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
Wednesday, June 30, 2010
Tuesday, June 22, 2010
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.
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.
Friday, June 11, 2010
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.
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.
Wednesday, June 2, 2010
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.
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.
Subscribe to:
Comments (Atom)
