QIRT Alerts!

December 21, 2016

Probe and Educate Strategy Continues

Filed under: home health — Quality In Real Time Blog @ 2:25 pm

CMS Announces a Continuation of the Home Health Probe and Educate Medical Review Strategy

In the December 16, 2016 MLN Release (SE1635), CMS announced that Medicare Administrative Contractors (MACs), in conjunction with CMS, have initiated Round 2 of the Probe and Educate Strategy for home health providers. This will be effective on or after December 15, 2016. The original Probe and Educate Strategy was constructed following a significant change in the CY 2015 Home Health PPS Final Rule. For providers, the specific change surrounding the F2F included the removal of the narrative requirement for the certification of the patient for home health. The final rule included the new expectations for how the certifying physician, or NPP, could incorporate the reasons for home health into the accompanying medical record from either the physician or the facility. Lastly, it outlined allowances for the physician to use portions from the home health medical record in the certification.

The first round of the probe involved select agencies experiencing five additional document requests (ADRs). The feedback from the ADRs offered details on agency deficiencies, along with an offer to provide additional education. With this second round, the anticipated strategy conclusion is one year from the date it is initiated. CMS is directing home heath MACs to select a sample of five claims for pre-payment review from each HHA within their jurisdiction, excluding those providers who had five claims reviewed in Round 1, with zero or one claim in error.

Whether or not your agency is included in this probe, QIRT has the solution to relieve ADR anxiety. Our expanded internal audit team is well versed in pre-claim audits. Let our team partner with your agency to provide a full audit of your claim-related data. Audits are conducted using the compliance measures CMS expects to be used when reviewing for medical necessity and full face-to-face compliance. Our team will audit the record and then partner with your team to educate on specific deficiencies. The QIRT compliance team can also prepare your already selected ADRs and submit to your MAC on your behalf. Call QIRT today for a discussion on how we can help!

Stefanie Woodrow


November 29, 2016

PCR Update: Palmetto Moving Forward Texas and Florida to Begin Testing eService Portal Now

Filed under: home health — Quality In Real Time Blog @ 4:16 pm

Last week, Palmetto announced that Texas and Florida providers could begin testing the Pre-Claim Review (PCR) eService Portal for submissions of PCR claims. This is the first indication that CMS intends to move forward with pre-claim review in the remainder of the five states previously identified. As of November 28, 2016, National Government Services (NGS) has nothing on their website to indicate how and when they plan to move forward with a plan for PCR.

Conventional thinking may lead agencies to believe that the lack of any information by NGS means there is nothing planned for Michigan and Massachusetts. QIRT experts would disagree. We believe NGS does not have the experience of the ramifications resulting from the rollout of the PCR process in Michigan and will not be prepared when CMS requires the process to begin.

On the other hand, we believe Palmetto has learned its lesson. It is more likely Palmetto is preparing agencies in Texas and Florida for entry into the PCR world in a more orderly fashion by allowing them to test the electronic system before another ‘mess’ occurs.

QIRT experts guess the remaining two Palmetto states (Florida and Texas) will soon receive the 30-day notice and will begin on January 1, 2017. The next following expectation is that NGS will come on board and begin the reviews soon after that date, perhaps in February or March.

As you have probably heard, the PCR process is reported to be improving. Affirmations have increased into the 80% range now. However, the number of provisional affirmations has still not caught up with the RAPs that have been submitted in Illinois. That bulk of RAP recoveries will take place on non-affirmed claims during the first week of December. Many agencies have yet to submit final claims. We will need to wait to experience the results of that fall-out.

The Michigan Association is working hard to keep agencies updated on the latest with PCR. We will notify you of any updates we receive on NGS’s plans to move PCR forward in Michigan.


Arlene Maxim


November 15, 2016

Pre-Claim Reviews: Curse or Cure?

Filed under: home health — bernadetteesmith @ 9:00 am

Pre-claim reviews (PCR) have caused quite a panic in the home care industry recently. QIRT consultants have been hearing terms such as “a big mess, chaos, etc.” used to describe this new process. PCR is, indeed, a change in the way agencies should be looking at the documentation showing actual beneficiary eligibility and unique care provided. The rules have not changed. However, the way the industry approaches these requirements must change if agencies want to survive in the PCR world.

So: is PCR a curse or a cure for our industry?

The curse of PCR can be measured in multiple ways. There is a large number of industry complaints about the “mess” agencies find themselves in since the onset of PCR. Added to this complaint are the number of delayed affirmations and complete non-affirmations, multiple inconsistent directions from the Medicare Administrative Contractor (MAC), …the list goes on.

But what if the MACs are right? What if it is the industry itself that has actually caused the curse?

As consultants, QIRT staff members have the unique opportunity of reviewing home care documentation from hundreds of agencies across our great nation. Unfortunately, many home care agencies actually create their own problems at times, ultimately leading to their own demise. With an increase in the number of fraud and abuse cases identified, one must wonder if the industry is being subjected to unfair reviews or if, in reality, PCRs are proving to be a wake-up call to enforce a predetermined, long-established process.

In completing reviews on records that have been subpoenaed by state and federal governments, I have found there is a noteworthy disconnect. This disconnect exists between CMS’s rules in determining beneficiary eligibility and the unwritten, self-imposed (or occasionally self-created) rules that many agencies actually follow. Although most agencies strive for compliance with CMS rules, old and hazardous habits are cause for alarm in the industry.

It is interesting to note that during FY 2013, 17.3% of all payments made to home health care were considered improper. These improper payments cost the Medicare program $3 billion. In FY 2014, the number of improper payments increased to 51.4%, carrying a $9 billion cost to Medicare. The largest percentage of the totals in each of these years was a direct result of the fact that documentation submitted for review did not support the claim. The documentation we are speaking of in this case is that related to the physician’s face-to-face and that of the clinician’s provision of care to frail, elderly, and vulnerable patients.

As the MACs review the records agencies submit seeking provisional affirmation, they are uncovering alarming findings. Findings include, but are not limited to:

  • G-codes are misrepresented (or simply not understood) by the agency.
  • Physician information supplied for face-to-face is inadequate and inconsistent.
  • Documentation by clinicians is woefully inadequate.

For years agencies have been told that documentation is the key to success. Documentation in the clinical record that clearly supports the use of the Medicare benefit as it was intended is missing. We need a documentation revolution. The lack of agency training and understanding of the home care benefit and the requirements for documentation with a high degree of specificity has taken its toll.

As experts in the industry, it is QIRT’s opinion that PCR may just be the reveille needed. These reviews may be the cure to what is actually causing the harm to our industry.

In the recent past, CMS has used other techniques to initiate corrective action within our industry with little (or not enough) success. PCR may be the answer. Medicare’s decision to stop the game of pay-and-chase has begun in Illinois and is headed to four more states very soon. Reviewing documentation related to eligibility and services to be rendered will provide CMS with data in real time, prior to paying claims. PCR promises to provide the Medicare program with a significant amount of data.

The homecare industry has never liked change. But change is here, and change can be our friend. If agencies heed the warnings from the issues being identified today, they may encounter the necessary cure and experience a better tomorrow.

Arlene Maxim

November 3, 2016

Summary of the Final Rule for HH PPS Rate CY2017

Filed under: home health — Quality In Real Time Blog @ 10:47 am
The end of October ushered in the release of the Centers for Medicare & Medicaid Services (CMS) Final Rule for the CY2017 Home Health Payment (CMS-1648). On the surface, it appears payment will increase for 2017 since the base rate increases in 2017 to $2989.97 from the 2016 base rate of $2965.12.

On the surface, this report sounds exciting, but realize that although the base rate has gone up in 2017, this increase will not translate to more money per episode. CMS had to increase the base rate to help offset the reductions created by adjustments to the case mix categories.

What does this really mean for home health agencies? It is estimated that the HH PPS pay rate will actually decrease by 0.7% in 2017.
Remember, you can always contact the QIRT team if you have any concerns. We are proud to support home care agency success.  – QIRT Education Team

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/

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