PGBA Enhances Home Health (HH) Consolidated Billing Enforcement

Effective Date: October 1, 2010

CMS is updating edit criteria related to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS).

Non-routine supplies provided during a HH episode of care are included in Medicare’s payment to the home health agency (HHA) and subject to consolidated billing edits as described in the Medicare Claims Processing Manual, chapter 10, section 20.2.1. If the date of service falls within the dates of HH episode, the line item was previously rejected by Medicare systems.

Effective October 1st, 2010, CMS is implementing new requirements to modify this edit in order to restore the original intent to pay for supplies delivered before the HH episode began. Such supplies may have been ordered before the need for HH care had been identified, and are appropriate for payment if all other payment conditions are met. The edit will be changed to only reject services if the ‘from’ date on the supply line item falls within a HH episode.


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,, and are available for download:

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

Have a great day!


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

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

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.

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.

Multiple Modality Billing On Same Date of Service

Good Afternoon MFS Bloggers, Please find below recent CMS postings regarding muliple modaliuty billing.

During a home health visit, nurses and therapists many times provide more than one service. Do we report multiple G-codes for all the services that were provided during the visit?
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

Good Morning MFS Bloggers, I have recently been asked the following question from a few providers:

Can a therapy assistant provide therapy visits?

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).


Good Afternoon MFS Bloggers, CMS is again pecking away at your pursestrings for

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:

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

Good Morning MFS Bloggers, In continuing with CMS’s clarification of the face-to-face rules, please be advised of the following issues clarified below:

What happens if the face-to-face encounter is completed during the 90-day period prior to the start of care (SOC) and then the patient’s condition changes?

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?


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.

Part 2: Face to Face Encounters

Good Afternoon MFS Bloggers, Here is Part 2 of CMS Clarification Guidelines on the Face to Face Encounters.

Is the same physician required to sign both the plan of care (POC) and certification of the need for home health care?

Per CMS, Prior to calendar year (CY) 2011, the Centers for Medicare & Medicaid Services (CMS) manual guidance required the same physician to sign the certification and the plan of care (POC). Beginning in CY 2011, CMS will allow additional flexibility associated with the POC when a patient is admitted to home health from an acute or post-acute setting. For such patients, physicians who attend to the patient in acute and post-acute settings are authorized to certify the need for home health care based on their face-to-face contacts with the patient (which includes documentation of the face-to-face encounter), initiate the orders (POC) for home health services and ‘hand off’ the patient to his or her community-based physician to review and sign off on the POC. CMS continues to expect that in most cases, the same physician will certify, establish and sign the POC, but the flexibility exists for home health post-acute patients if needed.