before the launch of PDGM and many agencies still have not educated their physicians on qualifying diagnoses, and they are still 12 to 15 days from SOC visit to care plan creation and RAP submission. Rapid cycle orders management and expedited clinical documentation that supports a plan of care, and data submitted to CMS to achieve positive outcomes, are challenges our industry has always faced but they will significantly exacerbate in the first two quarters of 2020.
"The process changes required under PDGM can be corrected in time if there is commitment at the agency level to do so. Eliminating after hours charting, working with intake on the referral process, and care planning are all key. One simple step, for example, is for agencies to pay attention to care planning and anticipate their patients' needs over a 30 to 60-day period of time. This will help reduce the volume of addendum orders required for physician signature. When the care plan is complete, there should be an understanding of the patient's potential needs while on your service and what outcomes, STAR and QAPI, are being affected.
"Throwing patient outcomes up in the air like popcorn to see if something sticks is what CMS is tired of. If you don't know the outcomes you are going to achieve when you lock your OASIS and submit your RAP, then what are you doing? CMS doesn't pay us to do visits, they reimburse us to get positive outcomes. Data-driven, evidence-based, best practice is the focus and the reason why a third of my team's time spent with customers is on care planning."If you are not able to produce the completed OASIS packet and be RAP ready in 48 to 72 hours, you are already behind the PDGM 8 ball; plus, you have a significant potential of overwhelming your QA department and field staff. Sit down, take a deep breath and re-evaluate.
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. email@example.com