Question 2: Medicare home health patient who drives

Determining homebound status is not as easy as it seems. This is in part to CMS's broad and non-specific definition. Most people within the homecare industry can recite that Medicare homecare patients have to have the condition "that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort." After this, there is definite discrepancy in what this exactly means.

As far as driving, this fact does not automatically exclude a patient from home health services. CMS answered a Q&A in 2008 to this effect. The bigger picture has to be looked at.

Question 2 does not indicate if there is a considerable and taxing effort to leave the home thus the correct answer would be not enough information to make a decision.

Partial Code Freeze Prior to ICD-10 Implementation

At the ICD-9-CM Coordination & Maintenance Committee Meeting (September 15, 2010), it was announced that the committee had finalized the decision to implement a partial freeze for both ICD-9-CM codes and ICD-10-CM and ICD-10-PCS codes prior to implementation of ICD-10 on October 1, 2013. There was considerable support for this partial freeze.


The partial freeze will be implemented as follows:

• The last regular annual update to both ICD-9 and ICD-10 code sets will be made on October 1, 2011.
• On October 1, 2012 there will be only limited code updates to both ICD-9- CM and ICD- 10 code sets to capture new technology and new diseases.
• There will be no updates to ICD-9 -CM on October 1, 2013 as the system will no longer be a HIPAA standard.

On October 1, 2014 regular updates to ICD-10 will begin. The ICD-9 Coordination & Maintenance Committee will continue to meet twice a year during the freeze. At these meetings the public will be allowed to comment on whether or not requests for new diagnosis and procedure codes should be created based on the need to capture new technology or disease. Any code requests that do not meet the criteria will be evaluated for implementation within ICD-10 on or after October 1, 2014, once the partial freeze is ended.

To view the transcript of the meeting, go to: http://www.cms.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp. From there, select the September 15-16, 2010 meeting transcript in the download section, and then from the ZIP files, select the 091510_Morning_Transcript file. This section appears on page 4 of the 78-page proceeding.

A walk at NAHC

Photos from Day 1 of NAHC

Great Opening Night at NAHC 2010

Wow, what a great start to the 29^th Annual National Association for Homecare and Hospice Expo. This year’s event is being held at the Gaylord Texan Resort on Grapevine Lake in Grapevine, TX, outside of Dallas. If you’ve never been here, it’s worth the trip. As they say, “everything is bigger in Texas” and that is no lie.

There are about 3,000 attendees and probably 300+ exhibitors with lots of energy. We posted a few videos on our YouTube channel to give you a feel of the festivities. You can also follow us on Twitter and be sure to like us on Facebook.

More to come later. Off to see former President George W. Bush give the keynote address.

More Than 10,000 Messages Sent Through NAHC LAN

NAHC REPORT

Your Help is Needed

With Congress Back in Session, More Opportunities for Advocacy to Come

After outstanding campaigns by the home care community to ramp up grassroots actions urging members of Congress to stop home health cuts (NAHC Report, 8/12/10), the National Association for Home Care & Hospice (NAHC) is proud to share our success stories.

More than 9,600 messages were generated through NAHC's Legislative Action Network (NAHC LAN) urging members of Congress to cosponsor the Home Health Care Access Protection Act (S. 3315; H.R. 5803), which would help stop the Centers for Medicare & Medicaid Services (CMS) from implementing the $1.5 billion in home health regulatory cuts over the next two years included in its proposed rule on 2011 home health payment rates (NAHC Report, 8/9/10). Advocates also attended town hall meetings, invited their members on home care visits, and submitted letters to the editor of their local newspapers.

As the congressional recess wraps-up -- with the Senate returning to business today and the House tomorrow -- home care advocates have unique opportunities to follow up on their recess advocacy efforts by continuing to urge their members of Congress (including by engaging their health care staffers) to cosponsor the Home Health Care Access Protection Act. Advocates also can help build support for other pending legislation important to the home health community such as the Home Health Care Planning Improvement Act, which would allow nurse practitioners and physician assistants to sign home health plans of care (NAHC Report, 7/20/10). More than 2,000 messages have already been sent from the NAHC LAN supporting this bill.

Now that Congress is back from recess, senators and representatives will be making decisions about what bills to sponsor and will officially register their support. It is important to be persistent by asking that your senators and representative let you know if they will agree to sign on these bills. You may review the current list of cosponsors by clicking on the bill numbers (S. 3315; H.R. 5803), and then clicking on the link that says "Cosponsors."

This last stretch of Congressional activity before the November elections provides a short -- but dedicated and fervent -- four-week work schedule before members go out again to campaign. There has been some talk on Capitol Hill of Congress leaving even before October 8, so now is the time to step up advocacy and let members of Congress know the importance of these bills and the strength of home care advocacy.

'Lame Duck Session' Offers Further Opportunities for Advocacy

The tentative congressional schedule includes a plan to return after the November 2 elections for what is known as a "lame duck session" to deal with unfinished business, including an extension of the temporary fix to the Medicare physician payment formula and the exceptions process for the outpatient therapy cap. Without congressional action, the current physician payment fix will expire on November 30, resulting in a substantial reduction in physician payments. The exceptions process for the therapy cap expires on December 31.

When these Medicare issues are addressed, there should be opportunities to pursue home care priorities such as reforming the regulatory process for evaluating home health case-mix changes (provisions of the Home Health Care Access Protection Act) and the new face-to-face physician encounter requirements. Another change sought by home care advocates is allowing nurse practitioners and physician assistants to sign home health plans of care (the Home Health Care Planning Improvement Act). Stay tuned to NAHC Report for coverage of what promises to be a very intense time on Capitol Hill and for more action alerts.

Home Care Leadership - What Agencies must do to Survive

As the debate over health care reform continues, home health agencies are facing an increasingly complex array of rules and guidelines that will dramatically reshape future business operations.

We've pulled out a great article written earlier this year by Daymarck's CEO and Founder, Nick Dobrzelecki, that discusses what home healthcare agencies must do to survive in this period of change.

Click here to read the full article. Feel free to post comments on your thoughts regarding this issue. We would love to get your perspective.

Why home health coders hold the edge as the healthcare arena continues to change

Complexity of home health coding dwarfs hospital issues.

A little more than 10 years ago in home health (HH), an agency could code as it wanted, with few restrictions, and get reimbursed at a high rate with no annual patient cap. Coding didn’t matter, according to many, because there wasn’t stringent regulation surrounding it. It was a time of PAIN-FREE CODING (TM).

Learn about the signifigant regulatory changes that have taken place over the last decade or so, and see some of the issues that distinguish HH coding from hospital coding. 

Read more of this article on the Daymarck website.

Decision Health Home Coding Summit

Packed house at Daymarck-sponsored Decision Health Home Coding Summit 2010 in Philadelphia.

8th Annual Home Health Coding Summit

This week August 8-12, for the second year in a row, Daymarck is a sponsor at the 8th Annual Home Health Coding Summit, the gold standard in coding education. The summit is being held at the Loews Philadelphia Hotel for the chance to network with fellow clinicians and coders. Check out our photos of the booth and who we are meeting.

Pictured here is Nick with Kathy Domenz, one of the first home care certified (HCS-D) coders at the program's inception in 2003.

Part I: Preparing for Audits - ZPIC Audits

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

The Centers for Medicare and Medicaid Services (CMS) are now conducting ZPIC audits. ZPIC’s are conducted by Zone Program Integrity Contractors. Unlike RAC audits that target identification of overpayment and CERT audits that attempt to pinpoint improper payments, ZPIC audits focus on fraud in the Medicare Program. This means that ZPIC contractors can audit the integrity of all Medicare claims, both pre- and post-payment.

CMS has established seven ZPIC zones. Contracts have been awarded in three zones thus far, as follows:

 Zone 5 – AdvanceMed: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia
 Zone 7 – SafeGuard Services: Florida, Puerto Rico, and the Virgin Islands
 Zone 4 – Health Integrity: Texas, Colorado, New Mexico, and Oklahoma

ZPIC contractors are currently especially active in Zone 4.

Action Alert :

Please encourage your congressional legislators to add their names as cosponsors of the Home Health Care Access Protection Act (H.R. 5803; S. 3315) introduced by Reps. Jim McGovern (D-MA) and Walter Jones (R-NC) and Sens. Susan Collins (R-ME) and Russ Feingold (D-WI). Go to NAHC Report, 7/15/10 for more information about this bill.


In light of the recent CMS rule that proposes to cut home health payments by 3.79 percent in 2010 and 3.79 in 2011 based on an unfounded allegation of "case mix creep" (NAHC Report, 7/19/10), this legislation is vitally important to preserve access to home health services because it would establish a fairer and more transparent process for evaluating case mix changes. Home health advocates also should ask their legislators to convey these significant concerns about payment cuts to CMS.

Click here and enter your zip code to find your federal legislators and their contact information. To access the text of the House bill and a list of House cosponsors, click here. To see the text of the Senate bill and a list of Senate cosponsors, click here. If your legislators have not yet cosponsored H.R. 5803 or S. 3315, please contact their offices and encourage them to do so. When calling, ask to speak with the staffer who handles Medicare issues. For talking points, click here.

To send an email on this issue to your members of Congress using the NAHC Legislative Action Network, click here. We encourage you to edit the sample email provided there by adding information about your own background and experience and the impact these payment cuts could have on home health patients in your state.

Join us for Upcoming Events

Over the next several months, Daymarck will be at industry shows where we hope to meet you, learn more about your home health agency, and tell you more about how we can make your home care coding as easy and pain-free as possible.

Tomorrow July, 14 we will be attending the NAHC and HHFMA 16th Annual Financial Management Conference & Exposition at the Sheraton Chicago Hotel & Towels. At a NAHC Conference, be sure to participate in user groups meetings, client appreciate receptions, in-booth educational sessions and more.

Nick and George will be at Booth # 301 so stop by for a free cost analysis and don't forget to pick up a calculator. If you are not able to attend, follow @Daymarck during the event for updates.

For the second year in a row, we are sponsors of Decision Health's Home Health Coding Summit at Loews Philadelphia Hotel August 8-12 to join expert coders and network with your peers while participating in an exclusive day of interactive, advanced-level coding and celebration of 2,010 certified coders in 2010! Plus new in 2010: Procedure coding — a new requirement for home health agencies — along with OASIS-C and coding interactions. In addition to being an exhibitor hosting a booth, we will be sponsoring the luncheon session where we are gathering thought leaders in a panel discussion. Stay tuned for more details.

Last, but not least, mark your calenders for October 2-6! Daymarck will be at the 2010 National Association for Home Care & Hospice 29th Annual Meeting & Exposition in Dallas, TX. 

Feel free to reach out to us at anytime with questions. We look forward to seeing you at all of the upcoming events!

Changes in Referral Relationships with Physicians

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

Significant changes are likely in the near future in relationships between providers and referring physicians. Trade associations, for example, are providing substantial guidance for their members on this subject. PhRMA, a trade association whose members are pharmaceutical research and biotechnology companies, recently updated its Marketing Code. The revised Code was applicable as of January 1, 2009. Although the Code applies only to members of PhRMA who voluntarily agree to follow it, the Code has helped providers to understand changing standards regarding acceptable marketing practices.

With regard to taking lunches to physicians’ offices, for example, the revised Code says that PhRMA members who elect to adhere to the Code may present information to healthcare professionals and their staff members during the workday, including at mealtimes. In connection with such presentations or discussions, the Code also says that it is appropriate for occasional meals to be offered as a business courtesy to the participants. The presentations must, however, provide scientific or educational value and meals must meet the following standards:

- Modest, by local standards;

- Not part of an entertainment or recreational event;

- Provided in a manner conducive to informational communication; and
- Limited to in-office or in-hospital settings.

Federal regulators have been active for many years in oversight and monitoring of referral arrangements with physicians and will surely continue to do so. The bases for these activities include the federal anti-kickback statute and the so-called Stark laws. Many states have enacted statutes and implemented regulations governing referrals.

State courts have also addressed these issues. In Sloan v. South Carolina Board of Physical Therapy Examiners, No. 26209 (S.C. Sept. 25, 2006), for example, the Supreme Court concluded that a state statute prohibits physical therapists from being employed by physicians who refer patients to them for therapy services. The Court also specifically recognized the right of the state’s Board of Physical Therapy Examiners to enforce the statute against therapists who violate it.

Recent activity seems to indicate that state legislatures and licensure boards are likely to further regulate these relationships even more aggressively. State licensure boards in New Jersey, for example, may require physicians to refuse lunches provided by representatives of pharmaceutical manufacturers. Physicians may also be required to disclose payments of more then $200.00 as a condition of licensure.

There seems to be a perception among state governments that federal regulation of relationships between physicians and providers who receive referrals from them has been ineffective. Consequently, state regulation is likely to become more extensive and frequent. Stay tuned for more information about this important trend.


©Copyright, 2010. Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

NAHC Report Article


Thursday, June 17, 2010

________________________________________

Fifty Representatives Endorse Home Health Care Planning Improvement Act

Bills Would Allow NPs, PAs, and Other Professionals to Sign Home Health Plans of Care

With the help of home care advocates, Rep. Allyson Schwartz (D-PA) has garnered 50 cosponsors for her legislation, the Home Health Planning Improvement Act of 2010 (H.R. 4993). The National Association for Home Care & Hospice (NAHC) thanks all home care advocates who helped encourage their representatives' support for this legislation (NAHC Report, 4/28/10) The bill would allow nurse practitioners (NPs), clinical nurse specialists, and physician assistants (PAs) to order home health services under Medicare in accordance with state law.

Rep. Schwartz -- who serves on the House Ways and Means Committee, which has jurisdiction over Medicare and Medicaid -- and the bill's Republican cosponsor, Walter Jones (R-NC), have been circulating a new, bipartisan "dear colleague" letter describing the bill and seeking cosigners among fellow House members.

"Even though nurse practitioners and physician assistants are currently able to order nursing home care for Medicare beneficiaries, they are not able to order less costly home care services," Schwartz and Jones point out in the letter. "The Home Health Care Planning Improvement Act, H.R. 4993, would ensure that our Medicare beneficiaries get the home health care they need in a timely manner." You can help by downloading the letter and forwarding it to your representative's office -- see below for information to help you do so. In addition, Sens. Susan Collins (R-ME) and Kent Conrad (D-ND) have introduced a Senate companion bill (S. 2814), and NAHC urges all home care advocates to encourage their senators to add their names as cosponsors.

TAKE ACTION: Have your congressional legislators added their names to these important bills?

Click here and enter your zip code to find your federal legislators and their contact information. If your members of the House and Senate have not yet cosponsored H.R. 4993 or S. 2814, respectively, please contact their offices and encourage them to do so. When calling, ask to speak with the staffer who handles Medicare issues. To send an email on this issue to your members of Congress using the NAHC Legislative Action Network, click here.

Why Discharge Planners/Case Managers Need to Know About Legal Implications of Provision of Free Services to Patients

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-Mail: ElizabethHogue@ElizabethHogue.net

Based upon their overriding commitment to patients, case managers or discharge planners may be tempted to “take up the slack” by urging post-acute providers to render free or voluntary services to patients. Case managers/discharge planners may state to post-acute providers that they will not receive additional referrals unless they agree to provide services to so-called “indigent patients,” some of whom may not have a payor source for their care.

Staff members who provide free services and organizations that allow staff members to do so run the risk of engaging in fraudulent conduct. Specifically; to the extent that free or voluntary services are perceived as an inducement to patients to initiate, continue, or re-initiate services with particular providers; organizations and practitioners may run the risk of violation of Medicare/Medicaid fraud and abuse prohibitions, especially the federal anti-kickback statute. Violations may also occur if provision of free services is an inducement for additional referrals, as described above. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS), a primary source of enforcement activity, has clearly stated that the provision of free services to beneficiaries may constitute a violation of these prohibitions.

The OIG has also clearly delineated limits on free items and services that may be provided to patients. Providers may give patients only non-cash items of nominal value. Non-cash items, including free services, may not exceed $10.00 in value at a time and $50.00 in value during a calendar year. Most post-acute services, including even one visit to a patient’s home, clearly exceed these limits.

This position may strike discharge planners/case managers as confusing and perhaps contradictory. Since the point of enforcement is to prevent unnecessary costs, shouldn’t the government welcome the provision of free services to beneficiaries by providers that save money, since they are free? Nonetheless, the government’s point of view is that, when free services result in additional utilization of services, there is a potential fraud problem.

The question of whether free services induce beneficiaries to utilize services paid for by the Medicare/Medicaid and other federal and state healthcare programs that they otherwise would not have utilized is certainly a tricky one to answer. In the current environment of hypersensitivity to fraud and abuse, the best course of action for post-acute providers is likely to completely avoid the provision of free services to patients.

In response to these concerns, providers may wish to develop and implement a policy that permits provision of so-called “charity care” after the requirements of the policy have been met. At a minimum, such policies should require providers to bill patients three times before writing off the services as “charity care.” This practice is likely to help “shield” providers from allegations of fraud.

The good intentions and fine motivations of case managers/discharge planners must be acknowledged. The “bottom line,” however, is that the provision of free services is problematic in today’s healthcare environment and should be avoided for all of the above reasons.

©2010

Elizabeth E. Hogue, Esq. All rights reserved.

No portion of these materials may be reproduced in any form without the advance written permission of the author.

The Latest on the Red Flags Rule

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

The Federal Trade Commission (FTC) will begin enforcement of the Red Flags Rule on June 1, 2010. This Rule was created to ensure that certain types of organizations are doing everything in their power to identify, prevent, and reduce incidences of identity theft. Most health care providers are subject to this Rule that requires businesses to develop identity theft Programs tailored to the characteristics of their organizations. Although the FTC will not take any enforcement action before June 1, 2010, providers are still required to comply. (See information below regarding available materials.) There is, however, legislation pending in Congress that may change requirements to comply with the Rule.

Specifically, on October 8, 2009 H.R. 3763 was introduced into the House of Representatives. This proposed bill would amend the Fair Credit Reporting Act to exclude small businesses, including some health care providers, from Red Flags Rule requirements. This legislation was passed by the House of Representatives on October 21, 2009. It is currently being reviewed by the Senate Committee on Banking, Housing, and Urban Affairs. Section 1 of the proposed legislation provides as follows:

(4) EXCLUSION FOR CERTAIN SMALL BUSINESSES – For purposes of this subsection, the term ‘creditor’ shall not include—

(A) a health care practice with 20 or fewer employees;…or

(D) any other business, if the Commission determines, following an application for exclusion by such business, that such business—

i   knows all of its customers or clients individually;

ii   only performs services in or around the residences of its customers; or

iii   has not experienced incidents of identity theft and identity theft is rare for businesses of that type.

(5) DEFINITIONS – For purposes of this subsection:

(A) EMPLOYEE – With respect to a business, the term ‘employee’ means any individual who works for such a business and is paid either wages or a salary.

(B) HEALTH CARE PRACTICE –

(iv) IN GENERAL – The term ‘health care practice’ means a business that’s primary service is providing health care via health care professionals employed by the business.

(v) HEALTH CARE PROFESSIONAL – For purposes of subparagraph (A), the term ‘health care professional’ means an individual engaged in providing health care and licensed under State law, including physicians, dentists, podiatrists, chiropractors, physical therapists, occupational therapists, marriage and family therapists, optometrists, speech therapists, language therapists, hearing therapists, and veterinarians

If this proposed legislation is enacted, the Red Flags rule may not apply to some providers. Some providers may also qualify for an exclusion from the Rule, as indicated above.

There’s always something new in healthcare!

We have developed materials for you to use to meet the requirements of the Rule. The materials are appropriate for use by all providers, including home health agencies; private duty agencies; hospices; HME suppliers; and individual providers, such as therapists, ALF’s/ILF’s, physicians, etc. The materials include a comprehensive Policy, as required by the Rule, which should be used to provide training that is also mandated by the Rule. In addition, the materials include a resolution to be adopted by the governing body per the Rule.

The cost of these materials is $200.00. Please send a check made out to Elizabeth E. Hogue, Esq. to: Fulfillment, 107 Guilford, Summerville, SC 29483. We are unable to accept credit cards. Please be sure to include the name and e-mail address of the person who should receive the materials. We will e-mail them to the designated recipient upon receipt of payment.

©2010
Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Why Discharge Planners/Case Managers Need to Know About Legal Implications of Provision of Free Services to Patients

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-Mail: ElizabethHogue@ElizabethHogue.net

Based upon their overriding commitment to patients, case managers or discharge planners may be tempted to “take up the slack” by urging post-acute providers to render free or voluntary services to patients. Case managers/discharge planners may state to post-acute providers that they will not receive additional referrals unless they agree to provide services to so-called “indigent patients,” some of whom may not have a payor source for their care.

Staff members who provide free services and organizations that allow staff members to do so run the risk of engaging in fraudulent conduct. Specifically; to the extent that free or voluntary services are perceived as an inducement to patients to initiate, continue, or re-initiate services with particular providers; organizations and practitioners may run the risk of violation of Medicare/Medicaid fraud and abuse prohibitions, especially the federal anti-kickback statute. Violations may also occur if provision of free services is an inducement for additional referrals, as described above. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS), a primary source of enforcement activity, has clearly stated that the provision of free services to beneficiaries may constitute a violation of these prohibitions.

Part 1 – Health Care Reform: Physicians and Patients’ Right to Freedom of Choice of Providers

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

To date, only hospitals are required to present lists of some types of providers to patients so that they can choose which providers they want to render services to them. Likewise, statutes in some, but not all states, require physicians and other types of providers to give notice to patients if they have financial/ownership interests in providers to which they make referrals. As a result of health care reform, the “picture,” with regard to physicians and patients’ right to freedom of choice, is about to change.

Specifically, physicians who make referrals for certain types of imaging services are required to inform patients in writing at the time referrals are made that patients may obtain services from providers of their choice. Physicians are also required to provide patients with a list of providers who supply such services in areas in which patients reside. It appears that the Secretary of the U.S. Department of Health and Human Services (DHHS) may also have the discretion to apply this requirement to other designated health services (DHS) under the so-called Stark laws, including home health and HME services.

Physicians and Patients’ Right to Freedom of Choice

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

Providers are increasingly concerned that physicians may violate patients' right to freedom of choice of providers.
First, it is important to note that longterm care, home health, including some services provided by private duty agencies, home medical equipment (HME) and hospice services are provided under the supervision of physicians based upon specific orders from them. Because physicians supervise these types of services, they are at risk for legal liability, along with providers and staff members, if providers supervised by physicians do no meet applicable standards.
Consequently, physicians have a clear interest in assuring the quality of care rendered by other providers to their patients. Physicians may, therefore, choose to designate in their orders which providers will render services to their patients in order to help assure quality of care and manage their risks of liability.

Advance Practice Reform

I was recently asked, why allowing advance practice providers to order and supervise patients under homecare services was needed. Here was my response:

First everyone needs to be clear what the Federal Register states:

§ 484.18 Condition of participation: Acceptance of patients, plan of care, and medical supervision states, “Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine.”

This federal regulation supersedes any state nurse practice acts that would allow nurse practitioners to provide this oversight. There are multiple reasons why H.R. 4993 bill or S. 2814 needs to be passed. Senator Collins (D-Maine) did a wonderful job outlining some of these reasons in her statement in November of 2009. Her statement can be found in one of my previous blogs.

I see this legislation being a critical first step in reforming home health care and positioning the industry to be a critical player in overall healthcare reform. There are several possible changes that will occur over the next few years as a result of healthcare reform. These changes include value-based purchasing (A.K.A. pay for performance) and post-acute bundling. I envision nurse practitioners as key solutions for these challenges.

I predict that nurse practitioners will be on staff in many home health agencies during the next decade. They will be in charge of disease management programs, case managing complex patients, and providing direct care to patients. The direct care will consist of caring for those patients exhibiting acute exacerbations of their disease. Instead of going to the ER or delaying treatment while waiting for a physician appointment, the NP would see those patients at home and order the appropriate treatment. This would decrease healthcare costs while accelerating patient outcomes and increasing patients’ overall satisfaction.

An example would be a Chronic Congestive Heart Failure patient beginning to experience an acute exacerbation. Currently, most agencies would notify the physician who then would instruct the patient to go to the ER. The ER physician, not knowing this patient feels this patient need to be hospitalized to be diuresed. After the expensive ER visit and several days in the hospital, the patient is diuresed.

Instead say that nurse notified the NP on staff. They see the patient in home and complete an assessment. Complete any necessary lab work then orders diuretics for the patient while at home. The agency increased the visits over the next few days until the patient stabilizes. This would cost a fraction of the ER/hospitalization bill.

In order to achieve this first step towards higher quality patient care, H.R. 4993 needs to be passed now. As health care reform becomes clearer, many groups will be aiming to be on top of the heap. If these bills are not passed now, I worry that physician lobbyist groups will fight much more fiercely in the future to not allow advance practice providers to practice in the homecare setting as is the case now. The home health industry is in a terrific position to become a major player in health reform. In order to situate ourselves to be a major stakeholder with Healthcare Reform, we must pass H.R. 4993.

Bills Would Allow NPs, PAs, and Other Professionals to Sign Home Health Plans of Care

Rep. Allyson Schwartz (D-PA) has jumped into the fight to pass overdue commonsense legislation (H.R 4993) which would allow for NPs, PAs and other professionals to sign home care Plans of Care. Senators Susan Collins (R-ME) and Ken Conrad (D-ND) had previously reintroduced a Senate Bill (S. 2814) that would also allow for this. That Senate Bill is currently at the Senate Finance Committee for review. No additional Senators have signed up to be cosponsor since it was introduced November 20, 2009.

The House version has had 37 cosponsors of the bill. Rep. Schwartz has been circulating a "dear colleague" letter describing the bill and asking for additional cosigners.

Here is a list of those who have signed on to these bills:

H.R. 4993
Rep. Allyson Schwartz (D-PA, sponsor) Rep. Tammy Baldwin (D-WI) Rep. Leonard Boswell (D-IA) Rep. Bruce Braley (D-IA) Rep. Dennis Cardoza (D-CA) Rep. Kathy Castor (D-FL Rep. Gerry Connolly (D-VA) Rep. Kathleeen Dahlkemper (D-PA) Rep. Rosa DeLauro (D-CT) Rep. Chaka Fattah (D-PA) Rep. Raul Grijalva (D-AZ) Rep. Jane Harman (D-CA Rep. Paul Hodes (D-NH Rep. Barbara Lee (D-CA) Rep. Patrick Murphy (D-PA) Rep. Ed Perlmutter (D-CO) Rep. Lucille Roybal-Allard (D-CA) Rep. Kurt Schrader (D-OR) Rep. Carol Shea-Porter (D-NH)
Rep. Peter Welch (D-VT) Rep. Earl Blumenauer (D-OR) Rep. Robert Brady (D-PA) Rep. Lois Capps (D-CA) Rep. Christopher Carney (D-PA) Rep. Mike Coffman (R-CO) Rep. Joe Courtney (D-CT) Rep. Peter DeFazio (D-OR) Rep. Sam Farr (D-CA) Rep. John Garamendi (D-CA) Rep. Deborah Halvorson (D-IL) Rep. Alcee Hastings (D-FL) Rep. Walter Jones (R-NC) Rep. Carolyn McCarthy (D-NY) Rep. John Olver (D-MA) Rep. Chellie Pingree (D-ME) Rep. Janice Schakowsky (D-IL) Rep. Jose Serrano (D-NY) Rep. Diane Watson (D-CA)

S. 2814
Sen. Susan Collins (R-ME, sponsor) Sen. Kent Conrad (D-ND, original cosponsor)

You can help by notifying your representatives of you support and encourage them to support these important bills.

FDA Asks Your Input on Negative Pressure Wound Therapy

The Food and Drug Administration's (FDA) Center for Devices and Radiological Health (CDRH) has requested valuable input from users of Negative Pressure Wound Therapy (NPWT) systems in the home environment.

FDA has received reports of adverse events associated with NPWT systems, especially those used at home and at extended care facilities. Since wound care can take place in the home and can be self-initiated, managed, or used with the help of a trained caregiver (often a family member), FDA wants to hear about your experiences with these systems.

If you use NPWT in the home environment and are willing to participate in an important FDA survey related to this treatment, please click on the link below and you'll be directed to a brief survey questionnaire. FDA notes that your information will be used strictly for this purpose and responses to the questionnaire will remain confidential, and thanks all those who participate. To take the survey, please go to https://vovici.com/wsb.dll/s/2ff9g430f1.

Should HIPAA Business Associate Agreements be Modified to Comply with HITECH?

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

Many providers have asked whether they should modify their business associate agreements to comply with the HITECH Act. There is, in fact, ongoing discussion and debate in the legal community about this issue. It seems fair to say that business associate agreements should be modified to comply with requirements of the HITECH Act regarding notification of breaches, since final regulations have been published implementing these requirements.

On August 19, 2009, the Department of Health and Human Services (HHS) issued an interim final rule entitled “Breach Notification for Unsecured Protected Health Information.” This rule describes how healthcare providers must notify patients when the security of their protected health information has been breached. Providers were required to comply with these new requirements beginning on September 23, 2009. Providers are also required to revise their internal policies to include these requirements.

Decision Health Home Health Coding Summit 2010 Sponsor

Daymarck is proud to be the title sponsor of the 2010 Decision Health Home Care Coding Summit, August 8-12 in Philadelphia. We hope to see you there as we share our learnings from the past year, collaborate with other home care leaders, and demonstrate how we can make your home care coding as pain free as possible.

Philadelphia is a fantastic city and we look forward to seeing you there.

Guest Post: Patients’ Right to Freedom of Choice of Hospices in Hospitals

Patients’ Right to Freedom of Choice of Hospices in Hospitals

Elizabeth E. Hogue, Esq.

Office:  877-871-4062

Fax:  877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

 All providers are required to abide by patients' right to freedom of choice.  There are a number of sources of this right as follows:

1)   All patients have a common law right, based upon court decisions, to control the care provided to them, including who renders it.  Thus, when patients voluntarily express preferences for providers, their choices must be honored, regardless of payor source, level of care, or type of treatment. 

2)   Federal statutes of the Medicare and Medicaid Programs guarantee Medicare beneficiaries and Medicaid recipients the right to freedom of choice of providers.  When Medicare and Medicaid patients voluntarily express preferences for post-acute providers of all types, these choices must be honored.

3)   The Balanced Budget Act of 1997 (BBA) requires hospitals to develop a list of home health agencies and SNF’s, not hospices.  The list of home health providers must include agencies that:

a.       Are Medicare certified;

b.      Provide services in the geographic areas where patients reside; and

c.       Ask to be on the list.

In addition, if hospitals place the names of agencies in which they have a discloseable financial interest on the list, the relationship between the hospital and the agency must be disclosed on the list.

This list must be presented to all patients who may benefit from home health services so that they can choose agencies they wish to provide services to them.

4)   Hospital Conditions of Participation (COP's) include the basic requirements of the BBA described above.

OIG on RAC Fraud Referrals

This was a report received thru the OIG Public Affairs.

Recovery Audit Contractors' Fraud Referrals (OEI-03-09-00130)

We found that between March 2005 and March 2008, recovery audit contractors (RAC) referred two cases of potential fraud to the Centers for Medicare & Medicaid Services (CMS). However, CMS reported that it received no potential fraud referrals from RACs during this period.

Care Plan Oversight

As I mentioned last month, Senator Collins (R-ME) and Senator Conrad (D-ND) introduced senate bill 2814 on November 20, 2009. This bill would allow for advance practice providers other than physician to order and monitor home care services for patients. Despite several State laws that already allow this, it is not allowed by the Federal Government so it is prohibited under federal reimbursed payment systems such as Medicare and Medicaid.

At the time I last blogged about this issue, it was not clear if this would allow for Advance Practice Providers to bill for care plan oversight. I did receive a letter from Senator Conrad stating that it would not allow for this provision. This is a shame. The Senate needs pressure from its home health constituents to pass this senate bill and add a provision for care plan oversight. I would take the bill as is but if Advance Practice Providers like Nurse Practioners are doing the equability work of a physician they should be reimbursed for that.

This bill still remains in the Senate Finance Committee for review. I would be interested in your feedback.

Guest Post: Skin Changes at Life's End

Skin Changes At Life’s End

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

In April of 2008, wound care experts met for a round table discussion of the occurrence of Skin Changes At Life’s End (SCALE). The condition of a patient’s skin can provide a great deal of insight into his/her internal health. Illnesses that usually worsen and result in death are frequently accompanied by pressure ulcers. SCALE, therefore, is a term for the compromise of the skin organ during the end stages of life.

As a result of their discussion of this phenomenon, and subsequent input from experts in wound care and palliative medicine, on October 1, 2009 the SCALE Expert Panel published the following ten consensus statements:

Month one of OASIS-C

Irrational rational

Illogic logic

Just a plain, what were they thinking?

I’m a big fan of the OASIS assessment because of the practical, efficient applications that result from the data collected; PPS calculation, quality measures and a standardized tool that every agency has to use. It intrigued me to learn the relationships of the specific questions and the complex calculations which either resulted in payment calculations or risk adjusted outcomes.

Learning these relationships over the years, we have learned small but critical improvements that were needed. M0700 ambulation/locomotion needed to be more specific in order to show the improvement a patient makes from using a walker to a single hand cane. Certain questions that were nonspecific and difficult to answer were eliminated, like M0280 Life Expectancy - likely hood a patient was going to live more than 6 months. For these details and other evidence based practices learned over the decade OASIS-C was created.

Guest Post: When Are Patients “Unsafe” for Home Care?

Daymarck Home Care Thought Leader Guest Posting

When Are Patients “Unsafe” for Home Care?

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

Discharge planners/case managers are likely to encounter instances in which home care, hospice, and home medical equipment (HME) providers state that they cannot accept patients because they are “unsafe” at home. The use of this term may be confusing to discharge planners/case managers. What is it about patients’ homes that make it “unsafe” for them to receive services there? Aren’t all patients appropriate for home care?


First, discharge planners/case managers may not have provided services in non-institutional settings. If so, it may be difficult to make a crucial distinction between institutional care and home health services.

New Day, New Programs

With the implementation of OASIS-C Jan 1st, agencies have the ability to do an extreme makeover and position themselves for Pay for Performance (P4P). Yes, P4P will still come despite all the other changes that are occurring. The Demonstration project ended in December. Findings will be published in the near future.

April will be the last Caspers report until this fall. Home Health Compare will also not update for 6 months. What is done with OASIS-B is done. Quality reports are going to be wiped clean and the first full OASIS-C episodes will begin your new quality report tallies. Some quality measures will remain, others will be added.

So what should agencies focus on? Continue to do business as usual. Defiantly not! Agencies need to take a step back and look at their operations to see what is working and what is not. Are you a proactive agency or a reactive agency? Proactive agencies foresee the problems as they arise and put checks and balances in place to prevent rework and poor outcomes. Reactive agencies are always looking hindsight and trying to figure out what went wrong. They are so busy looking backwards they do not see the opportunities going forward.

Advance Practice Providers Ordering Home Care

Senator Collins (R-ME) and Senator Conrad (D-ND) introduced senate bill 2814 on November 20, 2009. This bill would allow for advance practice providers other than physician to order and monitor home care services for patients. Despite several State laws that already allow this, it is not allowed by the Federal Government so it is prohibited under federal reimbursed payment systems such as Medicare and Medicaid.

This legislation is way overdue. Not clear is if it will allow for these advance practice providers to bill for Care Plan Oversight. This should be allowed due to the regulatory requirements for reviewing and communicating with the home health agency.

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Daymarck Remote Home Health Coding Services and Software from Daymarck Coding on Vimeo.

What Agencies Must Do to Survive

Home Care Leadership: What Agencies Must Do to Survive
By: Nick Dobrzelecki, Founder and Chief Executive Officer, Daymarck
January 2010

As the debate over health care reform continues, home health agencies are facing an increasingly complex array of rules and guidelines that will dramatically reshape future business operations.

For many agencies, the new rules and guidelines can seem daunting. Recently, the Centers for Medicare & Medicaid Services released the Final Rule updating the policies and rates associated with the Medicare home health prospective payment system (HH-PPS) for calendar year (CY) 2010.  In addition, the Department of Health and Human Services' Office of the Inspector General (OIG) has released its Work Plan for the fiscal year 2010, describing the areas and issues that the OIG will audit, evaluate and inspect in the coming year.

OASIS Surgical Wound Score

I have been on a mission to either get better understanding or change the CMS guidance on OASIS surgical wound score related to venous access devices. With the implementation of OASIS-C, there is better guidance as far as staging surgical wounds. However there is significant confusion on how to score M1340 related to central venous access devices and the WOCN guidance did not cover this issue.

Previous guidance from CMS states that central venous access devices are always considered surgical wounds. I believe the original intent was that the skin break (surgically created) which the access device was placed into the body is actually the surgical wound. CMS has taken the original written guidance to mean that the actual device is the surgical wound. Previous guidance states that when a venous access device such as a mediport is in place, even if not used, it will always be considered a surgical wound. This is confusing the homecare industry.

With the new OASIS guidance which states, "For the purpose of this OASIS item (M1340), a surgical site closed primarily (with sutures, staples or a chemical bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has been present for approximately 30 days, unless it dehisces or presents signs of infection. After 30 days, it is generally described as a scar and should not be included in this item." 


Industry consultants and CMS representatives state that venous access devices fall out of this guidance although the official OASIS-C guidance manual does not state this. They say that this is because WOCN stated in the past that a central venous access device is always considered a surgical wound therefore CMS has taken that stance.

There needs to be clarification from the WOCN on how to score venous access devices. Here are my suggestions:

***These guidelines are not approved by CMS or WOCN. These are just my suggestions for what they need to change. ***

First, the term of venous access devices needs to be broken down into two subcategories; implanted venous access devices and other central venous access devices.

Implanted venous access devices (i.e. mediport)

When scoring M1340 such as a mediport, the clinician will assess the surgical implantation site wound. If the wound has been epithelized for greater than 30 days, the clinician will mark No.

If the site is epithelialization is less than 30 days then M1340 would be marked 1 or 2. If 1, then score M1342 accordingly.

Other central venous access devices (i.e. central lines)

As the access device is keeping the original surgical wound open, M1340 would be answered 1 and then M1342 would be marked non-healing. Once the access device is removed, the surgical would then be scored accordingly to the WOCN guidelines. Once the site is epithelized for greater than 30 days, it is no longer considered a surgical wound.

***These guidelines are not approved by CMS or WOCN. These are just my suggestions for what they need to change. ***

These suggestions have been submitted to CMS and the Chairperson from the WOCN OASIS-C Committee. We will see if common sense prevails or not.