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.

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

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

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.

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

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:

• CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30.

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:

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.3.

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:

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.3

Please 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

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.”