Train Intake on Questionable Encounter Codes to Prepare for New Payment Model
Posted on Tuesday, June 12, 2018 2:54 PM
by: Kirsten Dize, Decision Health
Source: Home Health Line News, Published May 30, 2018, Re-published with permission
Use a checklist to educate your agency’s intake employees about information needed to improve specificity around codes. Certain non-specific codes might indicate questionable encounters occurred under a revised home health payment system slated to begin in 2020.
Educating intake will serve as a good exercise to prepare for the new payment model and will help improve coding, says Sherri Parson, director of staff development with Quality in Real Time (QIRT) in Floral Park, N.Y. It also will reduce the amount of time required to query the physician on the back end.
CMS hasn’t fully detailed what a new payment system will look like, but industry experts believe it likely will be similar to the Home Health Groupings Model (HHGM) that CMS proposed — but didn’t finalize — in the 2018 PPS rule.
Addressing the most common questionable encounter (QE) codes is a good place for agencies to begin preparations, says Sue Payne, MBA, RN, CHCE, vice president and chief clinical officer with Overland Park, Kan.-based The Corridor Group. (See benchmark for a list of the 10 most common QE codes.)
If HHGM had been finalized and agencies used those QE codes as the primary diagnosis in claims they submitted, the claims would have been kicked back to providers, industry experts say.
Under the current payment model, claims with QE codes listed as the primary diagnosis won’t be returned to provider on that basis alone. Even so, including as much specificity in coding as possible is currently a best practice.
Given this and the push for increased specificity under ICD-10 and the revised Home Health Conditions of Participation (CoPs), it’s more a question of when — not if — codes with a low level of specificity will become an area of increased scrutiny for reviewers, Parson contends.
Conduct an analysis, train accordingly
Agencies should cross reference their own common primary diagnosis codes with the list of QE codes outlined in the 2018 proposed PPS rule, Payne recommends. Alert intake staff to seek more information around QE codes your agency commonly uses.
Have intake staff use a checklist to identify the information needed to code more accurately, Parson adds.
When lung cancer is the reason for home care, for instance, intake should ask for location and laterality.
This will help avoid using C34.90 (Malignant neoplasm of unspecified part of unspecified bronchus or lung), which is among the top 20 questionable encounter codes, according to a recent analysis of 2017 data from Strategic Healthcare Programs (SHP) of Santa Barbara, Calif.
If the agency can identify at intake in which lung and which lobe the cancer is located, a more specific code can be used and a question of location won’t be a reason for later query.
Parson recommends starting conversations and sharing the checklist with discharge planners and liaisons working for frequent referral sources as well. Letting these key people know the information your agency will be seeking can help further smooth the process from the start, Parson says.
Note: It may be a little early to start those discussions with referral sources, Payne cautions. She recommends waiting on that part until more detail regarding specific QE-specific diagnoses in CMS’ new payment model is available.
Ultimately it will make sense to approach referral sources and let them know the additional information needed may be the difference between a patient having access to home care or not, Payne adds.
Agencies will want to let referral sources know that more detail also will help agencies focus care and ensure the patient receives the care the physician believes that patient needs.
Do this to improve QE code education
- Make training a game. Use a “fire drill” approach to keep intake staff engaged in the education. Stage calls from a doctor’s office and recognize your employees who ask the necessary questions and get the required specificity out of these calls. “Have fun with it,” Parson says. “Education can be so dry.” This training will help with more specific coding under the current and future payment model.
- Examine the root cause for using QE codes. Take time to evaluate your agency’s coding, Parson recommends. Ask the questions: What are your agency’s most common primary diagnosis codes? Are you using QE codes? If so, why? Is it an education issue, a time issue, a lack of query process, a lack of upfront info from intake or the hospital discharge planner? Once you determine the root cause, it will be easier to identify additional target areas for training and education.
- Set time limits. It’s important to find a balance between preparation for a new payment model and avoiding payment delays under the current model, Payne says. Designate how long your agency will wait for additional information on a query, she recommends. “You don’t want to hold up the process for things that aren’t required, but are recommended,” Payne says. As you start paying attention to what diagnoses would fall into questionable encounters, aim for a “sweet spot” between querying for everything — which could delay dropping your request for anticipated payment (RAP) — and not querying enough, Payne says. Striking that balance will help prevent payment delays under the current model and allow you to begin preparations for the new model.
Related links: View a sample intake diagnosis checklist at https://bit.ly/2LHML43 (Must be a home health line subscriber to view). To order Home Health Line go here.. To see a complete list of which codes would have been deemed questionable under HHGM, click on https://go.cms.gov/2xl4v1W, then click on HHGM Grouping Tool.
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