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.

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

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.)

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.

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

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

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.

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.

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.”

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.