Celebrating 10 years with NurseValue, Inc.

NurseValue, Inc. celebrates our 10 year anniversary on February 1, 2016. What a wonderful run we’ve had!  A special thanks to those who have trusted us with their most difficult cases.  We look forward to providing the same outstanding service to our accounts for many more years to come. 

What did they do to me in Physical Therapy?

Did they actually perform the therapy that that was billed?  A lot of names for physical therapy are tossed around.  Many have more than one definition within the main category.  To add to the confusion there are often just letters that represent the service.  I have assembled a few of the most common ones that are found in occupational therapy, physical therapy and chiropractic therapy notes. 

 Manual Therapy: 

• Hands on movement of joints and surrounding tissues by therapist to enhance the healing process by decreasing pain and increasing motion
• Joint Mobilization (JM):  Techniques to increase joint range of motion.  Restores normal joint movement and circulation to the joint.
• Myofascial release (MFR):  A “hands-on” treatment used to simultaneously assess and relax restricted soft tissues.
• Soft-Tissue Massage (STM):  Directed at trigger points, scars and muscle adhesions.  To improve blood flow, mobility and length of tissue.

 Exercise: 

• Passive Range of Motion (PROM):  A “hands-on” technique by a therapist to help increase a joint’s range of motion.
• Flexibility Exercises:  Exercise used to decease muscle tightness, improve soft-tissue and muscle length and increase range of motion
• Strengthening Exercises:  Use of resistance to increase muscle strength, tone and bulk.  Free weights or weight machines may be used.
• Manual Resistive Exercises:  Therapist applies resistance against patient’s effort through the range of motion to increase strength.
• Isokinetic Exercises:  A form of strengthening exercises using variable resistance at a fixed speed of movement.  Can also be used as a testing procedure.  Various brands of equipment include Cybex, Kin-Com, Biodex and Lido.
• Home Exercise Program (HEP):  Instruction in specific individualized exercise or functional activities to enhance improvements made in therapy.  Revised on an on-going basis as the patient progresses.
• Therapeutic Activities:  Activities or exercises designed to improve functional performance through simulation of functional movements, i.e. stair climbing.
• Neuromuscular Re-Education:  Exercises to improve balance, coordination, stabilization, posture and proprioception to correct movement patterns.
• Gait Training:  Instruction in use of devices such as crutches or cane, or correction of gait pattern.  Selection and fitting of assistive device may be included.

 Modalities: 

• Physical agents used to reduce swelling, pain and to prepare tissues for therapeutic exercises
• Biofeedback (EMG, BFB):  A device used to identify muscular activity and assess muscle imbalances.  Treatment may be designed to enhance or relax specific muscle groups. Often used for pain control.
• Cold Pack and Ice Massage (CP):  Also referred to as “Cryotherapy”.  Used to decrease pain, spasm, and swelling.
• Hot Packs or Moist Heat (HP or MH):  Packs of moist heat used to promote healing and relaxation and decrease pain.
• Electric Stimulation:  Electrical Muscle Stimulation (EMS):  An electrical device, which uses different frequencies of electronic current to treat a variety of conditions.  Indicated for swelling, pain, muscle spasms, nerve injury and re-educating weak muscles.
• Transcutaneous Electrical Nerve Stimulation (TENS):  Nerve stimulation device that helps to relieve acute or chronic pain. 
• Microcurrent Electrical Nerve Simulation (MENS):  Technique which uses very low levels of current to stimulate cellular growth and repair at the injury site.
• Interferential (IFC):  Another form of electrical stimulation used to decrease pain or swelling.
• Ultrasound (US):  Deep penetrating heat generated by sound waves.  Used to decrease swelling and muscle spasm.  Usually feel a minimal warmth since ultrasound reaches up to two inches below the skins surface.
• Phonophoresis:  Medicine, in a paste or gel, transferred by low levels of electrical current into tissue surrounding an injury site.
• Traction:  Often used for disorders of the neck and back.  A mechanical pull of soft tissue and joints to decrease pressure, relieve pain and guard muscles. 

 

The Appropriate Modifier for an Assistant in Surgery

In the event that an operative report indicates an assistant at surgery and the physician documents the purpose of the assistant appropriately, the next consideration is determining what modifier is appropriate for the surgical codes.  There are a number of options to choose from and each has its documentation requirements.

The modifier 80 identifies a surgical assistant.  Assisting surgeons usually charge between 20 to 25 percent of their normal fee for performing the surgery alone.  This reviewer has noted that often the charge is the full surgery fee normally charged by the surgeon.  This occurs most often due to the coding software that produces a fee for the main code and does not take into consideration the modifier.

Modifier 81 is appended when there is a minimum assistant at surgery.  This modifier is used when the surgeon plans to perform the procedure on his own, but due to circumstances in the surgical suite requires the assistance of another surgeon for a short period of time

Modifier 82 indicates that the procedure was performed requiring the presence of an assistant surgeon when a qualified resident surgeon was not available. In teaching hospitals, special requirements must be met to allow billing for an assistant surgeon, and modifier 82 is typically used in those instances. Check with your Medicare carrier for details.

Modifier AS is added to the primary surgical code when the assistant at surgery is a physician assistant, nurse practitioner, or clinical nurse specialist.  This modifier again requires specific documentation.  The operative report should note that no qualified resident was available, the reason for the assistant’s services, and a statement indicating that the primary surgeon has a policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients.

As with medical coding in general, all surgical modifiers must provide documentation as to the reason for the modifier and appending the code to an appropriate root surgical code.

Assistant at Surgery Billing

The first consideration in billing for an assistant surgeon is to be knowledgeable of the surgeries that require assistant surgeons.  The source that I use for this important consideration is the American College of Surgeon’s “Assistant Surgeon Study”.  It should be noted that this is a guideline and ultimately the surgeon and assistant surgeon’s documentation in the operative report will determine if an assistant surgeon will be allowed.  

To bill for an assistant at surgery, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant.

Once an operative report has been signed by the surgeon, it becomes a legal document and cannot be altered or redone. For claims denied for lack of documentation for assistant at surgery claims, the surgeon can dictate an addendum to the operative report and the claim can be resubmitted.

2016 Illinois Workers Compensatioon Fee Schedule

The 2016 Illinois Workers Compensation Fee schedule is available at https://iwcc.ingenix.com/download.asp

How to Choose a Surgeon

When you have the opportunity to consider a surgical procedure, there are number of things to consider. First and foremost the best way to have the best surgical outcome is to avoid surgery entirely.  This option is not always possible, but it is important to explore all options before determining if surgery is the best option for your particular problem.  Obtaining a second opinion is something you may want to consider if you have the time.  Once that is determined that your surgery is necessary, the following suggestions may prove helpful in determining who you would like to be your surgeon.  Not all surgeons with wonderful personalities have the most skill in a particular surgery.  There is much more to consider!

·         Is the surgeon board certified and is his certification up to date?  This can be researched on http://www.abms.org

·         How often has your surgeon performed your type of surgery in the past year?  The purpose of this question is not to get the busiest surgeon in your area, but rather to choose a physician with experience in your type of surgery and not one who has never performed or rarely performed your particular surgery.

·         Not all surgeons will answer this question, but many of the good ones will—What is your success, failure or complication rates with this type of surgery?

·         Where does your surgeon plan on performing the surgery?   There are now a number of websites that provide infection rates for particular hospitals. You may access this information at

http://www.consumerreportshealth.org.  On the landing page put in Hospital and you will be taken to a page that will allow you to research hospital infection rates.  This web site provides a lot of different type of health ratings/evaluations that may prove helpful.

·         Is the surgeon and the hospital he is affiliated covered by your health plan? 

·         Does the hospital that you and your surgeon are considering follow best healthcare practices?  Luckily there are a number of hospital comparisons done by Medicare.  You can access this information at www.hospitalcompare.hhs.gov.   Put in the area code of the hospital you are considering and you will be provided with the hospitals within that zip code so you can compare the findings at each hospital. 

NurseValue is proud to announce our newest certified case manager,  Cortney Hubbard, RN, CCM.  Cortney joined us in 2010.  She has been a very busy since that time.  Cortney became a certified professional coder (CPM) and then went on to complete nursing school and obtained her RN licensure.  She has done so much in the last 5 years while continuing to be an asset not only to NurseValue but to every client she works with.  Please join us in celebrating Cortney's long list of accomplishments!

Story from the trenches—is utilization review a good thing for healthcare?

 

There is renewed interest in utilization review in workers compensation claims management .  The purpose of utilization review is to provide oversight of professional healthcare decision making.  Utilization review can be viewed as providing reinforcement of the professional decisions rather than to undermine these decisions.  This author does not feel that the goal of utilization review should be to save claims’ cost.  This may be a byproduct of the process, but should never overshadow the ultimate goal of appropriate patient care.

 

UR—negative perspective

Many in the healthcare industry would view utilization review as undermining the autonomy of the healthcare providers as it imposes an external control that may mitigate the individual provider’s healthcare decisions.  The second major objection to utilization review is the amount of time it takes to provide the documentation for medical necessity which increases the cost of the provider’s business.  Those that find this a problem also point to the fact that it takes the clinician away from actual patient care.  Another negative often reported when the discussion centers around utilization review is that the standards and clinical guidelines imposed by the utilization review process fail to take into account those individuals who fall outside the standards either with comorbidities or with special needs.  Most important to this author is the risk of delaying access to care by long delays of the utilization review process.

 

UR—redeeming qualities

If one is to set aside the concerns voiced above, it is possible that the utilization review process may bolster the legitimacy of the medical profession by clinical guidelines and standards of care.

One area that may be influenced positively is that an external review may hold all practitioners accountable for their decision making and thus weed out the incompetent providers (or at least limit the questionable practices).  This oversight may in turn bolster the public’s confidence in medical care. 

 

It’s all what you make it...

The determination of utilization review as a “bad” process or a “good” is dependent upon the utilization review agencies policies and procedures.  There are many aspects of the process that either encourage or discourage appropriate care and positive outcomes.  There are several areas in which a payer can determine what utilization review process is most appropriate for their population and needs.  

·         How much documentation and paper work must a clinician submit for the UR process?

·         What is the willingness of the utilization review entity to adapt review protocols in response to changes in medicine and/or complaints of the treating providers?

·         To what extent does the UR process take into consideration demographic treatment norms?

·         Are non-physicians allowed to deny authorization for medical treatment?

·         To what extent are physician reviews allowed to deviate from the formal protocols or clinical guidelines of the utilization review vendor?

The reader may want to address the questions above (and others) when choosing a utilization review company.  Much of the angst for utilization review can be overcome by a clinically driven, but patient centered utilization review process.

Book review—Slow Dancing with a Stranger: Lost and Found in the Age of Alzheimer’s”

I just finished reading, “Slow Dancing with a Stranger: Lost and Found in the Age of Alzheimer’s,” by broadcast journalist Meryl Comer.  The words demonstrated the devastating cost—personal and financial—of caring for a loved one with Alzheimer’s disease. Comer’s husband, Dr. Harvey Gralnick, was chief of hematology and oncology at the National Institutes of Health until he received a diagnosis of early onset Alzheimer’s at age 58.  Comer’s mother, who also had Alzheimer’s disease.

I am reading all I have time for regarding Alzheimer’s disease as I have had the unfortunate opportunity to see this disease on an up-close, personal level.  The first thing that struck me when I picked up this book was the title.  I did not see my loved one’s as strangers.  They were still my father, my mother-in-law and my uncle.  They didn’t go anywhere...they were attacked by a progressive disease that often lasts for many years.

Beyond this subjective criticism of the book, I would not criticize the emotions felt or the decision made of anyone who has a loved one subjected to this disease.  We all try to do the best we can within the constraints of our resources.  I did find it interesting that Mr. Gralnick was aggressive and the health system recommended a mental health facility to “adjust his medication”.  There are few resources available for appropriate treatment of the complicated disease process of Alzheimer’s, but her description of options tried gives her audience insight into the road traveled and the hope for a new route in the future.

Despite these observations Comer’s purpose for writing this book seems not to be to inspire false hope, but to show why Alzheimer’s disease needs to receive the same level of attention and research funding as other major diseases—diseases which have seen a decrease in mortality rates while the incidence of Alzheimer’s disease is rising (one in three people now have Alzheimer’s disease when they die). A study by researchers at Rand Corporation and other institutions calculated that the direct cost of care for people with Alzheimer's and other dementia in 2010 was $109 billion. In comparison, healthcare costs for people with heart disease was $102 billion; for people with cancer, it was $77 billion. Yet cancer research was allocated an estimated $5.4 billion (2014) in federal funds, and heart disease will get $1.2 billion — while research on Alzheimer's and other dementias comes in at only a fraction of that, at $666 million.

For more information regarding research funding see

http://report.nih.gov/categorical_spending.aspx

  

 

Alzheimer Training vs. Psychotropic Drugs

Recently there has been much discussion of psychotropic drugs being prescribed to those with Alzheimer’s disease in both hospital and long-term care environments.  Many times these drugs are used to control a dementia patient when appropriate care of the individual is all that is needed.  The example below illustrates how important caregiver approach is to the Alzheimer’s patient.

A nursing assistant walks in a room and advises the patient that it is time for a shower.  He responds negatively stating that he just took a shower and doesn’t need another one.  She advises him that he has not had a shower this week and he must shower now.  She approaches the patient, taking his arm to guide him to the wheelchair.  The patient strikes out hitting her in the face.  The nursing assistant leaves the room and returns with reinforcements. Three people enter the room and advise the patient that he must take a shower.  The patient sees three individuals approaching and unsteadily turns to flee, falls and fractures his ankle...he would receive no shower today.

Utilizing the knowledge of how Alzheimer’s disease affects an individual’s thought process:   

1)      The Alzheimer’s patient does not have short term memory.  Reasoning with a patient with Alzheimer’s is not effective.  Cognitively, they are not able to participate in this high level skill.

2)      All individuals, but especially Alzheimer’s patients become fearful when approached by a group of individuals that he perceives as a threat to his safety.

 

Alternative scenarios: 

A nursing assistant walks into a room and advises the patient that is time for a shower.  He responds negatively stating that he just took a shower and doesn’t need another.  The nursing assistant notes that the patient his acting rather defiant this am and suggests that they take a walk together to look at the beautiful sunshine coming in the windows.  The patient and the nursing assistant take a short stroll which seems to calm the patient.  The nursing assistant then asks the patient if he would like to for another short walk to take a shower.  Having forgotten that he told the nursing assistant no a few minutes ago he willingly goes with her to the shower room.

 A nursing assistant walks into a room and advises the patient that it is time for a shower.  He responds negatively stating that he just took a shower and doesn’t need another.  The nursing assistant states “ok” and advises the patient that he looks tired and suggests that he may enjoy sitting in the recliner in the other room to relax.  He agrees and follows her to sit in his favorite chair.  A short time later the nursing assistant returns to the patient with his shower supplies in hand.  She approaches him and states that he looks like he is more rested and suggests that he get cleaned up for lunch.  The patient is assisted from the chair and makes the short walk to the shower room where he willingly participates in his shower.

There are many other ways to handle this situation keeping in mind that a person with an altered memory does not respond to attempts to convince them to act.  Alzheimer’s patients are programmed to fight or flee when threatened.  These individuals are often influenced by how they feel at the moment.  By changing how they feel, cooperation in daily tasks will follow.

AWP vs MAC for MSA Allocations

Beginning with Contract Year 2016 Medicare Pharmacy plans are to be reimbursed utilizing the Maximum Allowable Cost (MAC).  To date CMS has not incorporated MAC into their Medicare Set A-side review programs and continues to use the Average Wholesale Price (AWP) system that has found to overstate the drug pricing.  We hope to see a change in drug pricing for MSA allocations in the near future!

Nurse Case Management-Best Practices

Time Management

Adjuster Contacts

·        Sort contacts to adjuster by name and/or customer

·        Make calls/faxes to adjuster at a time when they are most accessible (early am or according to customer preferences)

·        Contacts with adjuster should be chronological and concise.  Questions and information should pertain on to the injury (i.e.: RTW, Tx plan, Dx, findings, nurse case management plan)

·        If communication with adjuster is by fax only, place all information that effects the direction of the case in bold face type

·        Request that adjusters return calls/faxes within a specified timeframe in order to keep the case moving.  If an adjuster does not respond, attempt a second contact by the same communication method in approximately 2 business days (unless the priority demands more aggressive follow-up)

·        Place the adjuster’s name, number and goal of the next contact in the activity portion of the next diary so it is easily acceptable.

Provider Contacts

·        Request telephonic information for 4 elements:  MD objective/subjective findings, injury diagnosis, treatment plan to include testing, therapy, surgery and work status.  Always ask about estimated return to work if client is not working.

·        Allow providers to return calls at a time convenient for them.  Many providers will leave information on a voice mail if you leave a specific request and advise them of the confidentiality.

·        If a provider will provide information only in writing, document this in your case notes and request that information to be faxed if possible.

·        If a provider refuses to give any information, use other methods of persuasion with the provider (letter of representation, verbiage relaying that cooperating with the case manager could expedite authorization for necessary treatment, ask the client to contact the provider’s office on your behalf). If all else fails you may contact the adjuster regarding the difficulty and ask that a letter be sent on your behalf or contact the client’s attorney (if they have one) and ask them to contact the MD office on your behalf or if they prefer, all medical information be sent to them and then forwarded to you (the case manager) in a timely manner.

·        Type while talking on the phone.  Put phone number in notes for easy accessibility when making the next call.

·        If you are having trouble getting return to work (RTW) information from the provider, try “we need this information regarding RTW so we know whether the injured worker needs another disability payment”.

Injured Worker Contacts

·        Manage the conversation with the injured worker around the injury, the response to treatment, and the work status. 

·        Assume you can contact the injured worker unless the injured worker or his attorney state you cannot.

 

Prioritize Daily Activities

 

·        Diary a case only one time per day

·        Use on activity to diary all contact for one case on one day

·        Balance daily workload throughout the work week

·        Attention the calls you are behind on first

 

Documentation

 

·         Use only approved abbreviations

·         Make sure your notes are clear

·         Request telephonic information on cases.  Written information should only be obtained if there is provider non-compliance.  Written confirmation is necessary only for post office visits, RTW slips, treatment or diagnostic orders

·         Identify provider specialty in every case notation

·         Identify all individuals spoke with by name and title

·         If you have received written reports, document (in your notes or update to adjuster) only the pertinent findings and treatment plan, not the entire report

·         Do not keep paper files of your case work

·         Refer to yourself as this consultant or I in the notes.  Do not use first person to refer to others.

·         Mark all faxed, emailed or overnight mailed notes as “sent”

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ABC NIGHTLINE Tells America About the Virtual Dementia Tour®

 

This technique for education should be added to all Alzheimer's Care Giver courses.  I did this for my Certified Nursing Students during restraint instruction.  They were quite verbal afterward regarding how they felt vulnerable and frightened when in restraints.

Happy Valentines Day

Hope all of you take some time to enjoy today!

Submitting Medical bills into Evidence—Illinois Collateral Source Rule

To submit medical bills into evidence at trial in Illinois it is typically required to show that the medical services provided and charges incurred were usual, customary, and reasonable.  To demonstrate the reasonableness of the provided services and the charges of those services it is often necessary to introduce the testimony of a person with knowledge  of both the medical necessity of the services rendered and the understanding of  usual  and customary charges for those services.

Many times the medical appropriateness of the services provided is introduced by the medical providers themselves or by providers within the same discipline.  These individuals are not always the best choice to demonstrate the appropriateness of the billed charges.

This analysis necessitates understanding the environment of the services rendered, in addition to healthcare reimbursement practices and methodologies

Complex System

The healthcare reimbursement system is complex with multiple layers culminating in both the billed price and the price that is ultimately reimbursed.  The process varies with each place of service.  A thorough understanding of the ICD (diagnosis medical record or the medical bills is fraught with a number of hurdles.  A HIPPA compliant release of information is the first tool.  The next step is identifying the individual within the facility or provider’s office that has the authority to release the record and the bills.  Within many facilities and large offices these are two different individuals.  A few well-placed calls to the provider will disclose the contact name and number and the process for requesting the information.  

As previously mentioned providers periodically change billing systems and methods.  You will be told the UB no longer is available.  To avoid this inevitable response it is prudent to request the medical bills periodically throughout a long treatment cycle or as soon as possible at the end of treatment.  A gentle reminder that UB must be supplied to the insurance carrier or the workers compensation provider to obtain payment for services may help to overcome a reluctant participant.  It may not hurt to remind them that HIPPA states the patient is entitled to obtain their entire PHI (protected health information). Ultimately, a subpoena may need to be issued to obtain the completed medical and billing records.  With proactive preparation and a qualified medical bill reviewer your bills will find their way to trial.

                                                                      Preparation… 

When enlisting the assistance of an individual to attest to the usual, customary and reasonableness of the medical bills the following documents should be obtained from the providers:

• CMS-1500 claim form for all professional bills (sometimes referred to a HCFA - the previous name for the CMS-1500 claim form)
• UB claim for all facility claims (UB92 or UB04 are acceptable)
• A dental Claim form from all dental providers
• Obtain an itemized statement from any ancillary service (durable medical equipment, pharmacy, transportation service, or medical supply company)
• Inform the provider that you are seeking all the procedure codes associated with the services rendered

Next…

It is necessity to obtain all corresponding medical records if it is determined that the person who will testify to the reasonableness of the bills will also be the individual responsible to attest to the appropriateness of the services provided. The medical reviewer will then be able to identify if the services provided are related to the injury of record, are appropriate to care for the diagnosis/ diagnoses, are medically necessary, and are actually documented as provided. 

Hurdles and Hope

The process of obtaining the necessary information for the medical reviewer to adequately assess the medical record or the medical bills is fraught with a number of hurdles.  A HIPPA compliant release of information is the first tool.  The next step is identifying the individual within the facility or provider’s office that has the authority to release the record and the bills.  Within many facilities and large offices these are two different individuals.  A few well-placed calls to the provider will disclose the contact name and number and the process for requesting the information.  

As previously mentioned providers periodically change billing systems and methods.  You will be told the UB no longer is available.  To avoid this inevitable response it is prudent to request the medical bills periodically throughout a long treatment cycle or as soon as possible at the end of treatment.  A gentle reminder that UB must be supplied to the insurance carrier or the workers compensation provider to obtain payment for services may help to overcome a reluctant participant.  It may not hurt to remind them that HIPPA states the patient is entitled to obtain their entire PHI (protected health information). Ultimately, a subpoena may need to be issued to obtain the completed medical and billing records.  With proactive preparation and a qualified medical bill reviewer your bills will find their way to trial.   By Barbara King, BSRN, QMRP, CPC, MSCC