QIRT Alerts!

October 20, 2016

The Future of Home Health Reimbursement

Filed under: home health — Quality In Real Time Blog @ 9:37 am

For many years, home health care experts have heard the rumblings…we have seen the signs. As an industry, we have known that eventually we would see another drastic change to the established reimbursement model. Even so, there are many who will not make preparations to move toward a methodology change until there is an effective date. But what if I told you that agencies currently have access to the information needed in order to prepare now for what is to come? All that we have to do is to look to the current CMS initiatives to know what course to take.

As a result of the Affordable Care Act (ACA) and prior initiatives, Congress established the CMS Innovation Center with one goal in mind. The center was established for the purpose of testing “innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits. In short, the Innovation Center is continually testing payment and service delivery models that deliver quality, efficiencies, and compliance. Because this goal is intact regardless of the initiatives or demonstrations, agencies can establish an operational infrastructure that will allow them to adapt to any reimbursement environment.

There are several things that home health care agencies can do now in order to be equipped to manage the future changes within the industry.

Agencies should:

  1. Establish an internal committee that constantly oversees agency operations and performance (multi-professional, multi-disciplinary).
  2. Conduct an operational assessment to evaluate processes, procedures, workflow, departmental flow, and compliance measures (must have interdepartmental comprehensive tool for accuracy).
  3. Review and revise necessary components of agency operations (based on the assessment findings).
  4. Adjust education plans to address the revisions. Education must be customized to applicable departments and roles within.
  5. Monitor and review the result of the education, as well as implement a compliance audit plan to produce measurable results.
  6. Revise compliance audit plan as needed. Multiple revisions of the new plan may be necessary in order to gain the most effective outcome.

The steps are simple. However, it is imperative that agencies have the proper tools and expertise to conduct a thorough analysis and the subsequent necessary revisions that come as a result. These steps will not be effective without the proper tools and/or resources. When completed properly, this exercise will lead to a radical culture change within your organization that will yield improved quality, streamlined efficiencies, and additions to your bottom line. QIRT (Quality in Real Time) has established a complete tool kit and complied a team of experts with the knowledge to carry out this process for your agency. Call or email us today to schedule your consultation.

Stefanie Woodrow, RN

Director of Education

October 4, 2016

Face-To-Face: When Will We Learn?

Filed under: home health — Quality In Real Time Blog @ 9:29 am

Following a recent conference call with industry leaders, it became clear that the home health care industry often fails to take advantage of changes in policy or in the many educational opportunities offered. The latest subject continuing to cause confusion has to do with face-to-face compliance.

In 2011, CMS issued a face-to-face rule that would significantly impede the home health care industry. The combination of the lack of clarity within the rule itself coupled with the industry having little to no control has initiated crippling financial consequences. Increased audits verifying specific compliance with the rule caused denial rates of 80-90% and stifled the growth of many agencies.

Never before had the homecare industry been at the mercy of physicians for the reimbursement of homecare services. CMS was charged with the responsibility of educating physicians on the elements required to complete the face-to-face form. However, the education provided was nearly non-existent and often proved to be ineffective. Most physicians (indeed most professionals) do not care for additional paperwork and this rule required a considerable amount of increased documentation with specificity.

As a result, a number of individual agencies and state and national organizations worked with CMS to change the rule. The initial direction for the 2015 change was confusing for agencies and physicians. QIRT experts’ experience in the field has shown us that most agencies still have not unraveled the requirements of the newest face-to-face rule. Many agencies continue to use the original face-to-face form created 5 years ago, even though the Medicare Administrative Contractors (MACs) have been very clear that the face-to-face form is not what they are looking for.

In 2015, the rule changed. Another five-record review by the MACs in 2015 found compliance with the new rule to be unchanged. In point of fact, the percentage of denials increased. It got worse. Why? Because homecare agencies did not follow the new rule.

Despite the warnings, attempted education, and written instruction by CMS and the MACs, agencies continued to ignore the direction, continued to use the same face-to-face form, ignored the requirement to secure the physician progress note, and more. Today, in the pre-claim review state of Illinois, most of the non-affirmations received from the reviewers are the result of a “lack of information in the physician file.”

Just what is the 2015 Face-to-Face Rule?

The information needed for face-to-face has actually not changed much from the 2011 rule. Agencies still need to show documentation of medical necessity and the two criteria for homebound status. What has changed is that it is now acceptable for the agency to provide the necessary information along with the physician’s information, as a supplement (not replacement) to his/her progress note.

So…it is actually fairly simple. If the agency provides specific items, such as OASIS responses related to skilled need and homebound status (M1800s), therapy evaluations, a medical update written by agency staff, etc., CMS will allow these items to be added to the physician progress note in response to a medical review request, including pre-claim reviews. It is important to understand that the agency documentation supplied must include the physician signature indicating he/she has reviewed and agrees with the supplemental assessment information.

With the 2015 rule, agencies now have the opportunity to support the information on the physician progress note with agency information. Why are agencies not doing this? Hopefully the simple steps outlined above will encourage agencies to review current practices and begin to provide the necessary information, resulting less denials and more accurate and timely reimbursement.


Arlene Maxim

VP Program Development

August 19, 2016

Pre-Claim Reviews and QIRT Seminars

Filed under: home health — Quality In Real Time Blog @ 11:05 am

QIRT is offering multiple seminars in affected states. Register today.

CMS recently announced they will go ahead with the prior authorization demonstration for homeware agencies in the following states: 

Illinois – August 1, 2016

Florida – October 1, 2016

Texas – December 1, 2016

Michigan and Massachusetts – January  1, 2017


  1. Expect approximately 40% decrease in agency numbers by end of CMS demonstration.
  2. Some experts believe agencies will require 1.5 additional FTE’s (1 RN and 1 clerical) for every 100 patient census.
  3. Do not resubmit claims until all information is collected.
  4. Be sure to attach the assigned pre-claim number to all final claims and resubmissions.
  5. Consider outsourcing this service.

The Solution

QIRT has formed a highly trained and credentialed Pre-Claim Review (PCR) Team. This team is specifically trained to review the documentation in the patient medical record related to the 5 Tasks.

The team will utilize tools that will alert the agency that:

All documentation is in one place and the agency can submit to the intermediary OR

One or more pieces of documentation is still needed before submission.

The team will work with the agency to put the required documentation in one place.


QIRT can provide:

  • Coding/OASIS Review to ensure coding and assessment documentation relate to the F2F encounter and need for home care.
  • PCRs independently
  • Coding/OASIS Review and then PCR Review and then billing for the initial RAP with a review of documentation present at the time of RAP

Let QIRT be your outsourced solution

Free staff to focus on what is necessary and important:

Provision of care

Documentation of care necessary for:

An auditor to form a picture about this specific patient

Care needed by the patient, provided by the agency, and documented by the clinician.

July 25, 2016

QIRT Acquires Woodrow Healthcare Consulting, LLC

Filed under: home health — bernadetteesmith @ 10:32 am

QIRT (Quality In Real Time) continues to expand post acute service offerings with second acquisition announcement in as many months.

FLORAL PARK, N.Y.July 25, 2016 — QIRT (Quality In Real Time), provider of home health and hospice coding, consulting, billing and education services, announced today the acquisition of Woodrow Healthcare Consulting, LLC (WHC). WHC specializes in providing consulting services in operations, clinical excellence, quality assurance, revenue accuracy, outcomes management, sales and marketing, strategic planning, business development and coding and OASIS reviews for home care and hospice agencies.

The acquisition will couple two of the leading home care and hospice leaders in the industry. WHC will expand QIRT’s Education Division to include online and on-site education, provided by an acclaimed entity in this area – Stefanie Woodrow. In addition, WHC’s qualified consulting, auditing and coding experts will join QIRT’s growing Quality, Education, and Clinical Consulting Divisions.

“Stefanie Woodrow and QIRT share missions of prioritizing education. A valued colleague on the cutting edge of home care and hospice, Stefanie has been providing much needed education to agencies and staff across the United States, and tirelessly seeks out new opportunities for staff enrichment. QIRT will combine resources with Stefanie and provide additional services to home care and hospice agencies in this era of health care reform so that agencies continue to prosper, preparing the next generation of agency caregivers with the requisite knowledge. I am thrilled to welcome these talented employees to QIRT, and we will continue to provide the highest level of quality service to our customers,” said Laura Page-Greifinger, QIRT CEO and President.

Stefanie Woodrow, President/CEO of Woodrow Healthcare Consulting, had this to say: “I first met the Quality in Real Time executive team in 2012, shortly after launching Woodrow Healthcare Consulting. Both teams realized quickly that we shared the same vision, mission and overall purpose. Our goals were aligned and there were clear synergies among our companies. Laura has made a great impression on our industry; to join with her team is an honor. The same great quality will continue to be delivered to our customers and to our employees. Together our resources will not only expand our footprint, but also allow us to have a greater impact on education within the industry.”

In January 2015, QIRT diversified its offerings by adding Financial and Education Divisions to what had previously been mainly a quality compliance business. At the same time, QIRT acquired LPG & Associates, a clinical consulting company, to become a full service homecare provider. The acquisition of WHC is further expanding QIRT’s Clinical Consulting, Quality and Education Divisions. With the addition of WHC, QIRT will now have an office and staff located in Birmingham, Alabama and will retain current offices in Floral Park, NY, Battle Creek, MI, and Troy, MI. Earlier this summer, QIRT also acquired A.D. Maxim, further expanding QIRT’s Clinical Consulting, Quality, and Education Divisions.

About Quality in Real Time

QIRT (Quality in Real Time) is an industry-leading provider of home health and hospice quality, consulting and compliance services. Serving over 150 agencies across the United States, QIRT is dedicated to enhancing the provision of care through four distinct, complementary divisions: Quality, Clinical, Financial, and Education. Find more information at QIRT.com.

June 10, 2016

A.D. Maxim Consulting Joins QIRT

Home health industry leaders QIRT and A.D. Maxim aim to provide more service and expertise to the industry.

FLORAL PARK, N.Y.June 2, 2016PRLog — QIRT (Quality In Real Time), provider of home health and hospice coding, consulting, billing and education services, announced today that A.D. Maxim and its subsidiary, CQI Coding and Quality Improvement, Inc., have joined QIRT. A.D. Maxim provides agencies with compliance consulting and oversight, ADR & appeal documentation and support, on-site staff and executive training, mock surveys, advisement and guidance in the start up of new agencies, development of plans of correction, preparation for survey or accreditation visits, coding/OASIS and Quality Assurance audits to facilitate growth and enhance financial performance.

QIRT’s established Clinical Consulting Division has previously provided services to New York, New Jersey, and Connecticut. With A.D. Maxim’s expert staff joining QIRT’s ranks, the scope of QIRT’s Clinical Consulting Division’s scope will now be able to match that of its Quality Division and expand nationally. In addition, the Clinical Consulting Division offerings in the compliance and education areas will also expand greatly to provide many additional services to QIRT’s customers.

“Due to new government payment programs, such as value-based payments, the home healthcare industry is looking into a future filled with both opportunity and uncertainty. While many large companies are answering these questions with offshore outsourcing, QIRT is taking a different approach to helping companies manage their risk. Arlene Maxim is a well-respected, “go-to” person within this industry. Her approach to compliance is comparable to no other, and is reflected through the beliefs of her clients that without A.D. Maxim, agencies would not be able to weather the changes that are part of this industry. Together, QIRT and A.D. Maxim can do more and be more to our clients. We believe that with experts such as Arlene Maxim and her staff, we can provide our customers with all the expertise and quality they need to succeed, in one company,” said Laura Page-Greifinger, QIRT CEO and President.

Arlene Maxim, CEO and President of A.D. Maxim Consulting and Owner of CQI, agreed: “Laura is absolutely right. The homecare and hospice industry can no longer conduct ‘business as usual.’ In the most recent 5-10 years, we have seen a paradigm shift from the quantity of services we provide to the quality of service provided to improve outcomes. Today quality is truly king. Opportunities are endless in making this shift in our homecare and hospice culture. Joining forces with QIRT allows us (QIRT and A.D. Maxim) to become uniquely positioned in providing the market with the most comprehensive, up-to-date solution in addressing agency risks in today’s environment. The healthcare landscape is changing. Mergers and acquisitions are happening all across the United States. Today it just makes sense for the best and the brightest to come together in a collaborative fashion.”

In January 2015, QIRT diversified its offerings by adding Financial and Education Divisions to what had previously been mainly a quality coding and compliance business. At the same time, QIRT acquired LPG & Associates, a clinical consulting company, to become a full-service home care industry support company. With the addition of A.D. Maxim, QIRT will now have an office and staff located in Troy, MI and will retain current offices in Floral Park, NY and Battle Creek, MI.

About QIRT

QIRT (Quality in Real Time) is an industry-leading provider of home health and hospice quality, consulting and compliance services. Serving over 150 agencies across the United States, QIRT is dedicated to enhancing the provision of care through four distinct, complementary divisions: Quality, Clinical, Financial, and Education. Find more information at QIRT.com.

May 23, 2016

It is official; AHIMA has clarified coding of Diabetes and assumed manifestations!

AHIMA has clarified coding of Diabetes and assumed manifestations, and QIRT will adjust coding practices accordingly. As of today, May 23, 2016, QIRT will code Diabetes and assumed manifestations per AHIMA clarification. The guidance is in relation to the use of the subterm “with” in the alpha index.

The ICD-10-CM Official Guidelines for Coding and Reporting states the following at Section I.A.15:

  • The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.
  • The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

AHA Coding Clinic has confirmed that any conditions listed following the indented subterm “with” under Diabetes is to be interrupted as a link between the manifestation and Diabetes as long as no other reason has been stated for the manifestation.

See below. All the conditions listed from amyotrophy to skin ulcer are assumed manifestations of the Diabetes unless another cause is listed. Please note that Osteomyelitis is not included on this list. Please see below for the subterm list associated with E11.9:

AHIMA new coding for diabetes

AHIMA has explained it very well in the following link: http://journal.ahima.org/2016/05/11/coding-diabetes-mellitus-with-associated-conditions/

January 14, 2016

Important CMS Update Regarding M1810, M1820, and M1860

Filed under: home health — Quality In Real Time Blog @ 3:48 pm

As of January 1st, CMS will no longer be awarding points for M1810, M1820, and M1860 (when lower than 4) for any early episode of care with therapy utilization of 14 or more. This will result in a higher number of F1s after completed audits. Please be advised that this could greatly impact payment in high therapy cases. The QIRT Quality Team will continue to answer the M1800 questions based on safe ability and documentation. QIRT auditors will also continue to answer M2200 based on documentation and agency specific requests. Be sure to include thorough documentation of each patient’s functional status.

For an easily printable version of this guide, click HERE. 

December 24, 2015

OASIS C2 effective January 1, 2017

Filed under: home health — Quality In Real Time Blog @ 8:11 am

CMS has the draft OASIS C2, which will be effective on January 1, 2017, available for download on their website (identified below).  The data set will introduce multiple new and revised M-00 items, such as M1028 for active diagnoses of PVD, PAD, or Diabetes, M1060 for height (in inches) and weight (in pounds), M1311 is replacing M1308, M1313 is replacing M1309, M1511 is replacing M1510, a new item identifying the patient’s mobility from lying to sitting at SOC/ROC and at discharge, M2001, M2003, M2005, M2016 are replacing M2000, M2002, M2004, M2015, respectively, and M2300 and M2400 are being renamed to M2301 and M2401, respectively.


OASIS Data Specifications V2.20.0

The OASIS Data Submission Specifications Version 2.20.0 are now available in the downloads section below. This new version applies to the OASIS-C2 item set which is scheduled for implementation on January 1, 2017.  These specifications are considered DRAFT.

Start working with your software vendor now on their timeline for availability of changes, testing, release, etc.  The specifications needed for software updates are available for download at:




December 21, 2015

CMS News: PR Medicare Fee-for-Service utilization and payment data available for Home Health Agencies

Filed under: home health — Kimberly Searcy @ 10:51 am



December 18, 2015


Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries



Medicare Fee-for-Service utilization and payment data available for Home Health AgenciesData serves as comprehensive resource for information on home health agencies costs and services


As part of our efforts to improve care delivery, payments to providers, and the sharing and utilization of information, the Centers for Medicare & Medicaid Services (CMS) today released a public data set that provides information on services provided to Medicare beneficiaries by home health agencies. The Home Health Agency Utilization and Payment Public Use File (Home Health Agency PUF) contains information on utilization, payments, and submitted charges organized by provider, state and home health resource group.


“The Home Health Agency data made available today focuses on our initiative of achieving better care, smarter spending, and healthier people throughout our health care system, “said CMS Administrator Andrew Slavitt. “CMS has been a pioneer in greater data transparency and views it as key to a more effectively functioning health care system where information flows more freely.”

The Home Health Agency PUF was created from CMS administrative claims data for Medicare beneficiaries enrolled in the fee-for-service program available from the CMS Chronic Condition Data Warehouse (www.ccwdata.org). The data covers calendar year 2013 and is based on home health agency Part A institutional claims. These new data include information on 11,062 home health agencies, over 6 million claims, and over $18 billion in Medicare payments for 2013. The data set does not contain any individually identifiable information about Medicare beneficiaries.

To view a fact sheet on the Home Health Agency data set, visit:




Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgov



The tentative date for the next Home Health & DME, Open Door Forum is schedule for: Wednesday, January 27, 2016. The agenda soon to come. Thank you for your continued interest and participation in the CMS Home Health & DME, Open Door Forums.

December 14, 2015

Clinical Nursing Documentation is Critical to a patient’s record

Filed under: home health — Kimberly Searcy @ 2:58 pm

Are you aware that home health regulations Conditions of Participation (CoPs) indicate the clinical record for patient’s must contain progress and clinical notes?  The Medicare Claims Processing Manual, Chapter 10, has specific instructions that HHAs are required to report all services provided to the beneficiary during each episode, which includes reporting each visit in line-item detail.  As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided.


Clinical notes are also expected to provide important communication among all members of the home care team regarding development, course and outcomes of the skilled observations, assessments, treatment and training performed.  Taken as a whole, the clinical notes should tell the patient’s story toward his goals as outlined in the Plan of Care.  This documentation serves to demonstrated to outside adjusters the reason skilled services are needed.


Clinician documentation notes must contain the following, as appropriate:


  1. The history and physical exam pertinent to the day’s visit, including the response or changes in behavior to previously administered skilled services, AND
  2. The skilled services applied on the current visit, AND
  3. The patient/caregiver’s immediate response to the skilled services provided; AND
  4. The plan for the next visit based on the rational of prior (and that day’s) results.


Clinical notes should be written to adequately describe the action of the patient to his skilled care, provide a clear picture of the treatment, as well as the “next steps” to be taken.  It’s inappropriate to use vague or subjective descriptions for he patient’s care.  An example of inadequate documentation would include:


  • Patient tolerated treatment well
  • Caregiver instructed in med management
  • Continue with POC


As a clinician, your documentation should include objective measurements of physical outcomes of treatment in a clear, precise description.  Include the changed behavior due to eduction program so that all agency staff members can pick up the chart and follow the results of applied services.


If a skilled service is being provided to maintain the patient’s condition or prevent or slow further deterioration, the clinical notes must include:


  1. A detailed rationale that explains the need for skilled service in light of the patient’s overall medical condition and experiences,
  2. The complexity of the service to be performed, AND
  3. Any other pertinent characteristics of the beneficiary or home.


Once you’ve written your skilled care review, read over it to ensure it’s accurate, complete, and objective. Payment for your agency could be impacted by clinical documentation so strive every day to ensure all appropriate information is present for each patient.

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