Go big, or go home health
“In my current role, I really don’t have an average day,” says Caryl Liptak, MSHAI, RHIA, system director of CDI and coding at Baptist Health System in Louisville, Kentucky, of her day-to-day work in a home health CDI program.
While most traditional inpatient CDI efforts have been around for more than a decade, efforts in outpatient CDI are gaining ground experientially, too. Those developing CDI efforts in home healthcare, however, have a different animal to contend with—one with its own documentation needs, policies, obstacles, and opportunities.
According to Medicare, home healthcare is “a wide range of healthcare services that can be given in your home for an illness or injury. Home healthcare is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility.” Home healthcare has the overarching goal of treating ailments with the hopes of helping a patient “regain independence, maintain current condition or level of function, and/or slow decline.”
While Medicare lists services of home healthcare to include wound care, intravenous or nutrition therapy, and monitoring serious illness and unstable health status, Paula Anderson of Landmark Health in Huntington Beach, California, notes that many of the cases she comes across are for patients in older generations. “Right now, most home health is for the geriatric population,” she says. “Familiarize yourself with Hierarchical Condition Category (HCC) models and the most common conditions in the geriatric population.”
While sepsis, respiratory failure, and malnutrition may send shivers down inpatient CDI professionals’ spines, home health CDI comes with its own set of complicated diagnoses.
“We see a lot of wound care needs being treated without documentation of the etiology,” says Regené Collier, RN-BC, BSN, COS-C, HCS-D, Baptist’s home health coding/CDI specialist manager. “Then we need to go back to the healthcare team and clarify the etiology in order to capture the specificity needed for coding,” again running into the need for performing an outside-source query.
As with inpatient and outpatient CDI, home health CDI often comes to a halt when a physician neglects to make a definitive diagnosis on a patient’s chart.
“Problems that we encounter in home health CDI involve not having a diagnosis for symptoms such as weakness, falls, and gait abnormalities,” Collier says. “The lack of confirmation for the etiology of wounds is another frequent reason we must place coding on hold and query the physician.”
“We also find that we need specificity for common diagnoses that are still queried on the inpatient side,” Liptak adds. “Such as specificity of diabetes and heart failure as well as linking a condition to the underlying cause with terms such as due to.”
“We cannot code suspected diagnoses or diagnoses that are resolved upon discharge from the inpatient facility,” Collier says as well.
“My company specializes in treating high-risk Medicare advantage plan patients,” says Anderson. “We treat the sickest patients and have to adhere for strict documentation standards for the CMS risk adjustment model.” With sicker patients comes stricter documentation standards, and thus even more of a necessity for the utmost specificity in diagnosis and coding.
Targeted home health efforts
Liptak and Collier are working with their team on “developing a process in which the coding and CDI team codes the chart at the time of referral before the first visit is made,” Collier says. The team then performs a quality check of the Outcome and Assessment Information Set (OASIS) form once the visit and clinical documentation is completed.
“This will allow us to determine if a query to the provider is needed for further specificity of diagnosis,” adds Liptak. “Then we can get a more accurate diagnosis earlier in the process of developing a care plan and completion of the OASIS, do a secondary concurrent review for quality, as well as any newly added diagnoses as the care plan evolves.”
CMS requires use of the OASIS form to track patient-specific assessment of care, determine the agency’s reimbursement, and measure the quality of care that the agency provides, says Collier. The form must be completed at specific points during a patient’s home health service and provides information on changes in a patient’s health status. It must be filled out at the start of care, recertification (or 60 days, if there is a significant change in condition), and upon end of care.
“If a patient goes to an inpatient facility while under home care, a transfer OASIS form must also be submitted,” Collier adds. “When the patient goes home, a resumption of care must be completed.”
“CDI can make a difference with these forms by making sure they are completely accurate before submission,” says Liptak. “Reviewing OASIS forms fits into the CDI flow because it’s a central part of what we do. It confirms a patient’s homebound status and need for continuing care.”
Collier adds that because the OASIS form measures both outcomes and risk factors, it is also a key component for an agency’s performance improvement.
While in some cases the home health agency may be an arm of the overarching healthcare system, there are also many third-party home health agencies, which may make tracking those medical records challenging.
“With home health CDI, we depend on medical records from outside sources,” says Anderson. “Some of these records are not always easy to obtain.”
Specifically, finding the sources of certain documentation—never mind finding complete documentation—can be tricky. The data may come from “the patient’s primary care physician, recent hospital visits, et cetera,” Anderson says.
In her book, The CDI Guide for Home Health and Hospice, Joan L. Usher, BS, RHIA, ACE, writes that CDI specialists can help home health agencies shore up lacking provider documentation.
“Home health agencies continue to struggle with obtaining timely and complete documentation of face-to-face meetings,” she writes. “This is where CDI may be able to step in and contact the physician, work with the hospitalist or community physician to identify needed documentation.”
As CDI professionals everywhere know, getting timely answers from clinicians isn’t as simple as it sounds. Home health CDI professionals face an even steeper climb.
“Being a postacute setting, I believe that home health presents the added challenge of not having a process that allows home health coding and CDI teams to query physicians directly,” says Collier.
“In home health, querying providers is very new,” adds Liptak. “In my discussions with others within the home health setting, I believe there are only a few agencies who are writing queries. […] Gaining buy-in from others within the home health agency as well as the providers takes time and understanding of the need.”
Though most home health CDI specialists do review charts concurrently, as is the case with inpatient CDI, this issue of delayed querying and long response times can make reviewing and coding charts concurrently a challenge. Because this is the case, Collier suggests holding charts until all documentation is received and all queries have a response from the physician.
Proving return on investment
As with outpatient CDI, proving return on investment (ROI) can be a difficult task. It is hard to show that specific home health CDI efforts are the reason behind certain financial gains, especially considering the field is so new and so niche. (For more information about outpatient CDI programs, read the article on p. 9.)
Sometimes, the proof of ROI is not even known to the CDI specialists. “In terms of ROI, that is determined by a team of healthcare economists that are much higher up than me,” says Anderson.
But there are a few tactics that can help. “I believe our biggest return on investment is shown with improvement of quality ratings,” says Liptak. “Being able to complete coding timelier and accurately on first pass through the department makes a difference. … When coding was outsourced, there was not a dedicated team reviewing the OASIS for quality.”
“Timely completion of coding, facilitating completion of the chart, and timely billing really helps,” echoes Collier. “Having coders and a CDI team who are vested in the agency and an integral part of the team is imperative.”
While there might not yet be hard data to support the home health CDI efforts, Liptak and Collier agree that they have set themselves up for success by hiring the right people for the job. “Of our seven coding and CDI specialists, five are RNs, one PT [physical therapist], and one OT [occupational therapist],” says Collier. “Everyone on the team has extensive home healthcare experience and is knowledgeable of CMS rules and regulations for home health and hospice services.”
“They have inherent knowledge of all this information,” Liptak says, “so that gave us a running start.” She also noted that they chose team members with coding knowledge, which helped with training both sides of the equation.
Tips for getting started
According to Collier, it’s important that the home health CDI specialists have experience and knowledge of certified home care regulations. “I recommend that the home health CDI specialists have a minimum of three to five years’ experience with a proven record of being a high performer in regard to assessment skills, documentation, and timeliness,” she says.
Liptak adds that education to providers on the need for queries is of the utmost importance—in particular, queries requesting specificity. “This is even more critical with the onset of the Patient-Driven Grouping Model (PDGM) starting January 1, 2020,” she says.
Also, just as in other settings, lean on your colleagues in other departments and seek leadership support, Collier says.
“We have been blessed to have the guidance and leadership from our inpatient CDI team,” she says. “This has provided the home health team with so many learning opportunities and resources.”
“At the end of the day,” Anderson adds, “CDI is all about the data and the documentation.”