THE PARRELLA BLOG

CMS POSTS REVISIONS TO OASIS-C MANUALS

2012-01-11T08:03:00.002-05:00

Good Morning MFS Bloggers, CMS recently revised the its OASIS-C Guidance Manual for Calendar Year 2011. The revisions and updated errata list are now available on the CMS site, https://www.cms.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp, and are available for download:

OASIS-C Guidance Manual Errata (December 2011)
and OASIS-C Guidance Manual (December 2011)

Have a great day!

Chris

DECEMBER 8, 2011: CMS CLARIFIES FACE-TO-FACE REQUIREMENTS

2012-01-04T10:48:00.002-05:00

Good Morning MFS Bloggers, In a December 8, 2011 CMS Listserv Update, CMS clarified its policy on its face-to-face documentation requirements. CMS stated as follows: “In the case of patients admitted to home health following an acute or post-acute stay, the BPM language allows for one physician to sign the certification and face-to-face documentation, while a different physician can sign the plan of care. If the face-to-face encounter documentation and the CMS-485 form collectively satisfy all of the certification and plan of care content requirements as defined in Chapter 7 Section 30 of the BPM, Medicare contractors shall accept a CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the certification, face-to-face encounter, and plan of care requirements. In this scenario, the certifying physician is the acute or post-acute physician, has initiated content on the CMS-485, and has completed and signed the face-to-face encounter documentation. The physician who signs the CMS-485 assumes care for the patient’s home healthcare.
Additionally, it has come to our attention that some contractors are denying claims for failure of the acute or post-acute physician to identify the community physician who will assume care for the patient. CMS has not mandated the acute or post-acute physician to follow a specific documentation protocol to hand-off a patient to the community physician.
For claims that have been previously denied for not having met face-to-face requirements in the scenarios described above, upon receiving a request from the home health agency for reopening of the claim, CMS contractors have been instructed to reopen and determine if face-to-face requirements have been met, due to their meeting the criteria described in the instruction described above. However, a determination that face-to-face requirements have been met would not result in an automatic pay of the claim. Contractors must subsequently perform a complete and full review to determine if payment should be made.
In summary, assuming all content requirements of the certification and the face-to-face documentation are otherwise met, in the case of patients admitted to home health following an acute or post-acute stay, Medicare contractors have been instructed to accept a CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the requirement of the certification, (which now includes the face-to-face encounter).”

Wishing you all a happy and healthy 2012.
Christopher A. Parrella, JD, CHC, CPC, CPCO

CY 2012 Home Health Final Rule Makes Changes to Face-to-Face Encounter Guidelines

2011-11-21T14:55:00.001-05:00

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.

New Enrollment Rules

2011-10-21T14:31:00.000-04:00

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

Multiple Modality Billing On Same Date of Service

2011-08-17T13:21:00.002-04:00

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

Home Health Services and Physical Therapy Assistants

2011-07-26T10:42:00.001-04:00

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).

CMS PROPOSES 2012 MEDICARE HOME HEALTH PAYMENT CHANGES

2011-07-06T13:53:00.002-04:00

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

CMS Offers Provider Community Clarity on Face-to-Face Rules

2011-06-20T10:43:00.003-04:00

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

Part 2: Face to Face Encounters

2011-06-03T12:11:00.002-04:00

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!

CMS Posts Face-to-Face Clarification Guidelines

2011-05-23T09:36:00.001-04:00

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.

HHA Timely FIling Rejections Ruled Improper

2011-05-03T15:50:00.000-04:00

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.

Requests for Anticipated Payment Incorrectly Rejected as Untimely

2011-04-14T09:41:00.002-04:00

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

CMS’s New Home Health Claims Reporting Requirements for G Codes Therapy and Skilled Nursing Services

2011-02-28T09:57:00.001-05:00

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.

Special Announcement: CMS Delays Enforcement of Home HEalth Face-to-Face Requirement

2011-01-11T08:42:00.002-05:00

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.

Home Health Billing Dispute Resolution Requests

2011-01-10T14:31:00.002-05:00

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.

CMS Clarifies POC Physician Signature Requirements

2011-01-04T12:27:00.001-05:00

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."

New HHA CHOW Rules Finalized

2010-12-20T09:47:00.001-05:00

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

2010-12-13T08:13:00.001-05:00

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

2010-12-06T09:37:00.002-05:00

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

2010-11-29T10:19:00.003-05:00

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

2010-11-22T11:07:00.002-05:00

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

2010-11-15T08:49:00.002-05:00

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

2010-11-10T09:39:00.001-05:00

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

2010-09-20T14:02:00.002-04:00

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

2010-09-13T12:03:00.002-04:00

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

2010-09-09T08:49:00.003-04:00

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

2010-09-01T13:25:00.003-04:00

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

2010-08-20T08:16:00.002-04:00

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

2010-08-09T09:03:00.002-04:00

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

2010-08-02T09:41:00.003-04:00

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

2010-07-29T09:37:00.003-04:00

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

2010-07-20T11:49:00.002-04:00

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

2010-07-13T12:01:00.001-04:00

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

2010-06-30T12:02:00.002-04:00

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

2010-06-22T12:22:00.004-04:00

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

2010-06-11T08:36:00.003-04:00

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

2010-06-02T13:01:00.001-04:00

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

2010-05-24T12:26:00.001-04:00

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

2010-05-18T11:54:00.002-04:00

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

2010-05-10T09:04:00.001-04:00

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

2010-05-05T08:40:00.003-04:00

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

2010-04-26T10:25:00.003-04:00

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

2010-04-20T13:28:00.003-04:00

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

2010-04-13T10:52:00.002-04:00

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

2010-04-01T11:02:00.001-04:00

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)

2010-03-30T08:50:00.002-04:00

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

2010-03-22T09:05:00.002-04:00

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

2010-03-16T09:23:00.001-04:00

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

2010-03-04T08:47:00.002-05:00

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

2010-02-05T07:38:00.003-05:00

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

2010-02-01T11:13:00.000-05:00

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

2010-01-18T11:04:00.001-05:00

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

2010-01-11T09:17:00.000-05:00

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?

2010-01-06T09:33:00.000-05:00

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.

ROUTINE MEDICAL SUPPLIES

2009-12-28T08:17:00.002-05:00

There exists much confusion regarding routine medical supplies in the HHA industry. The PPS rule states that the cost of routine medical supplies is bundled into the HHA’s PPS reimbursement. As such, HHA’s may not bill separately for routine supplies. Routine supplies are “supplies that are customarily used in small quantities during the course of most home care visits. Routine supplies would not include supplies specifically ordered by the physician or are essential to HHA personnel in order to effectuate the plan of care.”

Examples of supplies which are usually considered routine medical, but are not limited to:

A) Dressings and Skin Care
B) Infection Control Protection
C) Blood Drawing Supplies
D) Incontinence Supplies

If the above items are required in quantity, for a recurring need, these supplies may be considered non-routine and this may be a billable supply. This should be confirmed with your local Intermediary prior to billing.

NEW CHANGE OF OWNERSHIP/TRANSFER OF STOCK PROHIBITIONS

2009-12-14T08:25:00.001-05:00

Effective, January 1st, 2010 all HHA transfers of stock and those that are defined as a Change of Ownership (CHOW), which occur prior to the expiration of 36 months from the receipt of the HHA’s Medicare certification, will require that the acquiring party or entity enroll as a new provider via a CMS 855A and undergo a state survey or accreditation. This will cause a gap in billing from the time CMS-RO pends all claims of the deactivated HHA until the new provider agreement is activated.

MANAGEMENT AND EVALUATION

2009-12-11T09:06:00.000-05:00

The 2010 PPS Rule clarifies the rule that in the house health setting, management and evaluation of a patient care plan is considered a reasonable and necessary skilled service only when underlying conditions or complications are such that a registered nurse can ensure that essential non-skilled care is achieving its purpose. (42 C.F.R. 409.42(c)(1)(i))
Patient Education Services
The 2010 PPS Rule clarifies when patient education services constituted skilled services would be deemed to no longer be needed when it became apparent, after a reasonable period of time, that the patient, family, or caregiver would not be trained. Further teaching and training would cease to be reasonable and necessary in this case and would cease to be considered a skilled service. The services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching on training was unsuccessful.

2010 HHA PPS OUTLIER CAP AND NEW HHA CONGRESSIONAL CUTS

2009-12-07T15:13:00.000-05:00

Beginning calendar year 2010, CMS will cap home health outlier payments at 10% per HHA and target total aggregate outlier payments at 2.5% of all HH PPS payments. This is an agency level cap such that in any given calendar year, an individual HHA would receive no more than 10% of its total HH PPS payments in outlier payments.
In a 12/05/09 New York Times article, the impact of this legislation has been a topic of interest during the first week of Senate debate. Under Congress’s new legislation to insure more than 30 million Americans, home care would be hit disproportionately hard. Home care currently accounts for 3.7% of the Medicare budget but would take a 10.2% hit by the House bill and 9.4% hit by the Senate bill. This translates into a $55 billion reduction over 10 years in Medicare spending on home health services under the House bill and a $43 billion reduction under the Senate bill.

HHA PLAN OF CARE FALSE CLAIMS ACT SETTLEMENT

2009-11-18T18:38:00.000-05:00

HHA Agrees to Pay $2 Million to Resolve Claims of Failure to Collect Doctor Approvals

An Indiana home health care agency (HHA) and its parent company agreed to pay almost $2 million to resolve allegations it violated the False Claims Act by failing to obtain certain required physician approvals before submitting bills to Medicare, the Department of Justice announced Oct. 20.

The statement said that certain required physician signatures were not timely collected before final claims were submitted to Medicare, the DOJ release said.

In addition, certain documentation supporting the Outcome & Assessment Information set data for the claims did not exist, according to the settlement agreement.

Home Health Coalition Questions and Answers

2009-10-24T09:22:00.000-04:00

At a July 13th, 2009 PGBA meeting, the following information was provided by the Intermediary regarding an inpatient admission issue:

“A beneficiary does not have to be discharged from home care because of an inpatient admission.” An agency did not discharge at the beginning of the recertification period because they did not believe there was a need to based on the above quoted statement. The scenario is the recertification was completed as required but the patient was transferred to inpatient hospital before the beginning of the recertification period. When the patient was discharged from the hospital, which was the first visit after the beginning of the recertification period, a resumption of care was completed. Their claim is being denied due to overlapping services. What needs to be added to the claim so the agency is appropriately reimbursed?

The following reference was provided for that question in the July 13th, 2009 answer. Reference: The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual Chapter 10, Section 10.1.14 Home Health Agency Billing. Within this Section of the manual it states:
“Note that beneficiaries do not have to be discharged within the episode period because of admissions to other types of health care providers (i.e., hospitals, skilled nursing facilities), but HHAs may choose to discharge in such cases. When discharging, full episode payment would still be made unless the beneficiary received more home care later in the same 60-day period. Discharge should be made at the end of the 60-day episode period in all cases if the beneficiary has not returned to the HHA, and is not expected to return for treatment under any existing plan of care”.

Therefore, it is the provider’s choice whether or not to officially discharge the patient and submit a final claim. Additionally, this section of the manual reminds providers that without an early discharge date, 60-day episodes stand alone. If the 60-day episode ends while the patient is still hospitalized, recertification and a new plan of care will need to be done.

If the provider decides to leave the patient open to the current episode, there will not be an overlap of services if the patient returns to the agency within the 60 days because the HHA will not have line item dates of service on the same dates as the inpatient facility billing days.

The provider might also decide to discharge a patient immediately at the time of admission to a skilled facility. That is a decision that is made by the agency. However, in this scenario, should the patient return to the agency before the episode is over, a new SOC would be established and the first part of the episode would be PEP’d.

If the patient is “left open” to the home health episode, and the episode ends, the HHA should submit a final claim once the 60 day episode is finished. After that, should the patient be discharged from the facility back to a home health agency, a new episode and SOC would be done.

What’s New About the OASIS-C Numbering System.

2009-10-24T09:13:00.001-04:00

The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

What’s New About the OASIS-C Numbering System.

The OASIS-C represents the most comprehensive revision to OASIS since its original release in 1999. Please note that, with the exception of the tracking items and M0903/M0906, the OASIS-C items have been renumbered; thus the OASIS-B1 M0 item numbers do not correspond to the new OASIS-C numbering scheme.

Table 1: OASIS-C Numbering System.

Patient Tracking Items M0010 - M0069; M0140 – M0150
Clinical RecordsM0080 – M0110
Patient History Diagnoses -M1000s
Living Arrangements-M1100
Sensory Status-M1200s
Integumentary Status-M1300s
Respiratory Status-M1400s
Cardiac Status-M1500s
Elimination Status-M1600s
Neuro/Emotional Behavioral Status -M1700s
ADLs/IADLs-M1800s + M1900s
Medications-M2000s
Care Management-M2100s
Therapy Need and Plan of Care-M2200s
Emergent Care-M2300s
Date Collected at Transfer/Discharge -M2400s, M0903 + M0906

The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

Time Points

OASIS-C data are collected at the following time points:
Start of Care
Resumption of Care following inpatient facility stay
Recertification within the last five days of each 60-day recertification period
Other Follow-Up
Transfer to inpatient facility
Discharge from home care
Death at home

All of these assessments, with the exception of transfer to inpatient facility and death at home, must be conducted during a home visit because all require the clinician to have an in-person encounter with the patient. The transfer to an inpatient facility requires collection of limited OASIS data (most of which may be obtained through a telephone call).

At the start of care time point, the comprehensive assessment should be completed within five days of the start of care date. At the resumption of care, the comprehensive assessment must be completed within 48 hours of inpatient facility discharge. For the transfer to inpatient facility, discharge from home care, death at home, and other follow-up, the assessments must be completed within 48 hours of becoming aware of the transfer, discharge, death, or significant change in condition.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

Who completes OASIS-C?

As identified in (M0080) Discipline of Person Completing Assessment, the comprehensive assessment and OASIS data collection should be conducted by a registered nurse (RN) or any of the therapies (PT, SLP/ST, OT). An LPN/LVN, PTA, OTA, MSW, or Aide may not complete OASIS assessments.

In cases involving nursing, the RN completes the comprehensive assessment at SOC. Any discipline qualified to perform assessments – RN, PT, SLP, OT – may complete subsequent assessments. For a therapy-only case, the therapist usually conducts the comprehensive assessment. It is acceptable for a PT of SLP to conduct and complete the comprehensive assessment at SOC. An OT may conduct and complete the assessment when the need for occupational therapy establishes program eligibility. Note: Occupational therapy alone does not establish for the Medicare home health benefit at the start of care; however, occupational therapy may establish eligibility under other programs, such as Medicaid. The Medicare home health patient who is receiving services from multiple disciplines (i.e., skilled nursing, physical therapy, and occupational therapy) during the episode of care, can retain eligibility if, over time, occupational therapy is only remaining skilled discipline providing care. At that time, an OT can conduct OASIS assessments.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

Section 484.20(a) Standard: Encoding OASIS Data

Once the comprehensive assessment has been completed and OASIS data collected, HHAs enter the OASIS information into the computer system, which we call “encoding.” All the time points of the OASIS assessments have a uniform time frame of thirty days from the date the assessment is completed. (M0090 – Date Assessment Completed) for encoding and submitting data. Once the OASIS data are encoded (in software available from CMS or other software that conforms to the CMS standard electronic record layout, edit specifications, and data dictionary), the agency will review each assessment and edit it for transmission to the State Agency. During this preparation period, the HHA must run software application that subjects each patient data set to the CMS edit specifications and makes it transmission –ready. The agency must correct any information that does not pass the CMS specified edits (e.g., data is missing, incorrect, or inconsistent). Staff entering data may need to contact the qualified clinician who assessed the patient for assistance and clinical notes, which document the assessment, are better at a point in time closer to the assessment activity than if the edits and corrections are delayed.

HHAs have flexibility in the method used to encode their data. Data can be encoded directly by the skilled professional who conducts the assessment into a laptop or hand held computer, by a clerical staff member from a hard copy of the completed assessment, or by a data entry operator or service with whom the HHA may contract to enter the data. Any of these acceptable methods of meeting the regulatory reporting requirements for OASIS. However, the HHA is ultimately responsible for meeting the reporting requirements as well as maintaining patient confidentiality.

Non-clinical staff may not assess patients or complete assessment items; however, clerical staff or data entry operators may enter into the computer the OASIS data collected by the skilled professional. In entering the data, HHAs must comply with all requirements for safeguarding the confidentiality of protected health (patient-identifiable) information.

Once the OASIS data are encoded, HHAs use their software to review and edit the data prior to transmission to the State Agency. When editing the data prior to the transmission, it is important to remember that the edits include an electronic safety net to preclude the transmission of erroneous or inconsistent information and enforce he required formatting for the data set items. When transmitted, the patient assessment data are stabilized at the time point of the assessment, preventing the override of current assessment information with future or past information.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

Section 484.20(b) Standard: Accuracy of Encoded OASIS Data

The encoded OASIS data must accurately reflect the patient’s status at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data that are sent to the State. We expect that once the qualified skilled professional completes the assessment, the HHA will develop a means to ensure that the OASIS data input into the computer and transmitted to the State Agency (or CMS contractor) exactly reflect the data collected by the skilled professional. Appendix B contains recommendations for conducting data quality audits on a routine basis and includes information from the original OASIS Implementation Manual (Chapter 12). In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to the State.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

Section 484.20(c) Standard: Transmittal of OASIS Data

The encoded OASIS data must accurately reflect the patient’s status at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data that are sent to the State. We expect that once the qualified skilled professional completes the assessment, the HHA will develop a means to ensure that the OASIS data input into the computer and transmitted to the State Agency (or CMS contractor) exactly reflect the data collected by the skilled professional. Appendix B contains recommendations for conducting data quality audits on a routine basis and includes information from the original OASIS Implementation Manual (Chapter 12). In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to the State.

CMS requires that the HHA electronically transmit the accurate, completed, and encoded OASIS data to the State Agency (or CMS contractor) within 30 days of the completion of the assessment (M0090 Date Assessment Completed). Data must be transmitted in a format that meets the requirements specified in the data format standard (i.e., conforming to the CMS standard electronic record layouts, edit specifications, and data dictionary). CMS believes that this time frame for transmitting the data will minimize the burden on the HHA associated with frequency of transmission, maintain uniform assessment reporting time frames, and maintain a clear reporting time frame that eliminates the variation of days in a month. Therefore, HHAs are free to develop schedules for transmitting the data that best suit their needs. HHAs must use CMS-specified electronic communications protocols to contact the State Agency or CMS contractor, transmit the export file, and receive validation information. HHAs required to submit OASIS data must do so using browser software to access the State system via the Medicare Data Communications Network, which provides a direct telephone connection for submission and interim reports. Once transmitted, the State Agency or CMS contractor validates the information while the HHA remains on-line to ensure that some basic elements such as format and HHA information conform to CMS requirements. Once these file checks are completed, a message indicating whether the file has been accepted or rejected is sent back to the HHA's terminal and appears on its computer screen and is reported on the initial validation report displaying all Fatal File and Warning messages in relation to the submission file as a whole. If the submission passes the initial validation check, each individual record is then checked for errors or exceptions to the data specifications, and a Final Validation Report is generated. If the individual record is rejected, a message is sent to the HHA along with the rejected submission file for correction. A file or individual record may be rejected for a variety of reasons, (e.g., the provider identification name or number submitted may be incorrect, the number of records indicated in the trailer record does not match the actual number of records submitted). The HHA must make the corrections and resubmit the file to the State.

 
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

Condition of Participation: Comprehensive Assessment of Patients
42 CFR 484.55 requires that a patient receive from the HHA a patient-specific, comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. The comprehensive assessment must (1) identify the patient's continuing need for home care; (2) meet the patient's medical, nursing, rehabilitative, social, and discharge planning needs; and (3) for Medicare patients, identify eligibility for the home health benefit, including the patient's homebound status. The comprehensive assessment must also incorporate the exact use of the current version of the OASIS data set, which is found on the CMS OASIS web site at HYPERLINK http://www.cms.hhs.Qov/oasis; http://www.cms.hhs.Qov/oasis; click on "Data Set." A comprehensive assessment identifies patient progress toward desired outcomes or goals of the care plan.

CMS expects that HHAs will collect OASIS data in the context of a comprehensive assessment on adult Medicare or Medicaid patients (age 18 or over) receiving skilled health services from the HHA, except for patients receiving care for pre- and post-partum conditions. Patients receiving skilled health services, whose care is reimbursed by other than Medicare or Medicaid, must receive comprehensive assessments, but the collection of OASIS data is not required. For patients receiving only personal care services, regardless of payer source, a comprehensive assessment is also required, but not the collection of OASIS data. Patients who receive poly services such as homemaker, chore, or companion services do not require the comprehensive assessment.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.

Five standards are contained in the Comprehensive Assessment CoP.

Following are the requirements for each standard.

a. §484.55 Standard: Initial Assessment Visit

The initial visit is performed to determine the immediate care and support needs of the patient. This visit is conducted within 48 hours of referral or within 48 hours of a patient's return home from an inpatient stay, or on the physician-ordered start of care date. The initial assessment visit is intended to ensure that the patient's most critical needs for home care services are identified and met in a timely fashion. For Medicare patients, this initial assessment determines eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be conducted by a registered nurse unless rehabilitation therapy services are the only services ordered by the physician. Under the Medicare home health benefit, any one of three services (skilled nursing, physical therapy, or speech-language pathology) can establish program eligibility. If rehabilitation therapy services are the only services ordered by the physician, the initial assessment may be made by the appropriate rehabilitation skilled professional if the need for that service establishes eligibility for the home health benefit. The law governing home health eligibility prevents occupational therapy from establishing eligibility for the Medicare home health benefit at the initial assessment, though once eligibility is established, then continuing occupational therapy could establish eligibility for a subsequent episode (meaning that the occupational therapist could complete the Recertification assessment). If no skilled service is delivered at this initial assessment, this visit will not be considered the SOC nor is it considered a reimbursable visit for the Medicare home health benefit.

Note that for payers other than Medicare, the occupational therapist may complete the initial assessment if the need for occupational therapy establishes program eligibility.

The comprehensive assessment is not required to be completed at the initial assessment visit, although the HHA may choose to do so. If a skilled service is delivered at the initial assessment visit, thus establishing the SOC, the comprehensive assessment may be initiated at this visit and completed within the time frames discussed below, depending on agency policy.

b. §484.55(b) Standard: Completion of the Comprehensive Assessment

The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the start of care.

This requirement does not preclude an HHA from completing the comprehensive assessment during the SOC visit, and many HHAs currently operate in such a manner. This time frame provides operational flexibility to the HHA while maintaining patient safety in ensuring that all patient needs will be identified within a standard time period. Some HHAs have policies requiring that a nurse conduct the comprehensive assessment. Home care staff should follow agency policies governing which disciplines can complete the comprehensive assessment.

C. §484.55(c) Standard: Drug Regimen Review

Under this requirement, the comprehensive assessment must include a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

While patients receive their drug regimen from the physician, review of this regimen is an integral part of the comprehensive assessment. In addition, this review is an important safeguard for patients who may receive medications from a variety of physicians and pharmacies. Some agencies have policies requiring nurses to do the drug regimen review. In addition, some state practice acts may preclude therapists from completing the drug regimen review. Home care staff should follow state regulations and agency polices governing which disciplines can complete the drug regimen review.

d. §484.55(d) Standard: Update of the Comprehensive Assessment

The comprehensive assessment, which includes OASIS items for Medicare and Medicaid patients, must be updated and revised as frequently as the patient's condition requires, but not less frequently than every 60 days beginning with the start of care date; within 48 hours of the patient's return home from an inpatient facility stay of 24 hours or more for any reason except diagnostic testing; and at discharge. The update of the comprehensive assessment must include completion of all required OASIS items for that time point, plus any others determined necessary by the HHA for a comprehensive assessment. This assessment provides information for determination of changes in treatment or plan of care. Therefore, a comprehensive assessment also is required when there is a major decline or improvement in a patient's health status as defined by the HHA.

An inpatient facility admission as an event is generally a predictor of a change in the patient's health status and therefore should be captured in the OASIS data. In addition, because patients frequently improve rapidly upon returning home from an inpatient facility, it is important for the HHA to assess the patient's true needs as quickly as possible after discharge from the inpatient facility. Therefore, the comprehensive assessment is required within 48 hours of the patient's return to the home from an inpatient facility admission of 24 hours or more for any reason other than diagnostic tests.

Follow-up assessments must be completed every 60 days that a patient is under care. For Medicare and Medicaid patients, when a follow-up assessment is due, it must be completed no earlier than four calendar days before, and no later than the day marking the end of the 60-day period (i.e., day 56 through day 60 of the period).

e. §484.55(e) Standard: Incorporation of the OASIS Data Set

OASIS must be incorporated into the HHAs own assessment, exactly as written. Both the language and the groupings of the OASIS items must be maintained. Integrating the OASIS items into the agency's own assessment system in the sequence presented in the OASIS form would facilitate data entry of the items into data collection and reporting software. However, HHAs may integrate the items in such a way that best Suits the agency's own assessment.
The OASIS data set is not intended to constitute a complete comprehensive assessment instrument. Rather, the data set comprises items that are a necessary part of a complete comprehensive assessment and that are essential to uniformly and consistently measure patient outcomes. An HHA can use the data set as the foundation for valid and reliable information for patient assessment, care planning, service delivery, and improvement efforts.
The OASIS items are already used in one form or another by virtually all HHAs that conduct thorough assessments, and simply adding the OASIS data set to the rest of the HHA's paperwork would be burdensome and duplicative. Therefore, we expect HHAs to replace similar assessment items with OASIS items in their assessment forms to avoid lengthening the assessment unnecessarily. This may be accomplished by modification of existing forms or using commercially available comprehensive assessment forms that include OASIS items. The Mxxxx numbers for each OASIS data item should be retained to allow for easy recognition of the required OASIS item in the HHA comprehensive assessments.

Home Health Compliance Discussion

2009-10-13T13:25:00.000-04:00

Compliance issues frequently occur within the home health industry in referral patterns, billing and coding of claims, contractual and joint venture relationships, and licensure of home health professionals. Listed below are a few fact patterns that should be a cause for concern for the Agency compliance officer.

Q: When should the HHA compliance officer think “Stark”?
A: Anytime the HHA has a compensation/referral relationship with a physician. In a recent case, an Agency paid five physicians for services involving review of patients’ charts and plans of care, participation in regular meetings to review and discuss quality of care issues, and participation in training and staff evaluation. This relationship was held to have violated the Stark Law because it was found the physicians had a prohibited compensation arrangement. In the end, the HHA was held liable for approximately $400,000.

Q: When should the HHA compliance officer think “Anti-kickback!”?
A: Anytime there is a potential for giving anything of value for the referral of patients to someone in a position to refer.

Antikickback Example 1:
A HHA provided free medical alert pages and pager monitoring service to homebound patients during the period that they were receiving home health services. The OIG ruled that, while having potential for fraud and abuse, the arrangement did not violate the law, because the devices promoted and improved quality of care.

Antikickback Example 2:
A nation-wide network of HHAs decided to provide prospective customers with a free “preoperative home safety assessment.” This involved having a licensed physical therapist who either made a house call or telephoned the patient and reviewed with the patient whether the home was suitable for postoperative recovery. The OIG ruled that the assessment was something of value given to the patient which was used to solicit business, and the arrangement therefore violated the Anti-kickback Statute.

Q: When should the HHA compliance officer think “False Claim”?
A: Anytime the facts indicate that a false claim was “knowingly” submitted to the government. In a Department of Justice Press Release on February 9th, 2006, Intrepid USA, a chain of some 150 HHAs, paid an $8 million settlement with the government for submitting false claims to federal healthcare programs “where services had not been provided by a qualified person, where Intrepid had failed to complete and maintain the necessary documentation to support its claims, or where the company had otherwise violated Medicare’s regulations.”

Q: License credentialing. How important is it? When should the HHA compliance officer be on “licensing lookout”?
A: Tenet Hospital in Florida paid a settlement of some $29 million for alleged violations of the False Claims Act, including home health services provided by HHAs based on fraudulent statements or omissions regarding the patient’s medical records, condition, history, or eligibility for medical coverage. Services that were provided by unskilled, unlicensed, or uncertified personnel, or were never ordered by a physician may result in a false claim.

The Parrella Blog thanks Gregory M. Nowakowski
Of Rogers Mantese & Associates, P.C. for his permission to use excerpts of their previously authored article in the HCCA journal.

Revisions to Claims Processing Instructions for Osteoporosis Drugs under the Home Health Benefit

2009-09-29T10:11:00.001-04:00

Effective 01/01/2010, the date of service on claims submitted for osteoporosis drugs must fall within the start and end dates of an existing home health prospective payment system (PPS) episode.

PGBA-RHHI adds ICD-9 codes for PT

2009-09-29T10:10:00.002-04:00

PGBA-RHHI has added the following ICD-9 codes to support Physical Therapy for Home Health (LCD 99HH-021-L): 359.71, 359.78, 832.2 (effective 10/01/09) v15.88 (effective 09/17/09).

Falls Evaluation

2009-09-21T16:41:00.000-04:00

Falls Evaluations are components of existing quality improvement efforts for Medicare Part A providers.

Palmetto GBA has included V15.88 (history of falls) in the final policy to reflect this potential. While claims containing V15.88 would still require the addition of another covered ICD-9-CM code to specify the impairment of structure/function and/or activity limitation (e.q., ICD-9-CM 438.4 monoplegia of lower limb; ICD-9-CM 781.2 abnormality of gait), inclusion of the V15.88 code will help communicate the coverage available and help promote communication of reasonable and necessary physical therapy and/or occupational therapy interventions.

Changes to Outlier Payment Policies

2009-08-31T16:08:00.001-04:00

Home health agencies (HHAs) receive additional payments (outlier payments) for 60-day home health episodes of care that carry unusually high costs. CMS, in a recently proposed rule, is seeking to cap outlier payments at 10 percent per agency and target total aggregate outlier payment at 2.5 percent of total HH PPS payments. Currently, the target for outlier payment targets is 5 percent of total HH PPS payments. As such, CMS reduces home health rates by 5 percent to fund outlier payments. By lowering the total outlier payment target to 2.5 percent of total HH PPS payments, CMS would increase home health rates by 2.5 percent.

Final Percentage Payment Reminder

2009-08-17T13:59:00.001-04:00

The Plan of Care (Form 485) must be signed and dated by a physician before the claim for each episode for services is submitted for the final percentage payment.

Initial Percentage Payment Reminder

2009-08-17T13:58:00.001-04:00

If a physician signed Plan of Care (Form 485) is not available at the beginning of the episode, the HHA may submit a RAP for the initial percentage payment based on a physician’s verbal orders OR a referral prescribing detailed orders for the services to be rendered that is signed and dated by the physician. A billable visit must be rendered prior to the submission of a RAP.

DME as covered service by a Home Health Agency

2009-08-17T13:56:00.000-04:00

DME must be differentiated from routine and non-routine medical supplies which are bundled to the agency and included in the base rate payment. Durable Medical Equipment (DME) is paid separately from the PPS bundled rate and is excluded from consolidated billing requirements governing PPS. The determining factor is the medical classification of the supply, not the diagnosis of the patient.

CMS NEWS RELEASE

2009-07-17T09:33:00.000-04:00

Some payments for home health providers received by the Centers for Medicare & Medicaid Services (CMS) Healthcare Integrated Ledger Accounting System (HIGLAS) for processing for cycle dates from July 7, 2009 through July 9, 2009, may have been paid incorrectly due to the installation of the July release. Home health Request for Anticipated Payment (RAP) and Low Utilization Payment Adjustment (LUPA) claims and adjustments where the original or adjustment amount ended in zeroes were truncated, and the zeroes were dropped from the payment calculation. This has resulted in underpayments and some overpayments on claims processing for payment. The problem has been identified and was corrected on July 11, 2009 to prevent future occurrences.

Claims that were placed in the approved to pay location prior to the installation of the fix will pay at the incorrect amount. All future claims will be paid correctly. CMS is aggressively working to identify and calculate the payment differences on all impacted claims. A process to issue payments to providers is being developed by CMS with the highest priority, with an expected completion date on or about July 31, 2009. The corrected payments for the home health original claim underpayments will be issued on or about July 20, 2009, followed by corrected payments for the adjusted claim differences on or about July 31, 2009.

Impact to Providers

All amounts due will be issued as non-claim payments and appear with your normal remittance advice. Some claims on payments during the timeframe referenced above were underpaid and some adjustments were overpaid. The claim details related to these claim payments will be reported correctly within the remit, however, the payment difference will appear in the ‘Adjust to Balance’ field. There is no action required by providers regarding this issue, since CMS will be issuing corrected payments to all impacted providers.

OASIS – C Posted for Review

2009-07-14T13:18:00.000-04:00

Draft OASIS-C has been posted by CMS for review. The final version of the new OASIS-C is expected within the next few months with a roll-out date of January, 2010. CMS expects the OASIS User’s Manual to be updated in September, 2009 and will contain detailed guidance on the use of OASIS-C.

Non-Clinician and Patient’s First Home Health Visit

2009-07-14T13:16:00.000-04:00

If nursing services are ordered, federal regulations require the initial assessment visit to be performed by an RN and to be performed by a qualified therapist if services other than nursing services are ordered. Therefore, a non-clinician is prohibited by federal law from visiting the patient to collect patient identifying OASIS information regardless of the home health services ordered.

CMS Corrects Edit of HIPPS Codes for Home Health Claims

2009-05-13T23:20:00.001-04:00

With an implementation date of 10/05/09, CMS created a payment safeguard that ensures home health agencies no longer incorrectly change the supply severity level reflected in the 5^th position of Home Health Prospective Payment System (HH PPS) Health Insurance Prospective Payment System (HIPPS) codes. The fifth position of the HIPPS on the final claim can only differ from the fifth position of that code on the Request for Anticipated Payment (RAP) in cases where supplies were initially expected to be required, but were not supplied. Then, the code can only change from the S-X letter code on the RAP to its correspondence number (1-6) code on the final claim.

HHAs should change the fifth position of the HIPPS code on HH PPS claims only in order to report cases where supplies were or were not provided during the episode.

Home health prospective payment system

2009-04-14T22:10:00.000-04:00

On 01/01/09, CMS updated the 60 day national episode rates and the national per-visit amounts under the home health prospective payment system (HH PPS). Medicare home health payments for HHAs that report quality data will be increased by 2.9%, while payments for those HHAs that do not report quality data will be increased 0.9%. For more information on how to receive your 2.9% increase for reporting quality data, please call your RHHI at 866-801-5301.

Stamp signatures no longer be accepted

2009-04-14T22:05:00.000-04:00

Effective with dates of service beginning April 28^th, 2008 stamp signatures will no longer be accepted as a valid physician’s signature for home health orders, including the plan of care. Claims with physician stamp signatures will be denied during the medical review process.

THE PARRELLA BLOG

CMS POSTS REVISIONS TO OASIS-C MANUALS

DECEMBER 8, 2011: CMS CLARIFIES FACE-TO-FACE REQUIREMENTS

CY 2012 Home Health Final Rule Makes Changes to Face-to-Face Encounter Guidelines

New Enrollment Rules

Multiple Modality Billing On Same Date of Service

Home Health Services and Physical Therapy Assistants

CMS PROPOSES 2012 MEDICARE HOME HEALTH PAYMENT CHANGES

CMS Offers Provider Community Clarity on Face-to-Face Rules

Part 2: Face to Face Encounters

CMS Posts Face-to-Face Clarification Guidelines

HHA Timely FIling Rejections Ruled Improper

Requests for Anticipated Payment Incorrectly Rejected as Untimely

CMS’s New Home Health Claims Reporting Requirements for G Codes Therapy and Skilled Nursing Services

*****Special Announcement: CMS Delays Enforcement of Home HEalth Face-to-Face Requirement*****

Home Health Billing Dispute Resolution Requests

CMS Clarifies POC Physician Signature Requirements

New HHA CHOW Rules Finalized

New Therapy Regulations

RAP's

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

Home Health Change of Information 855A Applications

CMS Publishes Home Health Agency Patient Transfer Updates

LUPA Claims Paying Incorrectly

HHA TRANSFERS

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

Expansion of Scope of Edits for Home Health Agencies

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

CMS Proposes New Face-to-Face Encounter Requirement

CMS PROPOSES PAYMENT CHANGES TO MEDICARE HOME

2010 Office of Inspector General Work Plan: Home Health Agencies

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

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

PGBA Home Health Top Denial Codes: Part 12

PGBA Home Health Top Denial Codes: Part 11

PGBA Enhances Home Health (HH) Consolidated Billing Enforcement

PGBA Home Health Top Denial Codes: Part 10

PGBA Home Health Top Denial Codes: Part 9

PGBA Home Health Medical Review Top Denial Reason Codes

Continuation Blog of PGBA's Top Denial Reason Codes

Additional Outlier Payment Guidance - PGBA

PGBA RHHI Part A Medical Review Top Denial Reason Codes

PGBA RHHI Part A Medical Review Top Denial Reason Codes

PGBA Home Health Medical Review Top Denial Reason Codes

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

Medicare Home Health Rural Add-on

Responding to a Home Health Additional Development Request (ADR)

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

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

Therapy Cap Modifier KX Extended Through March 31

Home Health Direct Data Entry (DDE) Presentation

NPI Directory Available for Provider/Supplier Community

CMS Implements New Home Health Agency Stock Transfer Restrictions

Security Changes for Home Health OASIS Users

What is the timely filing period?

ROUTINE MEDICAL SUPPLIES

NEW CHANGE OF OWNERSHIP/TRANSFER OF STOCK PROHIBITIONS

MANAGEMENT AND EVALUATION

2010 HHA PPS OUTLIER CAP AND NEW HHA CONGRESSIONAL CUTS

HHA PLAN OF CARE FALSE CLAIMS ACT SETTLEMENT

Home Health Coalition Questions and Answers

What’s New About the OASIS-C Numbering System.

Home Health Compliance Discussion

Revisions to Claims Processing Instructions for Osteoporosis Drugs under the Home Health Benefit

PGBA-RHHI adds ICD-9 codes for PT

Falls Evaluation

Changes to Outlier Payment Policies

Final Percentage Payment Reminder

Initial Percentage Payment Reminder

DME as covered service by a Home Health Agency

CMS NEWS RELEASE

OASIS – C Posted for Review

Non-Clinician and Patient’s First Home Health Visit

CMS Corrects Edit of HIPPS Codes for Home Health Claims

Home health prospective payment system

Stamp signatures no longer be accepted

Special Announcement: CMS Delays Enforcement of Home HEalth Face-to-Face Requirement

Claim Denials for Non-PECOS Enrolled Ordering/Referring Providers