P.A.C.E. to Age in Place
…written by Christina Blackburn, CPC
PACE (Program of All-Inclusive Care for the Elderly) is a growing model of care.
The goal is to keep seniors living safely in the community, rather than, a nursing home. According to Medicare.gov in order to qualify for PACE, an individual must “be at least 55, live in a PACE service area, need a nursing home level of care as certified by the state and be able to live safely in the community with the support of PACE.”
The program includes a Day Center where participants can come to socialize and have a hot meal. Day Centers usually have an onsite medical clinic, physical therapy, occupational therapy, recreational therapy, Social Services, nutritional counseling, nursing care, activities & exercise and excursions. Often transportation is included to the Day Center and to medical appointments.
Covered services include outpatient services, inpatient services, dental, optometry, medicine, nutritional supplements, prescriptions, DME, respite, caregiver education, and home health/home care services. Referrals to specialists are also covered. An internal team approves services, equipment and home health hours. Participants don’t pay anything for authorized services.
PACE takes the place of a Medicare Part C plan. Services are covered by Medicare and Medicaid. Nationally, 90% of PACE participants are dual eligible for Medicare and Medicaid. Nine percent are Medicaid only and 1% pay a premium. (http://www.npaonline.org/) Many participants do not have a monthly payment. For those that do, the payment is based on monthly income.
PACE programs are reimbursed on HCCs. Many PACE participants have a number of co-morbidities.
As a coder for a PACE program, it is very important to understand and stay current with the guidelines.
For example, hyperglycemia and hypoglycemia are now considered complications, not symptoms of, diabetes (Bernard, 2018). Diabetes with hyperglycemia carries a higher RAF score than Diabetes without complications. Over time, it will cost more to care for a person who has Diabetes with complications. If the complications aren’t captured, then the program won’t be reimbursed appropriately.
According to the National PACE Association, 92% of PACE programs are run by a non-profit. In order to provide the care the participants need, it is vital not to leave any money on the table.
My typical day includes coding Medical Intakes, Semi-Annual Assessments, Annual Assessments and acute visits. HCCs must be captured at least once a year, or in the eyes of CMS they disappear. By scheduling semi-annual and annual assessments, we have at least 2 opportunities during the year to capture HCCs. I also review consult notes from previous providers, specialty providers and inpatient hospital stays. Towards the end of the year, an outside firm audits our charts from the previous year. They send a report with HCCs that may need to be added or redacted. I research to see if I can find evidence to support their findings. To this point I have done provider education as needed when I see an opportunity for improvement. Going forward, I would like to start offering provider education on different topics once a month.
If you are interested in learning more about PACE and if there is a program near you, visit the National PACE Association’s website: http://www.npaonline.org/
1. Bernard, S.P. (2018). Risk Adjustment Documentation & Coding. Chicago, IL: American Medical Association.
2. Medicare.gov. Get help paying costs → PACE. http://www.medicare.gov/your-medicare-costs/get-help-paying-costs Accessed July 16, 2018.
3. National Pace Association. PACE by the Numbers. http://www.npaonline.org/ Accessed July 16, 2018.