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CMS Posts Face-to-Face Clarification Guidelines

Can the face-to-face documentation be included with the Plan of Care (POC) and certification documentation?

Answer:

Per CMS, The Affordable Care Act requires the face-to-face encounter and corresponding documentation as a certification requirement. In other words, the face-to-face encounter is an additional certification requirement. Long-standing regulations have described the distinct content requirements for the plan of care (POC) and certification. Providers have the flexibility to implement the content requirements for both the POC and certification in a manner that works best for them. Many providers have implemented the requirements for the POC and certification by using one form which meets all the content requirements of both the POC and certification. This approach is acceptable and it will continue to be acceptable.

HHA Timely Filing Rejections Ruled Improper

CMS Change Request (CR) 7080 established the Medicare policy for claims that include span dates of service (i.e., a “From” and “Through” date span on the claim), the claim is used to determine the date of service for claims filing timeliness.

Current Medicare instructions require the “From” and “Through” dates to be the same date on the Request for Anticipated Payment (RAP) for HH PPS episode. This means the RAP will have an earlier “Through” date than the associated final claim for the same episode. Since CR 7080 was implemented, RAPs have been incorrectly rejected as untimely when the associated final claim was still timely. CMS has determined that this is an error and has instructed Medicare contractors to bypass the enforcement of timely filing on RAPs regarding this matter.

Cases have already occurred in which a RAP was incorrectly rejected as untimely and a timely submitted final claim for the same episode was returned to the provider due to the lack of a corresponding RAP on file. In some cases, these final claims are now past the timely filing deadline. CMS has determined that an administrative error exception to the timely filing requirement applies in these cases. Home health agencies affected by these cases should bring them to the attention of their Medicare intermediary, who will bypass timely filing for these claims so they may be processed.

Requests for Anticipated Payment Incorrectly Rejected as Untimely

Good Morning to All MFS Bloggers, Pursuant to CMS, its Change Request 7080 established the policy that for institutional claims that include span dates of service (i.e., a ‘From’ and ‘Through’ date span on the claim), the ‘Through’ date on the claim is used to determine the date of service for claims filing timeliness. This policy had an unintended impact on billing home health Prospective Payment System (HH PPS) episodes of care.

Medicare instructions require the ‘From’ and ‘Through’ dates to be the same date on the request for anticipated payment (RAP) for an HH PPS episode. This means the RAP will have an earlier ‘Through’ date than the associated final claim for the same episode. Since CR 7080 was implemented, RAPs have been rejected as untimely when the associated final claim was still timely. CMS has determined that this is an error and has instructed Medicare contractors to bypass the enforcement of timely filing on RAPs.

Cases have already occurred in which a RAP was incorrectly rejected as untimely and a timely-submitted final claim for the same episode was returned to the provider due to the lack of a corresponding RAP on file. In some cases, these final claims are now past the timely filing deadline. CMS has determined that an administrative error exception to the timely filing requirement applies in these cases. Home health agencies affected by these cases should bring them to the attention of their Medicare contractors, who will bypass timely filing for these claims so they may be processed.

Have a great day! CP

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

Good Morning MFS Bloggers,

The January 1, 2011 effective date means that these new and revised G-codes should be used for home health episodes beginning on or after January 1st, 2011.

CMS’s new requirements include:

– The revision of the current descriptions for the G-codes for physical therapists (G0151), occupational therapist (G0152), and speech-language pathologists (G0153), to include that they are to be used to report services that are provided by a qualified physical or occupational therapist, or speech language pathologist;

– The addition of two new G-codes (G0157 and G0158) to report restorative physical therapy and occupational therapy provided by qualified therapy assistants;

– The addition of three new G-codes (G0159, G0160 and G0161, physical therapist, occupational therapist, and speech language pathologists, respectively) to report the establishment, or delivery of therapy maintenance programs by qualified therapists;

– The revision of the current G-code definition for skilled nursing services (G0154) and the requirement that HHAs use this code only for the reporting of direct skilled nursing care to the patient by a licensed nurse (LPN or RN); and,

– The addition of three new G-codes (G0162, G0163, and G0164) that are required to report: 1) the skilled services of a licensed nurse (RN only) in the management and evaluation of the care plan; 2) the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse (LPN or RN) can determine the patient’s status until the treatment regimen is essentially stabilized; and 3) the skilled services of a licensed nurse (LPM or RN) in the training or education of a patient, a patient’s family member, or caregiver.

** More information regarding the new G codes can be found in CMS’s Change
Request 7182.

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

The Centers for Medicare & Medicaid Services (CMS) has agreed to delay enforcement of the home health face-to-face encounter requirement until April 1, 2011, though the January 1, 2011, implementation date remains in place. In November, CMS issued a final rule implementing the Affordable Care Act provision that requires face-to-face encounters between home healthcare patients and their physicians to initiate (SOC)Medicare coverage of home healthcare. CMS stated that while implementation of F2F would begin as planned on January 1, 2011, enforcement will not take place until after a three-month transition period. CMS has made it clear that the the three-month transition to enforcement of this face-to-face requirement will not be further extended.

Home Health Billing Dispute Resolution Requests

Good Afternoon MFS bloggers,

PGBA recently published an article regarding the fact that providers sometimes experience situations where they are unable to resolve a billing dispute with another provider either due to overlapping dates of service or sequential billing.
Home health providers should ensure that a patient’s Medicare eligibility records are reviewed before the patient is admitted. If the patient’s Medicare eligibility records reflect that care is or was being provided by another provider, and the records do not reflect that the previous provider has finalized their billing, the receiving provider is responsible for contacting the existing/previous provider to request that they complete their billing.

What should the agency do in case there is a dispute?
Should a dispute arise, both agencies are required under Medicare regulations to make an attempt to resolve the issue between them. If the agencies are unable to resolve the dispute, Palmetto GBA may be contacted for assistance.
Palmetto GBA will work with both agencies to settle the dispute. Providers seeking assistance from Palmetto GBA to resolve a billing dispute should complete the Billing Dispute Resolution Request Form found at the PGBA-RHHI website (forms.) All information on the form is required to assist the provider.

Note: Providers are not required to use the form, but all requests must include the elements contained in the form. If the form is incomplete or the written request does not include all the required information, the request will be returned to the provider. Providers should also note that the request to settle a billing dispute must pertain to claims that are within the timely filing requirements unless the situation falls within the exceptions to grant an extension to the timely filing requirement. Please refer to the Timely Filing Guidelines Job Aid for additional information on the timely filing requirements.

Upon receipt of the completed form or a written request that includes all the required information, Palmetto GBA will take the necessary steps to assist the provider with resolving the situation.

CMS Clarifies POC Physician Signature Requirements

Happy 2011 to all MFS Bloggers,

CMS recently clarified its position with regard to physician’s signing and dating Plans of Care. I have seen many POC denial determinations and post-payment audits incorrectly assessed by various Intermediaries based upon this policy.

Palmetto GBA published clarification due to recently received clarifications from the Centers for Medicare & Medicaid Services (CMS) in reference to physician signatures with stamped dates. CMS has clarified that physicians must sign and date home health plans of care, verbal orders and certifications. This changes Palmetto GBA’s long standing policy of accepting a date stamp or facsimile date as proof of timeliness in lieu of a physician dating his/her signature. This change is effective for all documents signed on or after January 1, 2011.

Based on the following CMS references, failure to meet these requirements may result in full or partial denial of services.

– CMS Internet Only Manuals (IOMs), Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Section 30.1 states that “the attending physician signs and dates the POC/certification prior to the claim being submitted for payment.”

– This manual requirement is also addressed in 42 CFR 424.22 (D)2 effective January 1, 2011, and states that “the certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.’ The instructions for re-certifications are found in this same Part and restates that it ‘must be signed and dated by the physician who reviews the plan of care.”

New HHA CHOW Rules Finalized

Good Morning MFS Bloggers and Happy Holidays!!!!

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

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

New Therapy Regulations

Good Morning MFS Bloggers,

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

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

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

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

RAP’s

Good Morning MFS Hoem Health Bloggers,

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

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

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

Have a great week!!!! Chris