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ACADEMIC HEALTH CENTERS CFG...continued from page 7 There’s also opportunities to gather information to monitor HIPAA effectiveness and risk management issues While you are reviewing the medical records, are there other opportunities to gather information for other compliance purposes? Is there a Notice of Privacy Policy, after April 14, 2003? How would you note a potential quality of care or risk management issue? Track outcomes both as number of outcomes within the sample, and the dollar value Reporting based on dollar values may either add emphasis or offer an alternative perspective. Be sure to identify the reasons for overpayments and underbilling. There may be several comments about a specific encounter, but its very helpful to be able to quickly identify which ones have the most significant financial impact. It’s also important to track based on specific findings. You may also want to be able to quickly identify findings that mirror prior issues or are a current regulatory focus. Compliance continues to evolve into ever increasing complexity Data elements captured will change as new issues and focus areas arise. Rules will change, so adding effective dates may be helpful. Tracking education, refunding, and follow up testing by provider can also be a useful tool in managing your compliance efforts and measuring effectiveness. ■ Database fields for physician services audits: Tracking the audit: Control number assigned to the audit Name of individual performing the review Name of individual providing supervision and review Provider information: Name of provider Provider number Physician, ARNP, or PA? Division Department Medical record: Name of the patient Medical record number Invoice number Date of service Type of documentation The bill: Was the encounter form signed? The service: Rendered by physician alone Resident involved in service Teaching physician documentation Site of service ARNP/PA involved in service ARNP/PA performed service alone Incident to CPT code(s) E&M service or procedure? ICD-9 code(s) Inpatient/Hospital-based/Outpatient setting Name of clinic Payor and payment: Payor Amount Charged Findings: Compliant or non-compliant? Corrected CPT code? Refund required? Full refund? Partial refund? Amount of refund? Reason for refund? Underbilled? Administrative or physician error? Description of error (additional tables can be added including extensive descriptors) ■ July 2003 8
COMPLIANCE FOCUS GROUP HOME CARE CMS clarification on homebound criteria for home care industry remains unclear By Lisa M. Silveria, RN Editor’s note: Lisa M. Silveria, RN, is Home Health Care Compliance Officer with Catholic Healthcare West (CHW). She may be reached at 209/956-2608. This article was submitted to Compliance Today by HCCA’s Home Care Focus Group Chair Chris Anderson, Vice President & Chief Compliance Officer, Gentiva Health Services. He may be reached in Melville, NY at 631/501- 7390. When asked to write an article for Compliance Today, I racked my brain to find a topic that is controversial, fairly subjective in nature, and still remains unclearly defined in the eyes of CMS and Congress. I didn’t have to search very far. I have also recently been approached by many of our CHW agencies, since the release of Transmittal 302, as to how they should approach this from an educational perspective and still remain objective and clear in definitions and examples of homebound. After all, as this is one of the qualifying criteria for home health services, providing such services to the nonhomebound patient can result in submission of a false claim. With varied clinical practices amongst same clinicians by trade, let alone different disciplines, this is clearly a hot topic area and therefore no wonder a continuing focus of the OIG. In short, additional language was added to HIM 11 under Section 204.1 in an attempt to further clarify the definition of homebound. It is worth noting that we are pleased from an industry perspective to see CMS recognize such events as family and religious endeavors as vital to a beneficiary’s recovery. For so long this patient population was not allowed to attend these functions for fear that the home health agency may be required to terminate medically needed services as the patient was able to leave the home setting and therefore could receive these services somewhere else. The problem was that there was usually not that somewhere else to which they might go. Home health agencies, still to this day, take homebound very serious and literally out of fear of non-reimbursement and now false claim submission. I believe this will also ease the physician’s mind more as he is required to certify in writing, by signing the Plan of Care, that the services are medically necessary and that the patient is homebound. It is refreshing for CMS to also look at this issue from the patient’s complete and lengthy health status and not just during the brief home health episode of care. Chronicity of illness is indeed a factor in the patient’s overall health status and response to care. Why do our national and state organizations have continued issue with it then? For the same reasons many Home Health Directors and Compliance Officers still do. Transmittal 302 clearly “muddies” and bends the interpretation even more. Subjectivity is more prevalent a consideration then before. It also hasn’t gone far enough. It addresses specific diagnosis (s) and degenerative chronic illness conditions but what about everyone else? Technology alone has allowed us more ability to care for people we haven’t been able to before. With these advancements come personal freedoms that enhance our patient population recovery and hopefully ward off exacerbations of illness. And of course we have our regional home health fiscal intermediaries to deal with along with state surveyors. Consistent training industry wide for interpretive guidance is essential. The GAO has chimed in also and has concerns that these changes along with others recommended by Congress, not yet approved, will increase Medicare cost. So, are we looking at an expansion of the regulation and at the same time a denial of services to cut cost? What is considered too many absences now under this ruling? Then we have the case where services are required but cannot be provided in the home setting based on equipment or treatment needs. The home health agency is then expected to make arrangements for such services under PPS and for those not included in PPS payment but part of the patient’s Plan of Care. How does homebound fit here? Same way. This homebound patient will generally require the use of an assistive device, potentially special transportation, and the assistance of another person to travel with them. Their condition is usually a bit more precarious so justifying homebound becomes a little easier. Continued on page 10 9 July 2003
Page 1 and 2: Volume Five Number Seven July 2003
Page 3 and 4: NewsFlash HCCA’s call for nominat
Page 5 and 6: the hospital and apparently approve
Page 7: COMPLIANCE FOCUS GROUP ACADEMIC/ RE
Page 11 and 12: COMPLIANCE FOCUS GROUP PAYOR/ MANAG
Page 13 and 14: pleted annually? More frequently? P
Page 15 and 16: would you tell me how many staff do
Page 17 and 18: By Frank Sheeder Frank Sheeder is a
Page 19 and 20: e prudent for compliance officers a
Page 21 and 22: in locating another physician. ■
Page 23 and 24: a tremendous amount of understandin
Page 25: Editor: Margaret R. Dragon, Directo

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