Good Afternoon MFS Bloggers!
The Affordable Care Act (the “ACA”) amended the requirements for physician certification of home health services to require that, as a condition of payment, prior to certifying a patient’s eligibility for the home health benefit, the certifying physician must document that the physician himself or herself, or an allowed nonphysician practitioner (NPP) working with the physician, has had a face-to-face encounter with the patient. HHAs have been required to comply with the face-to-face encounter requirements since April 1, 2011.
Importantly, CMS addressed what is called an “unintentional gap” in ACA by not explicitly including language that allows the acute or post-acute attending physician to inform the certifying physician regarding his or her face-to-face encounters with the patient to satisfy the requirement. CMS stated that ACA does not preclude a patient’s acute or post-acute physician from informing the certifying physician regarding his or her experience with the patient for the purpose of the face-to-face encounter requirement, much like a NPP currently can.
The final rule revises applicable regulations to incorporate CMS’ position: effective with starts of care beginning January 1, 2012, and later, for patients admitted to home health immediately after an acute or post-acute stay, the physician who cared for the patient in the acute or post-acute facility may perform the face-to-face encounter and communicate the clinical findings of that encounter to the certifying physician. CMS commented that the HHA may facilitate communications between the physicians, including sending the discharge plan to the certifying physician. The patient’s discharge summary or discharge plan can serve as the face-to-face documentation if it includes the signature of the certifying physician and the required content.
Monday, November 21, 2011
Friday, October 21, 2011
New Enrollment Rules
Good Morning MFS Bloggers,
The new Medicare provider enrollment revalidation effort does not change other aspects of the enrollment process. Providers should continue to submit routine changes (address updates, reassignments, additions to practices, changes in authorized officials, information updates, etc) - as they always have. If you also receive a request for revalidation, respond separately to that request.
All providers and suppliers who enrolled in the Medicare program prior to 03/25/2011 will have their enrollment revalidated under new risk screening criteria. DO NOT send in revalidated enrollment forms until you are notified by Medicare. You will receive a notice to revalidate between now and March, 2013.
ALL MEDICARE PAYMENTS TO BE MADE BY EFT
Medicare requires at the time of enrollment, enrollment change request or revalidation, providers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). As part of the revalidation efforts, all providers who are not currently receiving EFT payments will be identified, and required to submit the CMS-588EFT form with the provider revalidation application.
Have a great day, CP
The new Medicare provider enrollment revalidation effort does not change other aspects of the enrollment process. Providers should continue to submit routine changes (address updates, reassignments, additions to practices, changes in authorized officials, information updates, etc) - as they always have. If you also receive a request for revalidation, respond separately to that request.
All providers and suppliers who enrolled in the Medicare program prior to 03/25/2011 will have their enrollment revalidated under new risk screening criteria. DO NOT send in revalidated enrollment forms until you are notified by Medicare. You will receive a notice to revalidate between now and March, 2013.
ALL MEDICARE PAYMENTS TO BE MADE BY EFT
Medicare requires at the time of enrollment, enrollment change request or revalidation, providers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). As part of the revalidation efforts, all providers who are not currently receiving EFT payments will be identified, and required to submit the CMS-588EFT form with the provider revalidation application.
Have a great day, CP
Wednesday, August 17, 2011
Multiple Modality Billing On Same Date of Service
Good Afternoon MFS Bloggers, Please find below recent CMS postings regarding muliple modaliuty billing.
During a home health visit, nurses and therapists many times provide more than one service. Do we report multiple G-codes for all the services that were provided during the visit?
Answer:
In the course of a visit, a nurse or qualified therapist could likely provide more than one of the nursing or therapy services reflected in the new and revised codes. Home health agencies (HHAs) must not report more than one G-code for the nursing visit regardless of the variety of nursing services provided during the visit. Similarly, the HHA must not report more than one G-code for the therapy visit, regardless of the variety of therapy services provided during the visit. In cases where more than one nursing or therapy service is provided in a visit, the HHA should report the G-code which reflects the service for which most of the time was spent during that visit.
Note: Documentation should include details of all the services provided during the visit.
Is it true that if a home health agency (HHA) provides a therapy service and a nursing service on the same day for the same patient that the HHA can only bill one G-code for that day?Answer:
No. Change Request 7182 does not change the reporting requirements for HHAs. Claims must report all home health services provided to the beneficiary within the episode. Each service must be reported in line item detail. A separate G-code for therapy and a separate G-code for nursing for the same patient on the same day is acceptable.
Have a great afternoon, CP
During a home health visit, nurses and therapists many times provide more than one service. Do we report multiple G-codes for all the services that were provided during the visit?
Answer:
In the course of a visit, a nurse or qualified therapist could likely provide more than one of the nursing or therapy services reflected in the new and revised codes. Home health agencies (HHAs) must not report more than one G-code for the nursing visit regardless of the variety of nursing services provided during the visit. Similarly, the HHA must not report more than one G-code for the therapy visit, regardless of the variety of therapy services provided during the visit. In cases where more than one nursing or therapy service is provided in a visit, the HHA should report the G-code which reflects the service for which most of the time was spent during that visit.
Note: Documentation should include details of all the services provided during the visit.
Is it true that if a home health agency (HHA) provides a therapy service and a nursing service on the same day for the same patient that the HHA can only bill one G-code for that day?Answer:
No. Change Request 7182 does not change the reporting requirements for HHAs. Claims must report all home health services provided to the beneficiary within the episode. Each service must be reported in line item detail. A separate G-code for therapy and a separate G-code for nursing for the same patient on the same day is acceptable.
Have a great afternoon, CP
Tuesday, July 26, 2011
Home Health Services and Physical Therapy Assistants
Good Morning MFS Bloggers, I have recently been asked the following question from a few providers:
Can a therapy assistant provide therapy visits?
Answer:
No. As per CMS, the new therapy maintenance codes, G0159, G0160 and G0161 are described in Change Request (CR) 7182 as services performed by a qualified physical therapist, occupational therapist and speech-language pathologist in the home health setting within the establishment or delivery of a safe and effective maintenance program.
Additionally, CR 7182 revises the current descriptions for existing G-codes for physical therapists (G0151), occupational therapists (G0152) and speech-language pathologists (G0153) to include in the descriptions that they are intended for the reporting of services provided by a qualified physical or occupational therapist or speech language pathologist.
A qualified therapist is one who meets the personnel requirements in the Conditions of Participation (CoPs) which is available in the Code of Federal Regulations (42 CFR) Section 484.4 (PDF, 147 KB).
Can a therapy assistant provide therapy visits?
Answer:
No. As per CMS, the new therapy maintenance codes, G0159, G0160 and G0161 are described in Change Request (CR) 7182 as services performed by a qualified physical therapist, occupational therapist and speech-language pathologist in the home health setting within the establishment or delivery of a safe and effective maintenance program.
Additionally, CR 7182 revises the current descriptions for existing G-codes for physical therapists (G0151), occupational therapists (G0152) and speech-language pathologists (G0153) to include in the descriptions that they are intended for the reporting of services provided by a qualified physical or occupational therapist or speech language pathologist.
A qualified therapist is one who meets the personnel requirements in the Conditions of Participation (CoPs) which is available in the Code of Federal Regulations (42 CFR) Section 484.4 (PDF, 147 KB).
Wednesday, July 6, 2011
CMS PROPOSES 2012 MEDICARE HOME HEALTH PAYMENT CHANGES
Good Afternoon MFS Bloggers, CMS is again pecking away at your pursestrings for
2012.
Yesterday, the Centers for Medicare & Medicaid Services (CMS) today announced a number of proposed changes to Medicare home health payments for 2012.
A proposed rule was displayed at the Federal Register today proposing a 3.35 percent decrease in Medicare payments to home health agencies (HHAs) for calendar year (CY) 2012. This would be an estimated net decrease of $640 million compared to HHA payments in CY 2011. It would include the combined effects of market basket and wage index updates (a $310 million increase) and reductions to the home health prospective payment system (HH PPS) rates to account for increases in aggregate case-mix that are largely related to billing practices and not related to changes in the health status of patients (a $950 million decrease).
Provisions of the Affordable Care Act (ACA) mandate that CMS apply a one (1) percentage point reduction to the CY 2012 home health market basket amount; this would equate to a proposed 1.5 percent update for HHAs next year. As part of the HH PPS rate update, CMS also proposes to reduce HH PPS rates by 5.06 percent in CY 2012 to account for the increase in the case-mix that is unrelated to changes in patient acuity.
The Medicare HHA proposed rule would also make structural changes to the HH PPS by removing two hypertension codes from the case-mix system, lowering payments for high therapy episodes and recalibrating the HH PPS case-mix weights to ensure that these changes result in the same amount of total aggregate payments.
“CMS’s proposal reflects our commitment to ensure that we pay accurately for Medicare home health services as we improve the structure of our payment system and decrease incentives for upcoding,” said Jonathan Blum, Deputy Administrator and Director of the Center for Medicare.
Medicare pays home health agencies through a prospective payment system (PPS) which pays at higher rates to care for those beneficiaries with greater needs. Payment rates are based on relevant data from patient assessments conducted by clinicians; such data are currently required from all Medicare-participating home health agencies (HHAs).
Home health payment rates have been updated annually by either the full home health market basket percentage increase, or by the home health market basket percentage increase as adjusted by Congress. CMS uses the home health market basket index, which measures inflation in the prices of an appropriate mix of goods and services included in home health services. The Deficit Reduction Act of 2005 requires an adjustment to the home health market basket percentage update depending on HHAs submission of quality data. The proposed home health market basket increase for CY 2012 is 1.5 percent. HHAs that submit the required quality data would receive payments based on this full home health market basket update. If an HHA does not submit quality data, the home health market basket percentage increase would be reduced by 2 percentage points to -0.5 percent for CY 2012.
Under current Medicare policy a certifying physician or an allowed non-physician practitioner must see a patient prior to certifying a patient as eligible for the home health benefit. In today’s proposed rule filing, Medicare has proposed to add flexibility to allow physicians who attended to a home health patient in an acute or post-acute setting to inform the certifying physician of their encounters with the patient in order to satisfy the requirement.
In a separate proposed rulemaking filed today (CMS-2348-P), CMS would require comparable face-to-face (F2F) encounters for people receiving Medicaid home health services to adhere to the unifying nature of these provisions made under the ACA.
To qualify for the Medicare home health benefits, a beneficiary must be under the care of a physician, have an intermittent need for skilled nursing care, or need physical or speech therapy, or continue to need occupational therapy. The beneficiary must be homebound and receive home health services from a Medicare approved home health agency. Beneficiaries receiving Medicaid home health do not need to be homebound or require skilled care. Home health agencies participating in the Medicaid program must also adhere to Medicare conditions of participation.
Cindy Mann, director of CMS’ Center for Medicaid, CHIP and Survey & Certification, said the alignment of F2F encounter requirements between the two CMS programs fulfills Section 6407 of the Affordable Care Act. “We established the Medicaid implementation of this requirement to align with Medicare’s guidance to better facilitate home health services provided to individuals that are eligible for Medicare and Medicaid and to lessen the administrative burden on providers participating in both programs” Mann said.
This Medicaid regulation also clarifies long-standing CMS policy on locations and facilities in which home health services may be provided, in order for States to remain in compliance with the Olmstead Supreme Court decision.
The proposed rules went on display at 4:00 pm on 7/5/11 at the Federal Register. The rule can be located at: http://federalregister.gov/inspection.aspx
2012.
Yesterday, the Centers for Medicare & Medicaid Services (CMS) today announced a number of proposed changes to Medicare home health payments for 2012.
A proposed rule was displayed at the Federal Register today proposing a 3.35 percent decrease in Medicare payments to home health agencies (HHAs) for calendar year (CY) 2012. This would be an estimated net decrease of $640 million compared to HHA payments in CY 2011. It would include the combined effects of market basket and wage index updates (a $310 million increase) and reductions to the home health prospective payment system (HH PPS) rates to account for increases in aggregate case-mix that are largely related to billing practices and not related to changes in the health status of patients (a $950 million decrease).
Provisions of the Affordable Care Act (ACA) mandate that CMS apply a one (1) percentage point reduction to the CY 2012 home health market basket amount; this would equate to a proposed 1.5 percent update for HHAs next year. As part of the HH PPS rate update, CMS also proposes to reduce HH PPS rates by 5.06 percent in CY 2012 to account for the increase in the case-mix that is unrelated to changes in patient acuity.
The Medicare HHA proposed rule would also make structural changes to the HH PPS by removing two hypertension codes from the case-mix system, lowering payments for high therapy episodes and recalibrating the HH PPS case-mix weights to ensure that these changes result in the same amount of total aggregate payments.
“CMS’s proposal reflects our commitment to ensure that we pay accurately for Medicare home health services as we improve the structure of our payment system and decrease incentives for upcoding,” said Jonathan Blum, Deputy Administrator and Director of the Center for Medicare.
Medicare pays home health agencies through a prospective payment system (PPS) which pays at higher rates to care for those beneficiaries with greater needs. Payment rates are based on relevant data from patient assessments conducted by clinicians; such data are currently required from all Medicare-participating home health agencies (HHAs).
Home health payment rates have been updated annually by either the full home health market basket percentage increase, or by the home health market basket percentage increase as adjusted by Congress. CMS uses the home health market basket index, which measures inflation in the prices of an appropriate mix of goods and services included in home health services. The Deficit Reduction Act of 2005 requires an adjustment to the home health market basket percentage update depending on HHAs submission of quality data. The proposed home health market basket increase for CY 2012 is 1.5 percent. HHAs that submit the required quality data would receive payments based on this full home health market basket update. If an HHA does not submit quality data, the home health market basket percentage increase would be reduced by 2 percentage points to -0.5 percent for CY 2012.
Under current Medicare policy a certifying physician or an allowed non-physician practitioner must see a patient prior to certifying a patient as eligible for the home health benefit. In today’s proposed rule filing, Medicare has proposed to add flexibility to allow physicians who attended to a home health patient in an acute or post-acute setting to inform the certifying physician of their encounters with the patient in order to satisfy the requirement.
In a separate proposed rulemaking filed today (CMS-2348-P), CMS would require comparable face-to-face (F2F) encounters for people receiving Medicaid home health services to adhere to the unifying nature of these provisions made under the ACA.
To qualify for the Medicare home health benefits, a beneficiary must be under the care of a physician, have an intermittent need for skilled nursing care, or need physical or speech therapy, or continue to need occupational therapy. The beneficiary must be homebound and receive home health services from a Medicare approved home health agency. Beneficiaries receiving Medicaid home health do not need to be homebound or require skilled care. Home health agencies participating in the Medicaid program must also adhere to Medicare conditions of participation.
Cindy Mann, director of CMS’ Center for Medicaid, CHIP and Survey & Certification, said the alignment of F2F encounter requirements between the two CMS programs fulfills Section 6407 of the Affordable Care Act. “We established the Medicaid implementation of this requirement to align with Medicare’s guidance to better facilitate home health services provided to individuals that are eligible for Medicare and Medicaid and to lessen the administrative burden on providers participating in both programs” Mann said.
This Medicaid regulation also clarifies long-standing CMS policy on locations and facilities in which home health services may be provided, in order for States to remain in compliance with the Olmstead Supreme Court decision.
The proposed rules went on display at 4:00 pm on 7/5/11 at the Federal Register. The rule can be located at: http://federalregister.gov/inspection.aspx
Monday, June 20, 2011
CMS Offers Provider Community Clarity on Face-to-Face Rules
Good Morning MFS Bloggers, In continuing with CMS's clarification of the face-to-face rules, please be advised of the following issues clarified below:
What happens if the face-to-face encounter is completed during the 90-day period prior to the start of care (SOC) and then the patient's condition changes?
Answer:
In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care (SOC), the certifying physician or an allowed non-physician practitioner (NPP) must see the patient again within 30 days after admission. Specifically, if a patient saw the certifying physician or NPP within the 90 days prior to SOC, another encounter would be needed if the patient's condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan.
What role is a hospital permitted to play in certifying the need for home health care?
Answer:
For Medicare purposes, a physician who attended to the patient but does not follow the patient in the community, such as a hospitalist, is permitted to certify the need for home health care based on that physician's face-to-face contact with the patient in the hospital. Further, this physician may establish and sign the plan of care (POC), initiate the orders for home health services and 'hand off' the patient to his or her community-based physician to review and sign off on the POC. Only the certifying physician or certain non-physician practitioners (NPPs) can perform the face-to -face encounter. Additionally, only Medicare-enrolled physicians can certify home health eligibility, per the Affordable Care Act.
Happy Monday. CP
What happens if the face-to-face encounter is completed during the 90-day period prior to the start of care (SOC) and then the patient's condition changes?
Answer:
In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care (SOC), the certifying physician or an allowed non-physician practitioner (NPP) must see the patient again within 30 days after admission. Specifically, if a patient saw the certifying physician or NPP within the 90 days prior to SOC, another encounter would be needed if the patient's condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan.
What role is a hospital permitted to play in certifying the need for home health care?
Answer:
For Medicare purposes, a physician who attended to the patient but does not follow the patient in the community, such as a hospitalist, is permitted to certify the need for home health care based on that physician's face-to-face contact with the patient in the hospital. Further, this physician may establish and sign the plan of care (POC), initiate the orders for home health services and 'hand off' the patient to his or her community-based physician to review and sign off on the POC. Only the certifying physician or certain non-physician practitioners (NPPs) can perform the face-to -face encounter. Additionally, only Medicare-enrolled physicians can certify home health eligibility, per the Affordable Care Act.
Happy Monday. CP
Friday, June 3, 2011
Part 2: Face to Face Encounters
Good Afternoon MFS Bloggers, Here is Part 2 of CMS Clarification Guidelines on the Face to Face Encounters.
Is the same physician required to sign both the plan of care (POC) and certification of the need for home health care?
Per CMS, Prior to calendar year (CY) 2011, the Centers for Medicare & Medicaid Services (CMS) manual guidance required the same physician to sign the certification and the plan of care (POC). Beginning in CY 2011, CMS will allow additional flexibility associated with the POC when a patient is admitted to home health from an acute or post-acute setting. For such patients, physicians who attend to the patient in acute and post-acute settings are authorized to certify the need for home health care based on their face-to-face contacts with the patient (which includes documentation of the face-to-face encounter), initiate the orders (POC) for home health services and 'hand off' the patient to his or her community-based physician to review and sign off on the POC. CMS continues to expect that in most cases, the same physician will certify, establish and sign the POC, but the flexibility exists for home health post-acute patients if needed.
Have a great weekend!
Is the same physician required to sign both the plan of care (POC) and certification of the need for home health care?
Per CMS, Prior to calendar year (CY) 2011, the Centers for Medicare & Medicaid Services (CMS) manual guidance required the same physician to sign the certification and the plan of care (POC). Beginning in CY 2011, CMS will allow additional flexibility associated with the POC when a patient is admitted to home health from an acute or post-acute setting. For such patients, physicians who attend to the patient in acute and post-acute settings are authorized to certify the need for home health care based on their face-to-face contacts with the patient (which includes documentation of the face-to-face encounter), initiate the orders (POC) for home health services and 'hand off' the patient to his or her community-based physician to review and sign off on the POC. CMS continues to expect that in most cases, the same physician will certify, establish and sign the POC, but the flexibility exists for home health post-acute patients if needed.
Have a great weekend!
Monday, May 23, 2011
CMS Posts Face-to-Face Clarification Guidelines
Can the face-to-face documentation be included with the Plan of Care (POC) and certification documentation?
Answer:
Per CMS, The Affordable Care Act requires the face-to-face encounter and corresponding documentation as a certification requirement. In other words, the face-to-face encounter is an additional certification requirement. Long-standing regulations have described the distinct content requirements for the plan of care (POC) and certification. Providers have the flexibility to implement the content requirements for both the POC and certification in a manner that works best for them. Many providers have implemented the requirements for the POC and certification by using one form which meets all the content requirements of both the POC and certification. This approach is acceptable and it will continue to be acceptable.
Answer:
Per CMS, The Affordable Care Act requires the face-to-face encounter and corresponding documentation as a certification requirement. In other words, the face-to-face encounter is an additional certification requirement. Long-standing regulations have described the distinct content requirements for the plan of care (POC) and certification. Providers have the flexibility to implement the content requirements for both the POC and certification in a manner that works best for them. Many providers have implemented the requirements for the POC and certification by using one form which meets all the content requirements of both the POC and certification. This approach is acceptable and it will continue to be acceptable.
Tuesday, May 3, 2011
HHA Timely FIling Rejections Ruled Improper
CMS Change Request (CR) 7080 established the Medicare policy for claims that include span dates of service (i.e., a “From” and “Through” date span on the claim), the claim is used to determine the date of service for claims filing timeliness.
Current Medicare instructions require the “From” and “Through” dates to be the same date on the Request for Anticipated Payment (RAP) for HH PPS episode. This means the RAP will have an earlier "Through" date than the associated final claim for the same episode. Since CR 7080 was implemented, RAPs have been incorrectly rejected as untimely when the associated final claim was still timely. CMS has determined that this is an error and has instructed Medicare contractors to bypass the enforcement of timely filing on RAPs regarding this matter.
Cases have already occurred in which a RAP was incorrectly rejected as untimely and a timely submitted final claim for the same episode was returned to the provider due to the lack of a corresponding RAP on file. In some cases, these final claims are now past the timely filing deadline. CMS has determined that an administrative error exception to the timely filing requirement applies in these cases. Home health agencies affected by these cases should bring them to the attention of their Medicare intermediary, who will bypass timely filing for these claims so they may be processed.
Current Medicare instructions require the “From” and “Through” dates to be the same date on the Request for Anticipated Payment (RAP) for HH PPS episode. This means the RAP will have an earlier "Through" date than the associated final claim for the same episode. Since CR 7080 was implemented, RAPs have been incorrectly rejected as untimely when the associated final claim was still timely. CMS has determined that this is an error and has instructed Medicare contractors to bypass the enforcement of timely filing on RAPs regarding this matter.
Cases have already occurred in which a RAP was incorrectly rejected as untimely and a timely submitted final claim for the same episode was returned to the provider due to the lack of a corresponding RAP on file. In some cases, these final claims are now past the timely filing deadline. CMS has determined that an administrative error exception to the timely filing requirement applies in these cases. Home health agencies affected by these cases should bring them to the attention of their Medicare intermediary, who will bypass timely filing for these claims so they may be processed.
Thursday, April 14, 2011
Requests for Anticipated Payment Incorrectly Rejected as Untimely
Good Morning to All MFS Bloggers, Pursuant to CMS, its Change Request 7080 established the policy that for institutional claims that include span dates of service (i.e., a 'From' and 'Through' date span on the claim), the 'Through' date on the claim is used to determine the date of service for claims filing timeliness. This policy had an unintended impact on billing home health Prospective Payment System (HH PPS) episodes of care.
Medicare instructions require the 'From' and 'Through' dates to be the same date on the request for anticipated payment (RAP) for an HH PPS episode. This means the RAP will have an earlier 'Through' date than the associated final claim for the same episode. Since CR 7080 was implemented, RAPs have been rejected as untimely when the associated final claim was still timely. CMS has determined that this is an error and has instructed Medicare contractors to bypass the enforcement of timely filing on RAPs.
Cases have already occurred in which a RAP was incorrectly rejected as untimely and a timely-submitted final claim for the same episode was returned to the provider due to the lack of a corresponding RAP on file. In some cases, these final claims are now past the timely filing deadline. CMS has determined that an administrative error exception to the timely filing requirement applies in these cases. Home health agencies affected by these cases should bring them to the attention of their Medicare contractors, who will bypass timely filing for these claims so they may be processed.
Have a great day! CP
Medicare instructions require the 'From' and 'Through' dates to be the same date on the request for anticipated payment (RAP) for an HH PPS episode. This means the RAP will have an earlier 'Through' date than the associated final claim for the same episode. Since CR 7080 was implemented, RAPs have been rejected as untimely when the associated final claim was still timely. CMS has determined that this is an error and has instructed Medicare contractors to bypass the enforcement of timely filing on RAPs.
Cases have already occurred in which a RAP was incorrectly rejected as untimely and a timely-submitted final claim for the same episode was returned to the provider due to the lack of a corresponding RAP on file. In some cases, these final claims are now past the timely filing deadline. CMS has determined that an administrative error exception to the timely filing requirement applies in these cases. Home health agencies affected by these cases should bring them to the attention of their Medicare contractors, who will bypass timely filing for these claims so they may be processed.
Have a great day! CP
Monday, February 28, 2011
CMS’s New Home Health Claims Reporting Requirements for G Codes Therapy and Skilled Nursing Services
Good Morning MFS Bloggers,
The January 1, 2011 effective date means that these new and revised G-codes should be used for home health episodes beginning on or after January 1st, 2011.
CMS’s new requirements include:
- The revision of the current descriptions for the G-codes for physical therapists (G0151), occupational therapist (G0152), and speech-language pathologists (G0153), to include that they are to be used to report services that are provided by a qualified physical or occupational therapist, or speech language pathologist;
- The addition of two new G-codes (G0157 and G0158) to report restorative physical therapy and occupational therapy provided by qualified therapy assistants;
- The addition of three new G-codes (G0159, G0160 and G0161, physical therapist, occupational therapist, and speech language pathologists, respectively) to report the establishment, or delivery of therapy maintenance programs by qualified therapists;
- The revision of the current G-code definition for skilled nursing services (G0154) and the requirement that HHAs use this code only for the reporting of direct skilled nursing care to the patient by a licensed nurse (LPN or RN); and,
- The addition of three new G-codes (G0162, G0163, and G0164) that are required to report: 1) the skilled services of a licensed nurse (RN only) in the management and evaluation of the care plan; 2) the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse (LPN or RN) can determine the patient’s status until the treatment regimen is essentially stabilized; and 3) the skilled services of a licensed nurse (LPM or RN) in the training or education of a patient, a patient’s family member, or caregiver.
** More information regarding the new G codes can be found in CMS’s Change
Request 7182.
The January 1, 2011 effective date means that these new and revised G-codes should be used for home health episodes beginning on or after January 1st, 2011.
CMS’s new requirements include:
- The revision of the current descriptions for the G-codes for physical therapists (G0151), occupational therapist (G0152), and speech-language pathologists (G0153), to include that they are to be used to report services that are provided by a qualified physical or occupational therapist, or speech language pathologist;
- The addition of two new G-codes (G0157 and G0158) to report restorative physical therapy and occupational therapy provided by qualified therapy assistants;
- The addition of three new G-codes (G0159, G0160 and G0161, physical therapist, occupational therapist, and speech language pathologists, respectively) to report the establishment, or delivery of therapy maintenance programs by qualified therapists;
- The revision of the current G-code definition for skilled nursing services (G0154) and the requirement that HHAs use this code only for the reporting of direct skilled nursing care to the patient by a licensed nurse (LPN or RN); and,
- The addition of three new G-codes (G0162, G0163, and G0164) that are required to report: 1) the skilled services of a licensed nurse (RN only) in the management and evaluation of the care plan; 2) the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse (LPN or RN) can determine the patient’s status until the treatment regimen is essentially stabilized; and 3) the skilled services of a licensed nurse (LPM or RN) in the training or education of a patient, a patient’s family member, or caregiver.
** More information regarding the new G codes can be found in CMS’s Change
Request 7182.
Tuesday, January 11, 2011
*****Special Announcement: CMS Delays Enforcement of Home HEalth Face-to-Face Requirement*****
The Centers for Medicare & Medicaid Services (CMS) has agreed to delay enforcement of the home health face-to-face encounter requirement until April 1, 2011, though the January 1, 2011, implementation date remains in place. In November, CMS issued a final rule implementing the Affordable Care Act provision that requires face-to-face encounters between home healthcare patients and their physicians to initiate (SOC)Medicare coverage of home healthcare. CMS stated that while implementation of F2F would begin as planned on January 1, 2011, enforcement will not take place until after a three-month transition period. CMS has made it clear that the the three-month transition to enforcement of this face-to-face requirement will not be further extended.
Monday, January 10, 2011
Home Health Billing Dispute Resolution Requests
Good Afternoon MFS bloggers,
PGBA recently published an article regarding the fact that providers sometimes experience situations where they are unable to resolve a billing dispute with another provider either due to overlapping dates of service or sequential billing.
Home health providers should ensure that a patient's Medicare eligibility records are reviewed before the patient is admitted. If the patient's Medicare eligibility records reflect that care is or was being provided by another provider, and the records do not reflect that the previous provider has finalized their billing, the receiving provider is responsible for contacting the existing/previous provider to request that they complete their billing.
What should the agency do in case there is a dispute?
Should a dispute arise, both agencies are required under Medicare regulations to make an attempt to resolve the issue between them. If the agencies are unable to resolve the dispute, Palmetto GBA may be contacted for assistance.
Palmetto GBA will work with both agencies to settle the dispute. Providers seeking assistance from Palmetto GBA to resolve a billing dispute should complete the Billing Dispute Resolution Request Form found at the PGBA-RHHI website (forms.) All information on the form is required to assist the provider.
Note: Providers are not required to use the form, but all requests must include the elements contained in the form. If the form is incomplete or the written request does not include all the required information, the request will be returned to the provider. Providers should also note that the request to settle a billing dispute must pertain to claims that are within the timely filing requirements unless the situation falls within the exceptions to grant an extension to the timely filing requirement. Please refer to the Timely Filing Guidelines Job Aid for additional information on the timely filing requirements.
Upon receipt of the completed form or a written request that includes all the required information, Palmetto GBA will take the necessary steps to assist the provider with resolving the situation.
PGBA recently published an article regarding the fact that providers sometimes experience situations where they are unable to resolve a billing dispute with another provider either due to overlapping dates of service or sequential billing.
Home health providers should ensure that a patient's Medicare eligibility records are reviewed before the patient is admitted. If the patient's Medicare eligibility records reflect that care is or was being provided by another provider, and the records do not reflect that the previous provider has finalized their billing, the receiving provider is responsible for contacting the existing/previous provider to request that they complete their billing.
What should the agency do in case there is a dispute?
Should a dispute arise, both agencies are required under Medicare regulations to make an attempt to resolve the issue between them. If the agencies are unable to resolve the dispute, Palmetto GBA may be contacted for assistance.
Palmetto GBA will work with both agencies to settle the dispute. Providers seeking assistance from Palmetto GBA to resolve a billing dispute should complete the Billing Dispute Resolution Request Form found at the PGBA-RHHI website (forms.) All information on the form is required to assist the provider.
Note: Providers are not required to use the form, but all requests must include the elements contained in the form. If the form is incomplete or the written request does not include all the required information, the request will be returned to the provider. Providers should also note that the request to settle a billing dispute must pertain to claims that are within the timely filing requirements unless the situation falls within the exceptions to grant an extension to the timely filing requirement. Please refer to the Timely Filing Guidelines Job Aid for additional information on the timely filing requirements.
Upon receipt of the completed form or a written request that includes all the required information, Palmetto GBA will take the necessary steps to assist the provider with resolving the situation.
Tuesday, January 4, 2011
CMS Clarifies POC Physician Signature Requirements
Happy 2011 to all MFS Bloggers,
CMS recently clarified its position with regard to physician's signing and dating Plans of Care. I have seen many POC denial determinations and post-payment audits incorrectly assessed by various Intermediaries based upon this policy.
Palmetto GBA published clarification due to recently received clarifications from the Centers for Medicare & Medicaid Services (CMS) in reference to physician signatures with stamped dates. CMS has clarified that physicians must sign and date home health plans of care, verbal orders and certifications. This changes Palmetto GBA's long standing policy of accepting a date stamp or facsimile date as proof of timeliness in lieu of a physician dating his/her signature. This change is effective for all documents signed on or after January 1, 2011.
Based on the following CMS references, failure to meet these requirements may result in full or partial denial of services.
- CMS Internet Only Manuals (IOMs), Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Section 30.1 states that "the attending physician signs and dates the POC/certification prior to the claim being submitted for payment."
- This manual requirement is also addressed in 42 CFR 424.22 (D)2 effective January 1, 2011, and states that "the certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.' The instructions for re-certifications are found in this same Part and restates that it 'must be signed and dated by the physician who reviews the plan of care."
CMS recently clarified its position with regard to physician's signing and dating Plans of Care. I have seen many POC denial determinations and post-payment audits incorrectly assessed by various Intermediaries based upon this policy.
Palmetto GBA published clarification due to recently received clarifications from the Centers for Medicare & Medicaid Services (CMS) in reference to physician signatures with stamped dates. CMS has clarified that physicians must sign and date home health plans of care, verbal orders and certifications. This changes Palmetto GBA's long standing policy of accepting a date stamp or facsimile date as proof of timeliness in lieu of a physician dating his/her signature. This change is effective for all documents signed on or after January 1, 2011.
Based on the following CMS references, failure to meet these requirements may result in full or partial denial of services.
- CMS Internet Only Manuals (IOMs), Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Section 30.1 states that "the attending physician signs and dates the POC/certification prior to the claim being submitted for payment."
- This manual requirement is also addressed in 42 CFR 424.22 (D)2 effective January 1, 2011, and states that "the certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.' The instructions for re-certifications are found in this same Part and restates that it 'must be signed and dated by the physician who reviews the plan of care."
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