New HHA CHOW Rules Finalized

Good Morning MFS Bloggers and Happy Holidays!!!!

In CMS’s final rule published on November 2nd, 2010, a Change in Majority Ownership occurs when an individual or organization acquires more than a 50 percent direct ownership interest in an HHA during the 36 months following the HHA’s initial enrollment into the Medicare program or the 36 months following the HHA’s most recent change in majority ownership (including asset sale, stock transfer, merger, and consolidation). This includes an individual or organization that acquires majority ownership in an HHA through the cumulative effect of asset sales, stock transfers, consolidations, or mergers during the 36-month period after Medicare billing privileges are conveyed or the 36-month period following the HHA’s most recent change in majority ownership.

Unless an exception in (b)(2) of this section applies, if there is a change in majority ownership stock of a home health agency sale (including asset sales, stock transfers, mergers, and consolidations) within 36 months after the effective date of the HHA’s initial enrollment in Medicare or within 36 months after the HHA’s initial enrollment in Medicare or within 36 months after the HHA’s most recent change in majority ownership, the provider agreement and Medicare billing privileges do not convey to the new owner. The prospective provider/owner of the HHA must instead:
(i) Enroll in the Medicare program as new (initial) HHA under the provisions of 424.510 of this subpart.
(ii) Obtain a State survey or an accreditation from an approved accreditation organization.
(b)(2)(i) The HHA submitted two consecutive years of full cost reports. For purposes of this exception, low utilization or no utilization cost reports do not qualify as full cost reports.
(ii) An HHA’s parent company is undergoing an internal corporate restructuring, such as a merger or consolidation.
(iii) The owners of an existing HHA are changing the HHA’s existing business structure (for example, from a corporation to a partnership (general or limited); from an LLC to a corporation; from a partnership (general or limited) to an LLC and the owners remain the same.
(iv) An individual owner of an HHA dies.

New Therapy Regulations

Good Morning MFS Bloggers,

Beginning in 2011, as amended in CMS’s final rule at 42 CFR 409.44 on November 2nd, 2010, at least every 30 days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient in accordance with §409.44(c)(2)(i)(A). Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the needed therapy service and functionality reassess the patient in accordance with §409.44(c)(2)(i)(A) at least every 30 days.

If a patient is expected to require therapy visits, a qualified therapist (instead of an assistant) must provide all of the therapy services on the 13th therapy visit and functionally reassess the patient in accordance with §409.44(c)(2)(i)(A).

If a patient is expected to require 19 therapy visits, a qualified therapist (instead of an assistant) must provide all of the therapy services on the 19th therapy visit and functionally reassess the patient in accordance with §409.44(c)(2)(A).

Please review the final rule for more detail. Have a great day! CP

RAP's

Good Morning MFS Hoem Health Bloggers,

The RHHI recently posted an article on RAPs as they were noticing various errors within their system when receiving RAP from providers throughout the country.

Per the RHHI, RAP's will cancel as they normally do when any final claim posts to the Common Working File (CWF) or when the final claim is not received on time from the home health agency (i.e., within 60 days of the date the RAP was processed or 120 days from the start date of the episode).

Home Health Agencies often mistakenly resubmit RAPs because they do not receive payment on the RAP and believe that the RAP was not posted to CWF. The RAP does exist, so the RHHI requests that home health agencies do not resubmit another RAP unless the RAP auto-canceled because the final claim was not submitted on time. When the RAP is processed, it will go into a "P" status, but does not receive payment and receives a "Z" no pay code because of an open MSP record. The home health agency should not send a request for the RAP to be cancelled or adjusted. The home health agency provider should submit the final claim with the correct information and/or MSP codes. If the final claim was previously submitted and has been rejected (R status), check to see if it has posted to the CWF. If so, then the home health agency provider must submit an adjustment request once they have received payment from the primary insurer, a denial or have information documenting Medicare is primary.

Have a great week!!!! Chris

**Claim Denials for Non-PECOS Enrolled Ordering/Referring Providers**

Good Morning MFS Bloggers, I hope you each had a very happy thanksgiving. CMS recently posted a new article regarding the PECOS enrollment requirements for all referring physician's. It is imperative for the sustainability of your cash-flow that you confirm your referral sources are PECOS enrolled.

Providers who order or refer items or services for Medical beneficiaries and who are not enrolled in the Provider Enrollment, Chain and Ownership System (PECOS), must submit an enrollment application to Medicare. This can be done using internet-based PECOS or by completing the paper enrollment application. If you reassign your Medicare benefits to a group or clinic, you will also need to complete the CMS-855R.

Phase 1 of the claim editing initiative began on October 5th, 2009, and is scheduled to end on January 2, 2011. During phase 1, if the ordering/referring provider does not pass the edits, the claim will be processed and paid (assuming there are no other problems with the claim); however, the billing provider (the provider who furnished the item or service that was ordered or referred) will receive an informational message from Medicare in the remittance advice.

Scheduled to begin January 3, 2011, these messages will no longer be informational. They will be denial messages and the billing provider will not be paid for the items or services that were furnished based on the order or referral of the physician not enrolled in PECOS.

Home Health Change of Information 855A Applications

Good Morning MFS Bloggers, With the new arsenal of overpayment weapons PGBA is utilizing to sanction providers for failing to notify them of changes within their organization, I thought this was a good time to post a blog regarding the Change of Information (COI) issue.

Home Health Providers are required to use the CMS 855A Provider/Supplier Enrollment Application for notifying Medicare of changes of information. Providers must notify the Medicare contractor of any changes to the information contained in the application within 90 days of the effective date of the change except for Change of Addresses which must be made within 30 days.

All provider changes must be signed by the authorized representative or a delegated official for the facility. The authorized representative is an appointed official to whom the provider has granted legal authority to enroll it in the Medicare program, to make changes and/or updates to the provider’s status in the Medicare program and to commit the provider to fully abide by the laws, regulations, and program instructions of Medicare. The authorized official must be the provider’s general partner, chairman of the board, chief financial officer, chief executive officer, president, direct owner of 5% or more of the provider.

Wishing you all a very happy thanksgiving. CP

CMS Publishes Home Health Agency Patient Transfer Updates

Good Morning MFS Bloggers, Due to the vast number of regulatory and reimbursement changes in the industry, more and more agencies are trandferring and thus, receiving, patients to/from thsir agency.

According to CMS, a transfer is described as a single beneficiary choosing to change HHAs during the same 60-day period.

During this transfer prociess, it is imperative that both HHAs work together.

I. Steps for the Receiving HHA:
• Check the Health Insurance Query (HIQH) for HHAs to determine if the beneficiary is currently under an established Plan of Care with another HHA. A patient status of “30” indicates that the patient is currently under an established plan of care. Therefore, regardless if whether or not the receiving agency is admitting a patient outside of the episode currently reflected in HIQH, the transfer requirements apply.
• Document in the record that you accessed HIQH by printing and stamping page 3 in HIQH.
• If the patient is under the care of another HHA:
- Contact the initial HHA to work out the transfer date.
- Document you contacted the other agency and include; who you talked to at the agency, date contacted and time contacted.
- Inform the beneficiary that the initial HHA will no longer receive Medicare payment on behalf of the patient and therefore, will no longer provide Medicare covered services to the patient after the date of the patients elected transfer.
- Document in the patient’s file that the beneficiary was notified of the transfer criteria and the possible payment implications.

II. Steps for the Transferring HHA:
- Document the receiving agency contacted you to inform you of the beneficiary transfer and that you accepted the transfer.
- Include the name of the person you spoke with at the agency, date, time and date agreed upon for the transfer to take place.
- Submit your final claim with Patient Status Code ‘06’ to indicate transfer to another HHA.

**For a full explanation of CMS’s transfer guidelines, please refer to the Medicare Claims Processing Manual (PUB 100-02.)

LUPA Claims Paying Incorrectly

Recently, CMS identified that the Home Health Low Utilization Payment Adjustment (LUPA) are being paid incorrectly by the RHHI. CMS is rectifying the problem and will adjust any underpayments in future DDE/EOB’s. Please forward this on to all interested billing personnel.

HHA TRANSFERS

Good Afternoon MFS Bloggers, I recently came across this very informative RHHI memo on transfers. Given the fact that CMS nor the RHHI has posted anything recently on the prevalent issue of patient transfers, I thought it would be a good idea to post a blog with the informaiton. Happy reading!!

What is a Transfer? A transfer is described as a single beneficiary choosing to change home health agencies (HHAs) during the same 60-day period. It is imperative that HHAs work together during a transfer situation.

Steps for the Receiving Home Health Agency:
• Check the Health Insurance Query for HHAs (HIQH) to determine if the beneficiary is currently under an established plan of care with another HHA.
• Document in the record that you accessed HIQH by printing and date stamping page 3.
o If the patient is under the care of another HHA:
• Contact the initial HHA to work out the transfer date.
• Document you contacted the other agency and include the name of the person you spoke with and the date and time of contact.
• Inform the beneficiary that the initial HHA will no longer receive Medicare payment on behalf of the patient and therefore will no longer provide Medicare covered services to the patient after the date of the patient's elected transfer. Document in the patient's file that the beneficiary was notified of the transfer criteria and the possible payment implications.
• Submit your Request for Anticipated Payment (RAP) with source of admission code 'B' to indicate transfer from another HHA.

Steps for the Initial Home Health Agency:•
Document the receiving agency contacted you to inform you of the beneficiary transfer and that you accepted the transfer.
• Include the name of the person you spoke with at the agency, date, time and date agreed upon for transfer to take place.
• Submit your final claim with Patient Status Code 06' to indicate transfer to another HHA.

What should you do if there is a dispute?
Should a dispute arise, both agencies should try to work out the issue between them prior to calling the Fiscal Intermediary. In the instance when a resolution cannot be made then the initial HHA should contact the Palmetto GBA Provider Contact Center at (866) 801-5301. Palmetto GBA will work with both agencies to settle the dispute however, certain information will need to be provided.

If the receiving HHA can provide documentation to support the bullets listed under Steps for the Receiving Home Health Agency above were completed, the initial HHA will not receive payment for the period of overlapping dates in addition to receiving the Partial Episode Payment (PEP) adjustment to their claim.
If the receiving agency cannot provide documentation to support an appropriate transfer was completed, the receiving agency's Request for Anticipated Payment (RAP) and/or Final Claim will be canceled and full payment will be made to the initial HHA.

NOTE: To obtain information in regards to Home Health Overlaps, please refer to the How to Avoid Overlapping Home Health Episodes job aid at www.PalmettbGBA.com/rhhi

HHA Prepayment Review Letters a/k/a Additional Development Requests

Good Afternoon MFS Bloggers, I have seen an influx of ADR letters recently coming from wither the RHHI or your local ZPIC's requesting medical records prior to adjudicating your caims for payment. The below information is taken from a recent CMS transmittal. Please follow these CMS instructions very carefully when responding to an ADDR letter as your cash flow depends upon your strict adherence.


Additional Development Requests (ADRs)

An ADR is a request from Palmetto GBA for copies of medical records for review purposes:
- A provider has 30 days to respond and submit documentation for review
- ADRs are mailed in a bright yellow envelope with ‘ADR Request Time Sensitive’ in red on the envelope.
- Submit the requested documentation to the address on the ADR using the appropriate mail code.
- It is suggested that the provider track an ADR from the time it is received/printed until the status/location SB6001
- To print a hardcopy ADR from DDE, select 01 ‘inquiries’. Press enter and select 12 for ‘Claims’ at the sub-menu. Press enter. Tab to the S/LOC field and type SB6001. All claims in this S/LOC will be reflected in the ‘Claim Summary Inquiry’ screen.
- Following medical review, if there is a difference on the Remittance Advice between the submitted charges and the agency’s payment, the provider can access the Remarks section to determine the reason for any denials/down codes of claim. At the DDE Main Menu, select 02. Press Enter. Select 26 and press enter. Enter page number ‘04’ and press enter. Medical Review remarks are located on page 04. If a review note is not available on this page, contact the PCC for assistance.

Good Luck!!! CP

Expansion of Scope of Edits for Home Health Agencies

Good Morning MFS Bloggers, The following excerpt was taken from a recent CMS Transmittal. Happy reading!

Effective Date: October 1, 2010 (Phase 1); January 1, 2011 (Phase 2)

Provider Types Affected
This article is for free-standing and provider-based Home Health Agencies (HHAs) who bill Medicare Regional Home Health Intermediaries (RHHIs) for services provided to Medicare beneficiaries.

Background
The Centers for Medicare & Medicaid Services (CMS) is expanding claim editing to meet the Social Security Act requirements for the attending physician when a plan of treatment is needed and submitted from an HHA. In this document, the word ‘claim’ means both electronic and paper claims. The following are the only providers who can order/refer HHA beneficiary services:
- Doctor of medicine or osteopathy; and
- Doctor of podiatric medicine.

CMS claim editing is being expanded to verify that the attending physician on an HHA claim is eligible and is enrolled in Medicare’s PECOS. The editing expansion will be done in two phases:

• Phase 1 (October 1st, 2010 – December 31st, 2010) When a claim is received, CMS will determine if the attending physician is required for the billing service. If the attending physician’s NPI is on the claim, Medicare will verify that the attending physician is on the national PECOS file. If the attending physician NPI is not on the national PECOS file during Phase 1, the claim will continue to process but a message will be included on the remittance advice notifying the billing provider that claims may not be paid in the future if the attending physician is not enrolled in Medicare or if the attending physician is not of the specialty eligible to be an attending physician for HHA services.

• Phase 2 (On or after January 1, 2011) As stated above, Medicare will determine if the attending physician’s NPI is required for the billed service. If the billed service requires an attending physician and the attending physician’s NPI is not on the claim, the claim will not be paid. If the attending physician’s NPI is on the claim, Medicare will also verify that the attending physician is on the national PECOS file. If the attending physician is on the PECOS file, but not as specialty eligible to be an attending physician, the claim, during Phase 2, will not be paid.

Home Health Agencies (HHAs) Providing Durable Medical Equipment (DME) in Competitive Bidding Areas

Good Afternoon MFS Bloggers, If your agency is located or doing business in a competitive bidding area (CBA), please pay special attention to the CMS information posted below. This information will have profound effects on your DME revenue, if in fact you submit claims for DMEPOS for your hha beneficiaires. For those of you not currently located in a competitive bidding area, please take note as these restrictions will certainly effect your Agency once the competitive bidding program is expanded to your zip code.

Provider Types Affected
This article is for all HHAs submitting claims to Regional Home Health Intermediaries (RHHIs) for DME provided to Medicare beneficiaries residing in competitive bidding areas.

Provider Action Needed
The Centers for Medicare and Medicaid Services (CMS) issued Change Request (CR) 7014 to alert HHAs that edits will be in place, effective for services on or after January 1, 2011, to prevent HHAs from billing competitively bid DME items in competitive bidding areas and consequently preventing the in appropriate payment of competitively bid DME items to HHAs. Make certain your billing staffs are aware of these changes.

Background
Beginning January 1, 2011, in competitive bidding area, a supplier must be awarded a contract by Medicare in order to bill Medicare for competitively bid DME. Therefore, HHAs that furnish DME and are located in an area where DME items are subject to a competitive bidding program must either be awarded a contract to furnish these items in this area or use a contract supplier in the community to furnish these items. The competitive bidding items will be identified by HCPCS codes and the competitive bidding areas will be identified based on zip codes where beneficiaries receiving these items maintain their permanent residence. The DME MACs will have edits in place indicating which entities are eligible to bill for competitive bid for items and the appropriate competitive bid payment amount.

Key Points of CR 7014•
Your Medicare contractor will return HH claims (types of bill 32x, 33x and 34x) to you when such claims contain Healthcare Common Procedure Coding System (HCPCS) codes that are identified as being for items or services subject to competitive bidding in a competitive bidding areas.
• For your HHA to bill competitively bid items, your HHA must also be a contract supplier under Medicare’s DME competitive bidding program.
• Note: All suppliers for competitively bid DME must bill the DME Medicare Administrative Contractors (MAC) for these items and will no longer be allowed to bill for competitive bid items to Medicare contractors processing home health claims. Home health claims submitted for HCPCS codes are subject to a competitive bidding program will be returned to the provider to remove the affected DME line items.
• The applicable HCPCS codes and Zip Codes for the competitive bidding areas can be found on the “Supplier” page of the following Competitive Bid Implementation Contractor (CBIC) Web site at http://www.dmecompetitivebid.com/Palmetto/Cbic.nsf/DocsCat/Home on the internet.
• Claims for DME furnished by HHAs that are not subject to competitive bidding may still be submitted to the appropriate home health claims processing contractor.

CMS Proposes New Face-to-Face Encounter Requirement

Good Morning MFS Bloggers, The following excerpt was taken directly from CMS's recently published proposed rule on the POC face-to-face physician encounter requirement:

"On March 23, 2010, the Patient Protection and Affordable Care Act (The Affordable Care Act) of 2010 (Pub. L., 111-148) was enacted. Section 6407 (a) (amended by section 10605) of The Affordable Care Act amends the requirements for physician certification of home health services contained in Sections 1814 (a)(2)(c) and 1835 (a)(2)(A) by requiring that, prior to making such certifications, the physician must document that the physician himself or herself or specified non-physician practitioner has had a face-to-face encounter (including through the use of telehealth, subject to the requirements in section 1834(m) of the Act), with the patient incident to the services involved.
Therefore, we propose revising §424.22 (a)(1)(v) such that for initial certifications, prior to a physician signing that certification and thus certifying a patient’s eligibility for the Medicare home health benefit, the physician responsible for certifying the patient for home health services must document that a face-to-face patient encounter (including through the use of telehealth if appropriate) has occurred no more than 30 days prior to the home health start of care date by himself or herself, or by an authorized non-physician practitioner (as specified in sections 1814(a)(2)(c) and 1835(a)(2)(A) of the Act) working in collaboration with or under the supervision of the certifying physician as described above.
Similarly, we prose to revise §424.22(a)(1)(v)(B) to reflect that if a home health patient has not seen the certifying physician or one of the specified non-physician practitioners as described above, in the 30 days prior to the home health episode start of care, the certifying physician or non-physician practitioner, would be required to have a face-to-face encounter (including the use of telehealth, subject to the requirements in section 1834(m) of the Act and subject to the list of Medicare telehealth services established in the most recent year’s physician fee schedule regulations) with the patient within two weeks after the start of the home health episode to comply with the requirements for payment under the Medicare program.
We propose implementing the above face-to-face patient encounters provisions as they relate to home health episodes beginning 01/01/2011 and later."

CMS PROPOSES PAYMENT CHANGES TO MEDICARE HOME

Good Morning MFS Bloggers, On Friday, July 16, 2010, the Centers for Medicare & Medicaid Services (CMS)announced a number of proposed changes to Medicare home health payments for 2011.

The proposed rule, on display in the Federal Register, represents a 4.75 percent decrease in Medicare payments to home health agencies (HHAs) for calendar year (CY) 2011. This is an estimated net decrease of $900 million compared to payments HHA’s received in CY 2010. It includes the combined effects of a market basket update, a wage index update, reductions to the home health prospective payment system (HH PPS) rates to account for increases in aggregate case-mix that are unrelated to underlying changes in patients' health status, and other provisions mandated by the Affordable Care Act (ACA) of 2010.

The ACA mandates that CMS apply a 1 percentage point reduction to the CY 2011 home health market basket amount, which equates to a proposed 1.4 percent update for HHA’s in CY 2011. CMS also proposes to further reduce HH PPS rates in CY 2011 to account for additional growth in aggregate case-mix that is unrelated to changes in patients' health status. Based on updated data analysis, instead of the planned 2.71 percent reduction for CY 2011, CMS proposes to reduce HH PPS rates by 3.79 percent in CY 2011 and an additional 3.79 percent in CY 2012.

The ACA also changes the existing home health outlier policy through a 5 percent reduction to HH PPS rates, with total outlier payments not to exceed 2.5 percent of the total payments estimated for a given year. HHAs are also permanently subject to a 10 percent agency-level cap on outlier payments.

2010 Office of Inspector General Work Plan: Home Health Agencies

Good Morning MFS Bloggers, I thought you would be interested in reading the areas of home health enforcement the Office of Inspector General will be taking a closer look at in the next year. I highly recommend each of you review your compliance programs to ensure these areas are addressed during your audits. The following text is taken directly from the OIG 2010 WorkPlan.

Part B Payments for Home Health Beneficiaries
We will review Part B payments for services and medical supplies provided to beneficiaries in home health episodes. Most services and nonroutine medical supplies furnished to Medicare beneficiaries during home health episodes are included in the HHA prospective payments. The Social Security Act, §§ 1832(a)(1) and 1842(b)(6)(F), require that in the case of home health services furnished under a plan of care of an HHA, payment for those services be made to the HHA, including payment for services and supplies provided under arrangements by outside suppliers. We will identify Part B payments made to outside suppliers for services and medical supplies that are included in the HHA prospective payment and examine the adequacy of controls established to prevent inappropriate Part B payments for services and medical supplies.

Home Health Agencies: Accurately Coding Claims for Medicare Home Health Resource Groups
We will review Medicare claims submitted by HHAs to determine the extent to which the billing codes for home health resource groups (HHRG) are used in determining whether payments to HHAs are accurate and supported by documentation in the medical record. The Social Security Act, § 1895, governs the payment basis and reimbursement for claims submitted by HHAs, including a case-mix adjustment using HHRGs. Medicare pays for home health episodes based on a PPS that categorizes beneficiaries into groups, referred to as HHRGs. Each HHRG has an assigned weight that affects the payment rate. We will assess the accuracy of HHRG assignment and identify patterns of miscoded HHRGs.

Medicare Home Health Payments for Insulin Injections
We will review the incidence of Medicare home health services outlier payments for insulin injections. Insulin is customarily self-injected by a patient or is injected by a family member. However, CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 7, § 40.1.2.4.A.2, states that when a patient is either physically or mentally unable to self-inject insulin and no other person is able and willing to inject the patient, the injections would be considered a reasonable and necessary skilled nursing service under the Medicare home health benefit. The unit of payment under the home health PPS is a national 60-day episode rate with applicable adjustments. The law requires the 60-day episode to include all covered home health services, including medical supplies. When beneficiaries experience an unusually high level of services in a 60-day period, Medicare systems will provide additional “outlier” payments to the episode payment. Outlier payments can result from medically necessary high utilization of home health services. CMS makes outlier payments when the cost of care exceeds a threshold dollar amount. We will also examine billing patterns in geographic areas with high rates of home health visits for insulin injections.

Home Health Agency Outlier Payments
We will review CMS’s methodology for calculating outlier payments to HHAs to determine whether the methodology reimburses HHAs as intended for high cost episodes. Pursuant to the Social Security Act, § 1895(b)(5), the HHS Secretary may provide outlier payments for episodes of care that incur unusually high costs. In recent years, outlier payments have significantly increased.

Home Health Prospective Payment System Controls
We will review compliance with various aspects of the home health PPS, including billings for the appropriate location of the services provided. Pursuant to the Social Security Act, § 1895, the home health PPS was implemented in October 2000. Since that time, total payments to HHAs have substantially increased from $8.5 billion in 2000 to $16.4 billion in 2008. We will also analyze various trends in HHA activities, including the number of claims submitted to Medicare, the number of visits provided to beneficiaries, arrangements with other facilities, and ownership information.

Home Health Agency Profitability
We will review cost report data to analyze HHA profitability trends under the home health PPS to determine whether the payment methodology should be adjusted. The Social Security Act, § 1895, added by the Balanced Budget Act of 1997 (BBA), § 4603, requires a PPS for home health services. Since the PPS was implemented in October 2000, HHA expenditures have significantly increased. We will examine various trends, including profitability trends in Medicare and the overall profitability trends for freestanding and hospital-based HHAs.

Medicare Home Health Payments for Diabetes Self-Management Training Services
We will review Medicare home health payments for diabetes self-management training services. Medicare covers diabetes self-management training services (DSMT) to educate beneficiaries in the successful self-management of diabetes. The Social Security Act, §§ 1861(s)(2)(S) and (qq), permits Medicare coverage of DSMT when these services are furnished by a certified provider who meets certain quality standards. Other conditions for coverage of DSMT are included in 42 CFR pt. 410, subpart H, which includes requirements for plans of care and physician certification. Services include instructions in self-monitoring of blood glucose, diet and exercise education, an insulin treatment plan, and motivation for patients to use the skills for self-management. We will examine billing patterns in geographic areas with high utilization of diabetes self-management training services.

Oversight of Home Health Agency Outcome and Assessment Information Set Data
We will review CMS’s oversight of Outcome and Assessment Information Set (OASIS) data submitted by Medicare-certified HHAs. Federal regulations at 42 CFR § 484.55 require HHAs to conduct accurate comprehensive patient assessments that include OASIS data items and submit the data to CMS. OASIS data reflect HHAs’ performance in assisting patients to regain or maintain their ability to function and perform activities of daily living. OASIS data also include measures of physical status and use of services, such as hospitalization or emergent care. CMS has used OASIS data for its HHA PPS since 2000; began posting OASIS-based quality performance information on its Home Health Compare Web site in fall 2003; and started a home health pay-for-performance demonstration based on OASIS data on January 1, 2008. We will review CMS’s process for ensuring that HHAs submit accurate and complete OASIS data.

CMS’s July, 2010 Proposed Rule Most Likely Changes Mergers and Acquisitions Landscape

Good Morning MFS Bloggers, The following text was taken directly from the CMS Proposed Rule and changes the landscape (if published in final form) for all mergers and acquisitions in the HHA industry:

“In last year’s home health prospective payment system final rule titled, "Medicare Program: Home Health Prospective Payment System Rate Update for Calendar Year 2010," we finalized several home health program integrity provisions. Specifically, we finalized a provision in 42 CFR 424.550(b) (1) stating that if an owner of an HHA sells (including asset sales or stock transfers), transfers or relinquishes ownership of the HHA within 36 months after the effective date of the HHA's enrollment in Medicare, the provider agreement and Medicare billing privileges do not convey to the new owner. The prospective provider/owner of the HHA must instead: (i) Enroll in the Medicare program as a new HHA under the provisions of §424.510, and (ii) Obtain a State survey or an accreditation from an approved accreditation organization.

In particular, we are proposing to revise 42 CFR §424.550(b) by adding subparagraph (2) as exemptions to 42 CFR §424.550(b)(1):
- A publicly traded company is acquiring another HHA and both entities have submitted cost reports to Medicare for the previous five (5) years.
- An HHA parent company is undergoing an internal corporate restructuring, such as a merger or consolidation, and the HHA has submitted a cost to report to Medicare for the previous five (5) years.
- The owners of an existing HHA decide to change the existing business structure (e.g., partnership to a limited liability corporation or sole proprietorship to subchapter S corporation), the individual owners remain the same, and there is no change in majority ownership (i.e., 50 percent or more ownership in the HHA.)
- The death of an owner who owns 49 percent or less (where several individuals and/or organizations are co-owners of an HHA and one of the owners dies) interest in an HHA.
Change in Majority Ownership within 36 months of Initial Enrollment or Change in Ownership. HHA’s and other provider organizations must report a change of ownership of 5 percent or more of the equity in the company.

Accordingly, in §424.550(a)(1) we are proposing that any change in majority control and/or ownership during the first 36 months of when the HHA is initially conveyed Medicare billing privileges or the last change of ownership (including assets sale, stock transfer, merger or consolidation) would trigger the provisions of §424.550(b)(1). We believe that this approach would allow individuals or organizations to purchase or sell an ownership interest in an HHA as long as it did not change majority ownership or control within the first 36 months of ownership.
Consequently, we are proposing a definition of “Change in Majority Ownership” to mean an individual or organization acquires more than 50 percent interest in an HHA during the 36 months following the initial enrollment into the Medicare program or a change of ownership (including asset sale, stock transfer, merger, or consolidation). This includes an individual or organization that acquires majority ownership in an HHA through the cumulative effect of asset sales, stock transfers, consolidations, and/or mergers during a 36 month period.“

(See Pages 123-128 of the Rule for More Detail)


Have a great day! Chris

PGBA/ZPIC'S Assessing Overpayments for HHA-PT Services

Good Afternoon To All, Based upon a recent wave of overpayment assessments for PT-HHA servicves by PGBA-ZPIC'S, I thought it important that you each renew your familiarity with PGBA'S PT-HHA general guidelines and then review the LCD in more detail regarding the modalities your Agencies are providing.

LCD No. 99HH-021-L - Physical Therapy for Home Health

General Physical Therapy Guidelines:
1. Physical therapy services are covered services provided the services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed physical therapist or under his/her supervision. Services normally considered to be a routine part of nursing care are not covered as physical therapy (i.e., turning a patient to prevent pressure injuries or walking a patient in the hallway postoperatively).

2. Covered physical therapy services must relate directly and specifically to an active written treatment regimen established by the physician, with input from the qualified physical therapist, and must be reasonable and necessary to the treatment of the individual's illness or injury.

3. Additionally, in order for the plan of care to be covered, it must address a condition for which physical therapy is an accepted method of treatment as defined by standards of medical practice, and must be for a condition that is expected to improve materially within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program.

4. Therefore, physical therapy is only covered when it is rendered under a written treatment plan developed and approved by the individual’s physician to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration.

5. The therapist must document the patient’s functional limitations in terms that are objective and measurable.

Have a great day! CP

PGBA Home Health Top Denial Codes: Part 12

5F031/5A031 - Skilled Observation Not Needed from Start of Care
Reason for Denial

The claim was fully or partially denied because the clinical documentation submitted for review did not support the medical necessity of the skilled services from start of care.

How to Avoid a Denial

PGBA recommends the following in avaoiding this type of denial:

• Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services. The documentation should support a reasonable potential of a complication or further acute episode in the patient's condition. The key to Medicare coverage is for the documentation to "paint a picture" of the beneficiary's overall medical condition indicating the need for skilled services.

• Ensure a legible signature is present on all documentation necessary to support orders and medical necessity.

• Submit all documentation that would support medical necessity for services. Some examples for services may include, but are not limited to, the following:

1. New and/or changed prescription medications.
2. "New" medications are those that the patient has not taken recently, i.e. within the last 30 days.
3. "Changed" medications are those that have a change in dosage, frequency or route of administration within the last 60 days.
4. New onset or acute exacerbation of diagnosis.
5. Hospitalizations (include the date and reason.)
6. Acute change in condition.
7. Changes in treatment plan as a result of changes in condition (i.e. physician's contact, medication changes.)
8. Changes in caregiver status.
9. Complicating factors (i.e. simple wound care on lower extremity for a patient with diabetes.)
10. Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals

For more information, PGBA recommends you refer to:
• Code of Federal Regulations, Sections 409.32, 409.33 and 409.44
• CMS Internet-only Manuals (lOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.2.1
• CMS Internet-only Manuals (lOMs), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1.

PGBA Home Health Top Denial Codes: Part 11

In many post-payment overpayment cases, this seems to be the primary reason for the denial determination as assesse4 by the local ZPIC (Program Safeguard COntractor.)

The following was published by PGBA-RHHI.

5FT10/5AT10 - Documentation Does Not Support Homebound Status
Reason for Denial
The services billed were not covered because the medical records submitted for review did not support homebound status.

A beneficiary is considered to be homebound if there exists a condition due to illness or injury that restricts the ability to leave the place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if leaving home is medically contraindicated.

For more information, refer to:
• 42 (CFR) Code of Federal Regulations Sections 409.42 and 424.22

• CMS Internet-Only Manuals (IOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1 and 30.1.1

PGBA Enhances Home Health (HH) Consolidated Billing Enforcement

Effective Date: October 1, 2010

CMS is updating edit criteria related to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS).

Non-routine supplies provided during a HH episode of care are included in Medicare’s payment to the home health agency (HHA) and subject to consolidated billing edits as described in the Medicare Claims Processing Manual, chapter 10, section 20.2.1. If the date of service falls within the dates of HH episode, the line item was previously rejected by Medicare systems.

Effective October 1st, 2010, CMS is implementing new requirements to modify this edit in order to restore the original intent to pay for supplies delivered before the HH episode began. Such supplies may have been ordered before the need for HH care had been identified, and are appropriate for payment if all other payment conditions are met. The edit will be changed to only reject services if the ‘from’ date on the supply line item falls within a HH episode.

PGBA Home Health Top Denial Codes: Part 10

Good Morning All, This is the 10th and final posting of the top PGBA Home Health denial reasons. I hope you all garnered some vlauable insight from these postings. See you all again next week.

10. 5F01215T012 — Physician's Plan of Care and/or Certification Present - Signed but Not Dated
Reason for Denial

The services billed were not covered because the physician signed but did not date the plan of care and certification prior to billing Medicare.

How to Avoid a Denial
• In order to avoid unnecessary denials for this reason, the provider should verify that the physician has dated his or her signature. If the physician does not date his or her signature on the plan of care (Form CMS-485) in field 27, the provider may write or stamp in field 25, the date on which the signed plan of care was received from the physician. If the stamp date is not in field number 25 of the plan of care, the stamp date must indicate "Received" with the date. The stamp date should be in black ink, as red or blue ink does not photocopy. The physician must certify that:

• The home health services were required because the individual was confined to his or her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy.

• A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and the services were furnished while the individual was under the care of a physician.

• Since the certification is closely associated with the plan of care, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible.

• There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary.

• The physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed and must be signed by the same physician who signs the plan of care. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary_

For more information, refer to:

• Code of Federal Regulations, 42 CFR - Sections 409.41, 409.42,409.43 and 424.22.
CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2 and 30.5.

• CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30.

PGBA Home Health Top Denial Codes: Part 9

PGBA Medical Review Top Denial COdes No. 9

9. 5FU39/5AU39 - Valid Endpoint Given, But Not Realistic

Reason for Denial

The services billed were not covered because the endpoint statement to daily skilled nursing visits was not realistic.

How to Avoid a Denial

• Ensure that the endpoint to daily visits is realistic based on the beneficiary's overall condition. Include how you plan to achieve the stated endpoint goal in the documentation.

• Endpoint refers to when the daily skilled nursing visits are expected to be reduced to less than 7 days a week. Medicare will pay for daily skilled nursing visits for a temporary, but not for an indefinite period of time. There may also be circumstances where the patient's prognosis indicates a medical need for daily skilled services beyond 3 weeks. As soon as the patient's physician makes this judgment, which usually should be made before the end of the 3-week period, the home health agency must forward medical documentation justifying the need for such additional services and include an estimate of how much longer daily skilled services will be required. A person expected to need more or less full-time skilled nursing care over an extended period of time would not qualify for home health benefits.

• There may be times when an endpoint needs to be adjusted if it becomes evident that the original endpoint is not realistic. Documentation must support the revised endpoint as realistic and what precipitated the change in medical condition. Continual extensions of endpoint for daily skilled nursing visits may be viewed as not finite and predictable.

For more information, refer to:

• Code of Federal Regulations, 42 CFR - Sections 409.34, 409.42 and 409.44.

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.3.

PGBA Home Health Medical Review Top Denial Reason Codes

Good Afternoon to All, Please find below the continuation blogspot as to PGBA's top denial reason codes for home health.

5FT39/5AT39 - No endpoint to daily skilled nursing visits
Reason for Denial

The services billed were not covered because documentation submitted for review did not include an acceptable endpoint statement to daily skilled nursing visits.

OR

The endpoint statement to daily skilled nursing visits was given; however, it was not valid or was unrealistic.



How to Avoid a Denial
• The provider should submit documentation for review that clearly indicates the date skilled nursing visits will be less than daily.

• The endpoint statement should be based on the beneficiary's overall condition.

• Documentation submitted for review should reflect how you plan to achieve the stated endpoint goal. For example, if wound care is the reason for daily skilled nursing visits, documentation should reflect interventions that would promote improvement in the wound to the point of decreasing the frequency of visits. Some of these interventions may include, but are not limited to, the following:

o Correspondence with the physician
o Changes in treatments and/or medications
o Medical social worker involvement
o Dietician consultation regarding nutritional/hydration needs o Evaluation of supply or durable medical equipment needs
o Other interventions

• There may be times when an endpoint needs to be adjusted if it becomes evident that the original endpoint is not realistic Documentation submitted for review must support the revised endpoint as realistic and what precipitated the change in medical condition.

• Continual extensions of endpoint for daily skilled nursing visits may be viewed as not finite and predictable.

• The Medicare Home Health Benefit was not established to provide daily skilled nursing services, but rather, to provide intermittent skilled nursing services.

For further information, refer to:

• Code of Federal Regulations, 42 CFR - Sections 40934,409.42 and 409.44

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.3

Continuation Blog of PGBA's Top Denial Reason Codes

Pleae find below the most recent posting on PGBA's top denial reason codes

6. 5T099 -Billing Error

Reason for Denial
The service(s) billed (was/were) not covered because, according to the documentation in the medical record, the home health agency made a billing error. Therefore, no Medicare payment was made. The home health agency may not charge the beneficiary for service(s) that (was/were) billed in error.

How to Avoid a Denial
• Check all charges for accuracy/timeliness prior to submitting the final bill to Medicare.

• Check to ensure that all documentation submitted in response to the ADR corresponds to the service(s) rendered and the dates of service(s) billed.


For more information, refer to:
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 10, Sections 10.1.11 and 10.1.23
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.1.1

Additional Outlier Payment Guidance - PGBA

CMS Pub 100-04, Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing (10.1.21 Adjustments of Episode Payment - Outlier Payments)

Effective January 1, 2010, for calendar year 2010, the outlier payments made to each home health agency (HHA) will be subject to an annual limitation. Medicare systems will ensure that outlier payments comprise no more than 10 percent of the HHAs total HH PPS payments for the year. Medicare systems will track both the total amount of HH PPS payments that each HHA has received and the total amount of outlier payments that each HHA has received. When each HH PPS claim is processed, Medicare systems will compare these two amounts and determine whether the 10 percent has currently been met.

If the limitation has not yet been met, any outlier amount will paid normally. (Partial outlier payments will not be made. Only if the entire outlier payment on the claim does not result in the limitation being met, will outlier payments be made for a particular claim.) If the limitation has been met or would be exceeded by the outlier amount calculated for the current claim, other HH PPS amounts for the episode will be paid but any outlier amount will not be paid. When the calculated outlier amount is not paid, HHAs will be alerted to this by the presence of claim adjustment reason code 45 on the accompanying remittance advice. This code is defined "Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement."

PGBA RHHI Part A Medical Review Top Denial Reason Codes

This is 4th posting in a series of top Home Health denial reasons as published by PGBA. A reference section has been added at the end of each denial code by PGBA to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.

4. 5F071/5TO71- Orders Do Not Cover All Visits Billed

Reason for Denial

The submitted physician's orders for services did not cover all of the visits billed. An example of this is when physician's orders were submitted for seven physical therapy visits; however, 10 were billed.

How to Avoid a Denial

In order to avoid unnecessary denials for this reason code, ensure that the physician's orders (1) include a legible physician signature dated prior to billing Medicare, and (2) cover the services to be billed. The Medicare program requires that the physician order all services and that a plan of care is set up for furnishing services. When responding to an ADR, do the following:

• Ensure that all orders for services billed are included with the medical records.
• If orders do not cover the visits billed or visits need to be added, submit a corrected, hardcopy UB-04 with a 337 or 327 bill type with the medical records.

For more information, refer to:• Code of Federal Regulations, 42 CFR - Sections 409.43 and 484.18

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.1, 30.2.2 and 30.2.5

PGBA RHHI Part A Medical Review Top Denial Reason Codes

This is a continuation from last week's posting of Reason No. 2.

This is Reason No. 3

PGBA recently posted this to their website and encourages all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. A reference section has been added at the end of each denial code to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.

3. 5F041/5A041 – Information Provided Does Not Support the Medical Necessity for All or Part of This Service

Reason for Denial
This claim was fully or partially denied because the clinical documentation submitted for review did not support the medical necessity of the skilled services billed. For example, the submitted documentation may have indicated there was no longer a reasonable potential for change in the medical condition, or sufficient time had been allowed for teaching or observation of response to treatment.

How to Avoid a Denial

• Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services.

• Use the most appropriate ICD-9-CM codes to identify the beneficiary's medical diagnosis/diagnoses.

• Submit documentation to support the need for skilled care. Some reasons for services may include, but are not limited to, the following:

1) New onset or acute exacerbation of diagnosis (Include documentation to support signs and symptoms and the date of the new onset or acute exacerbation.)
2) New and/or changed prescription medications - New medications: those the beneficiary has not taken recently, i.e., within the last 30 days. Changed medications: those, which have a change in dosage, frequency, or route of administration within the last 60 days.

3) Hospitalizations (date and reason)

4) Acute change in condition (Be specific and include changes in treatment plan as a result of changes in medical condition e.g., physician contact, medication changes.)

5) Changes in caregiver status or an UNSTABLE CAREGIVING situation (i.e., involvement of many services or community resources, unsafe or unclean environment which interferes with putting the plan into action)

6) Complicating factors (i.e., simple wound care on lower extremity for a beneficiary with diabetic peripheral angiopathy)

7) Inherent complexity of services; therefore, the services can be safely and effectively provided only by a skilled professional.

8) Lack of knowledge or understanding of the beneficiary's care, which requires initial skilled teaching and training of a beneficiary, the beneficiary's family or caregiver on how to manage the beneficiary's treatment regime.

9) Reinforcement of previous teaching when there is a change in the beneficiary's physical location (i.e., discharged from hospital to home)

10) Any type of re-teaching due to a significant change in a procedure, the beneficiary's medical condition, when the beneficiary's caregiver is not properly carrying out the task, or other reasons which may require skilled re-teaching and training activities.

11) The need for a nurse to administer an injection of a self-injectable medication such as insulin or Calcimar. Clinical documentation needs to indicate: (a) the beneficiary's inability to self inject and the non-availability of a willing/able caregiver, (b) the appropriate diagnosis to warrant administration of the medication, (c) laboratory results (if required to meet Medicare criteria), and, (d) dosage of the medication.

12) The need for foley/suprapubic catheter changes and/or assessment/instruction regarding complications.

13) The need for gastrostomy tube changes and/or assessment/instruction regarding complications.

14) The need for administration of 1M/IV medications based on medical necessity, supporting diagnosis, and accepted standards of medical practice.
15) Dressing changes for complicated wound care including documentation (at least weekly) of wound location, size, depth, drainage, and complaints of pain.

16) The need for management and evaluation of a complex care plan. Answering "yes" to the following questions may be helpful in determining this need:

o Is the patient at HIGH RISK for hospitalization or exacerbation of a health problem if the plan of care is not implemented properly (i.e., multiple medical problems Or diagnosis, limitations in activities of daily living or mental status, cultural barriers, history of repeated hospitalizations)?

o Does the patient have a COMPLEX, UNSKILLED care plan (i.e. many medications, treatments, use of complex or multiple pieces of equipment, unusual variety of supplies)?

o Is there an UNSTABLE CAREGIV1NG situation (i.e. involvement of many services or community resources, unsafe or unclean environment that interferes with putting the plan into action)?

o Does it require the skills of a registered nurse or a qualified therapist to ensure safe and appropriate implementation of the plan of care?

For more information, refer to:

• Code of Federal Regulations, 42 CFR - Sections 409.32, 409.33 and 409.44

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual,, Chapter 7, Sections 40.1.2.1, 40.1.2.2 and 40.1.2.3

PGBA Home Health Medical Review Top Denial Reason Codes

PGBA recently posted this information when filing claims to prevent denials and to ensure your HHA claims are processed timely. A reference section has been added at the end of each denial code to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.

1. 56900 - Lack of Response to Medical Record Request (Refer to Section 1— Denial Reason Code 56900)
Section 1- Denial Reason Code 56900
The denial reason 56900, lack of response to Additional Development Requests (ADRs), has been reported as one of the top denial reasons for most of these benefit types. Since 56900 is common to most benefit types, we have listed this denial code separately to encourage providers to follow the instructions in the How to Avoid a Denial section before submitting claims to Palmetto GBA. Following these instructions should decrease delays in processing your claims.

Reason for DenialMedical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.

How to Avoid a Denial

• Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted.

• Alert your mail staff that the ADRs will be mailed by Palmetto GBA in bright yellow envelopes with "ADR REQUESTS TIME SENSITIVE" stamped in red on the outside of the envelope to assist them in readily identifying the ADRs.

• Be aware of the need to submit medical records within 30 days of the ADR date. The ADR date is in the upper left corner of the ADR request.

• Gather all information needed for the claim and submit it all at one time.

• Submit medical records as soon as the ADR is received.

• Attach a copy of the ADR request to each individual claim.

• If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensue each set of medical records is bound securely so the submitted documentation is not detached or lost.

• Do not mail packages C.O.D.; we cannot accept them.

• Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department.




2. 5CHG1 - Medical Review HIPPS Code Change/Documentation Contradicts M0 Item(s)
Reason for Denial

The services billed were paid at a different payment level. Based on medical review, the original HIPPS code was changed.

How to Avoid a Denial
To avoid changes for this reason, the documentation should paint a consistent picture of the patient's condition.

For more information, refer to:
• Outcome and Assessment Information Set Implementation Manual www.cms.hhsgov/oasis/

• American Health information Management Association (Web based training course available) - www.ahlma.org

• Centers for Disease Control and Prevention lCD and ICF Home Page www.cdc.gov/nchs/icd.htm

October, November and December 2009 RHHI Medical Review Top Denial Reason Codes

Medicare's Home Health Intermediary PGBA encourages all providers to review the information below when filing claims to prevent denials and to ensure their claims are processed timely. A reference section has been added by PGBA at the end of each denial code to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive by PGBA.

Med Form Store will be posting 10 weekly PGBA denial code prevention updates. Enjoy the first posting below.

Denial Reason #1: Code 56900

The denial reason 56900, lack of response to Additional Development Requests (ADRs), has been reported as one of the top denial reasons for most of these benefit types. Since 56900 is common to most benefit types, we have listed this denial code separately to encourage providers to follow the instructions in the How to Avoid a Denial section before submitting claims to Palmetto GBA. Following these instructions should decrease delays in processing your claims.

Reason for Denial

Medical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.

How to Avoid a Denial

• Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted.

• Alert your mail staff that the ADRs will be mailed by Palmetto GBA in bright yellow envelopes with "ADR REQUESTS TIME SENSITIVE" stamped in red on the outside of the envelope to assist them in readily identifying the ADRs.

• Be aware of the need to submit medical records within 30 days of the ADR date. The ADR date is in the upper left corner of the ADR request.

• Gather all information needed for the claim and submit it all at one time.

• Submit medical records as soon as the ADR is received.

• Attach a copy of the ADR request to each individual claim.

• If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensue each set of medical records is bound securely so the submitted documentation is not detached or lost.

• Do not mail packages C.O.D.; we cannot accept them.

• Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department.

Medicare Home Health Rural Add-on

Pursuant to a recent CMS posting, on March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which creates a 3% add-on to payments made for home health services to patients in rural areas. The add-on applies to episodes ending on or after April 1, 2010, through December 31, 2016. Similar to temporary rural add-on provisions in the past, claims that report a rural state code (code beginning with 999) as the Core Based Statistical Area (CBSA) code for the beneficiary’s residence will receive the additional 3% payment. The CBSA code is reported associated with value code 61 on home health claims.

The Centers for Medicare & Medicaid Services is working to expeditiously implement the home health rural add-on provision, Section 3131(c), of the PPACA.

Responding to a Home Health Additional Development Request (ADR)

In the April 2010 Medicare Advisory, the RHHI provided the the following list as a recommendation for what to include when responding to a Home Health Additional Development Request (ADR):

Plan of Care and Certification

1. Plan of Care and Certification must be signed and dated prior to billing the end of episode claim.

2. Plan of Care must cover entire billing period.

3. Physician orders not included on the Plan of Care must be signed and dated prior to billing the final claim to Medicare.

4. If alternative signatures are used, submit documentation as outlined in Centers for Medicare & Medicaid Services (CMS) Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2.8.

Documentation of services rendered

1. Adequate documentation is needed to determine medical necessity of all services billed and to support the Health Insurance Prospective Payment System (HIPPS) code (or level of payment) billed.

2. If the medical review for this claim is revenue code specific, you may choose to send notes for the discipline in question, a summary of services rendered or complete field 15 of Form CMS 486 for other disciplines billed; however, all services billed will be reviewed.

3. When intermittency is in question, documentation must include in/out time for nurse and aide visits and the projected endpoint to daily skilled nurse visits. An endpoint statement must include when daily skilled nurse visits are projected to decrease to less than daily.

4. Documentation for all PRN visits, including dates, reason for the PRN visits, outcome of visits and orders for services must be included.

5. Include any other pertinent documentation that may be needed to establish medical necessity (e.g., date of hospitalization, medication changes, laboratory values, physician contacts/visits, etc).

6. Submit documentation denoting treatment week, when different from calendar week.

7. Itemized supply list if billed:

a. Include the quantity and cost of each item.
b. Include physician orders signed and dated prior to billing the end of episode claim to cover all supplies billed.

8. Please send a manifest with medical records submitted and send the medical records in secure packaging to ensure the security of medical records.

9. If responding to multiple requests in a single envelope, ensure each response is clearly separated. If responding to more than one date of service on the same beneficiary, send a response for each request separately. Include a manifest or list identifying each ADR response sent.

10. Attach a copy of the ADR request to each individual claim.

11. Use one staple or elastic band per record to attach the documentation and ADR together. DO NOT use paper clips as they can become dislodged.

12. Do not punch holes in medical records, as this may obscure valuable information.

13. Return the medical records to the appropriate address listed below or on the ADR.

For Postal Delivery Use:
Medicare Part A Medical Review Mail Code: AG-230
P.O. Box 100238
Columbia, Sc 29202-3238

Courier Service, Use:
Medicare Part A Medical Review
Mail Code: AG-230 Building One
2300 Springdale Drive
Camden, South Carolina, 29020-1728

14. Do not include any correspondence other than ADR responses to the medical review department in your envelope.

15. If billing corrections are needed, submit a hardcopy UB-Uniform Billing (latest version from CMS), with a XX7 bill type along with your medical records.

16. Unfortunately, we are not able to accept packages on a C.O.D. basis. Please make sure that you have sent packages with the shipping prepaid.

The Palmetto GBA Medical Review Department developed a Responding to a Home Health Additional Development Request (ADR) checklist. Please complete this checklist and include it when responding to an ADR. This checklist is available on the Palmetto GBA Web site to access this checklist from the Palmetto OBA Web site:

1. Go to www.PalmettoGBA.com/rhhi.

2. Go to the Resources section and select Medical Review

3. Select the Responding to a Responding to a Home Health Additional Development Request (ADR) article.

4. Scroll down to the end of the article and select the PDF document.

Updated address to mail resumees to request Registered Nurse (RN) psychiatric approval for home health visits

PGBA has indicated as of last week that home health agencies should submit the resume of any RN that will be providing psychiatric services under the home health Medicare benefit to the following address:

Palmetto GBA
Medical Affairs, Part A
Mail Code AG-300
P.O. Box 100238
Columbia, SC 29202-3238

10% Cap Outlier Menu Options Available on the Direct Data Entry (DDE) System

According to PGBA, a new inquiry screen has been created in the Direct Data Entry (DDE) system for home health providers which will display the home health payment information that is being accumulated in relation to the 10% cap on outlier payments. Providers may access the information by selecting Option 01 (Inquiries) from the DDE Main Menu and option 67 (Home Health Payment Totals Inquiry) from the submenu. Providers will be required to enter their OSCAR (Provider number) and National Provider Identifier (NPI) to access this information.

The information provided in this article was current as of March 15, 2010. Any changes or new information superseding the information in this article will be provided in articles and publications with publication dates after March 15, 2010 posted at www.PalmettoGBA.com/rhhi.

Therapy Cap Modifier KX Extended Through March 31

On March 2, 2010, President Obama signed into law the “Temporary Extension Act of 2010.” Among other things, this law extends through March 31, 2010, the exception process for therapy claims reaching the annual cap, retroactive to January 1, 2010. Affected providers may submit claims for exceptions to the annual therapy caps, with dates of service January 1 through March 31, 2010, using the KX modifier, following the pre-January 1, 2010, requirements for therapy cap exceptions.

Home Health Direct Data Entry (DDE) Presentation

PGBA has posted the The Home Health Direct Data Entry (DDE) Handout for you to download or print in PP format. This is an extremely useful resource and a must know for all who are connected to HH billing and appeals.
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/82CR6D6188?opendocument

NPI Directory Available for Provider/Supplier Community

As stated in the Centers for Medicare & Medicaid Services (CMS) provider listserv messages that were sent last fall concerning CRs 6417 and 6421, CMS has made available a file that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment web site: www.cms.hhs.gov/MedicareProviderSupEnroll: click on “Ordering/Referring Report” on the left-hand side.

This .pdf file contains approximately 800,000 records. A new file will be made available periodically that will replace the posted file; at any given time, only one file (the most recent) will be available. The file can be viewed online. In addition, it can be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Please note the following: (1) Records are in alphabetical order based on the surname of the physician or non-physician practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are not displayed. (3) There are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness. (4) Deceased physicians and non-physician practitioners are not included in the file. (5) If a user is unsure of a physician or non-physician practitioner’s NPI, he or she can look it up in the NPI Registry (https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do).

Keep in mind that the record in the NPI Registry is not the Medicare PECOS enrollment record.

CMS Implements New Home Health Agency Stock Transfer Restrictions

Provider Types Affected

Home Health Agencies (HHAs) submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.



Provider Action Needed

This article is based on Change Request (CR) 6750, which implements two provisions from the Home Health Agency (HHA) Prospective Payment System Final Rule (CMS-1560-F). The first provision requires an HHA whose Medicare billing privileges have been deactivated to undergo a State survey or obtain accreditation from a CMS-approved accrediting organization prior to having its billing privileges reactivated. The second provision holds that an HHA may not undergo a change of ownership or transfer of ownership if the effective date of the change or transfer occurs within 36 months of: (1) the effective date of the provider’s enrollment in Medicare, or (2) the effective date of the last ownership change or transfer for the HHA. The provider must instead enroll as a new HHA, undergo a State survey or obtain accreditation from a CMS-approved accrediting organization, and sign a new provider agreement.

An “ownership change” includes any of the following:
Change of ownership (CHOW);
Acquisition/merger;
Consolidation;
Change request reporting a 5 percent or greater ownership change (including, stock transfer or asset sale); or
Change request reporting a change in partners, regardless of the percentage of ownership involved.

If a Medicare contractor receives an application for an ownership change from an HHA, it will determine whether the effective date of the transfer is within 36 months of either the effective date of the provider’s initial enrollment in Medicare or last ownership change. The Medicare contractor will verify the effective date of the ownership transfer by requesting a copy of the transfer agreement, sales agreement, bill of sale, etc., rather than relying upon the projected date of the sale listed on the application.

If the transfer date falls within the 36-month period after the effective date of the provider’s enrollment in Medicare or last ownership change, the Medicare contractor will return the application and notify the provider that, per 42 CFR 424.550(b), the HHA must:

Enroll as an initial applicant;
Obtain a new State survey or accreditation from a CMS-approved accrediting organization after it has submitted its initial enrollment application and the Medicare contractor has made a recommendation for approval to the State; and
Sign a new provider agreement as part of the initial enrollment.
As the new owner must enroll as a new provider, the Medicare contractor will also deactivate the HHA’s billing privileges if the sale has already occurred. If the sale has not occurred, the contractor will alert the HHA that it must submit a CMS-855A voluntary termination application (see http://www.cms.hhs.gov/cmsforms/downloads/cms855a.pdf on the CMS website).

If the transfer date is more than 36 months after the effective date of the provider’s enrollment in Medicare or most recent ownership change, the application can be processed normally, without the need for a new State survey or an approval from an approved accreditation organization.

Security Changes for Home Health OASIS Users

In February 2010, CMS will change the way Home Health Agencies (HHA) users’ login to submit assessment files and access agency reporting. The changes will be rolled out to transition login IDs away from shared agency login IDs, used by multiple people, to individual user IDs.

Beginning in February 2010 and wrapping up in August 2010, small groups of states will transition to individual user IDs about every two weeks.

Information regarding the roll out schedule, as well as, detailed instructions will be available in the upcoming months.

As the information is available it will be posted on your state’s OASIS State Welcome Page and the QIES Technical Support Office at http://www.qtso.com on the Internet.

What is the timely filing period?

The timely filing period for both paper and electronic Medicare claims is on or before December 31 of the calendar year following the year in which the services were furnished. Services furnished in the last quarter of the year are considered furnished in the following year as listed in the chart that is included in the Timely Filing Job Aid (PDF, 104 KB) that is listed in the Job Aids section of the Palmetto GBA Web site at www.PalmettoGBA.com/rhhi.