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.

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.

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 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 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.

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.

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

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

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.

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.

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

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.

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.