Wednesday, December 4, 2013

Home Health Ordering/Referring Edits Effective, January 6, 2014

The Centers for Medicare & Medicaid Services (CMS) issued a revision to the Medicare Learning Network (MLN) Matters® article SE1305, which is available in this bulletin, announcing that effective, January 6, 2014, the Fiscal Intermediary Standard System (FISS) will implement the ordering/referring physician edits.  Billing transactions and adjustments for home health services with the “FROM” date of service on or after January 6, 2014, will be denied if the attending physician National Provider Identifier (NPI) and name do not exactly match the NPI and name that is on the Provider Enrollment, Chain and Ownership System (PECOS) file. 

NOTE: The edits will compare the first four letters of the last name.  When submitting home health billing transactions and adjustments, include the first and last name as it appears on the ordering and referring file found at on the CMS website.  Middle names (initials) and suffixes (such as MD, RPNA, etc.) should not be listed in the ordering/referring fields.

Please review the following to learn how Requests for Anticipated Payment (RAPs), final claims, and adjustments will process in the Fiscal Intermediary Standard System (FISS) and how to prevent denials for this reason. 

Requests for Anticipated Payment (RAPs)
If the attending physician NPI and name submitted on the RAP does not match the NPI and name in PECOS, the RAP will process with zero payment.  If this occurs, you may either:
  • Cancel the RAP and resubmit a new RAP with the correct attending physician NPI and name to receive the RAP payment; OR
  • Submit the final claim with the correct attending physician NPI and name to receive the full episode payment. 
Final Claims and Adjustments
Final claims and adjustments will deny when the “FROM” date is on or after January 6, 2014, AND:
  • The attending physician National Provider Identifier (NPI) is not found in the eligible attending physician file from PECOS; or
  • The attending physician NPI is found in the eligible attending physician file from PECOS but the name on the claim/adjustment does not match the name in the PECOS file; or
  • The specialty code is not a valid eligible code to order and refer.
Appeal Process
If the final claim or adjustment is denied, to receive Medicare payment, you must follow the appeal process by submitting a redetermination.  To avoid administrative costs that providers experience with filing an appeal, take action now to develop an internal process to prevent such denials. 

How to Prevent Denials
  • Review the “Ordering Referring File” to ensure the information that you submit exactlymatches the information as it appears in the file. 
  • Review your billing transaction before submitting to Medicare, to ensure there are no typos. 
Please note the following clarifications.
Medicare Learning Network (MLN) Matters® Articles
Obtained from:

Wednesday, November 27, 2013

CGS Home Health Edit for Hypertension Continues to Show a High Denial Rate

The home health widespread edit 5023T continues to show a high denial rate upon quarterly data analysis, and therefore will remain an edit.  This edit, “5023T”, is a widespread topic edit that selects claims for pre-pay review based on the hypertension diagnoses and length of stay greater than two episodes of care.  Claims that were reviewed for this edit last quarter received a denial rate of 85%.  This is down from the 95% denial rate a year ago but remains high. The top denial for these claims was 5HMED, not medically necessary.

Supportive Documentation of Medical Necessity
Although the topic of the edit is driven by a diagnosis, the denials were not due to “coding”.  The entire medical record is reviewed, and the top denial is related to documentation of medical necessity of the skilled services, primarily for skilled nurse visits for observation and assessment. For a skilled service of observation and assessment to be covered by Medicare, there must be clear documentation of the patient’s condition that warrants this service.  Typically, documentation of changes in diagnosis, exacerbations, medication or treatment changes that continue to put the beneficiary at risk for further plan of care changes shows the medical necessity for observation and assessment.  The Medicare Benefit Policy Manual (CMS Pub 100- 02), Ch. 7, §, states “Observation and assessment of the patient’s condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient’s condition that requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures until the patient’s treatment regimen is essentially stabilized.”  Nursing may continue observation and assessment when there have been continued changes and risks for further need to change the plan of care.

The Medicare Benefit Policy Manual (CMS Pub 100-02), Ch. 7, §, also states, “However, observation and assessment by a nurse is not reasonable and necessary to the treatment of the illness or injury where these indications are part of a longstanding pattern of the patient’s condition which itself does not require skilled services and there is no attempt to change the treatment to resolve them.”

In summary, your documentation must clearly support the medical necessity of all services provided.  For further examples and discussion of all types of skilled services, please reference the Medicare Benefit Policy Manual (CMS Pub 100-02), Ch. 7, at

Obtained from:

Tuesday, October 8, 2013

Join Our Team! Several Positions Available

Home Care Medical Coder
Coder/Compliance Specialist/Reviewer
Full time home care coder/documentation reviewer opportunities available immediately. Positions require the ability to make independent decisions regarding accurate ICD-9/10-CM code assignments, but also to work under the guidance of a Coding Manager and as a team player. Audits medical records to ensure compliance with the customer's coding procedures and standards.
Positions require HCS-D, and COS-C, HCS-O, and/or BCCHH-C certification. General experience in coding/OASIS review is preferred. Works from home. Reports to Coding Manager. Two years’ experience in coding and/or working in home care setting preferred. Familiarity with standard concepts, practices, and procedures within the field is preferred.
Send all resumes to Thanks and we look forward to hearing from you!

Friday, June 7, 2013

CGS Initiates a Widespread Home Health Probe on Face-To-Face Encounter Documentation

As a result of numerous errors identified by both CGS and the Comprehensive Error Rate Testing (CERT) contractor related to home health face-to-face (FTF) encounter documentation, CGS will be initiating a widespread edit for all home health providers.  The topic code for this review will be 52xxT (‘xx’ denotes various numbers) and the edit will select start of care home health claims equally across the provider community.  Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity compliance with all CMS coverage guidelines, correct billing and coding.

In addition, beginning July 8, 2013, CGS will begin requesting the initial certification face-to-face (FTF) encounter documentation is submitted with all home health claims selected for Medical Review. The Centers for Medicare & Medicaid Services (CMS) clarified the “face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes.” (CMS FAQ # 44)

The previous was from CGS website: Site goes into additional details of examples of what should be included and what would be considered insufficient within FTF documentation. The site also recommends actions for agencies to prepare for this edit which will come in the form of an Additional Documentation Request (ADR) letter. They recommend:

  1. Checking for claims in the Additional Development Request status/location in the Fiscal Intermediary Standard System (FISS) at least weekly.
  2. Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency.
  3. Mailing your documentation for claims selected to CGS by day 30.

Thursday, June 6, 2013

CMS Issues ICD-9 to ICD-10 Transition Claims Instructions

CMS published a special MedLearn Matters article addressing ICD-9 to ICD-10 transition claims instructions. The article SE1325, addresses institutional provider which includes home health and hospice providers. Providers will be required to split claims so that all ICD-9 codes remain on one claim with Dates of Service (DOS) through September 30, 2014 and all ICD-10 codes placed on the other claim with DOS beginning October 1, 2014 and later. While the processing requirements for hospice should be clean because they bill on a monthly basis, home health has several challenges and issues to clarify.

Since home health does episodic billing, will all Medicare and Medicaid patients be required to be discharged and readmitted at their first billable visit on or after October 1, 2014? Under important details in the article, Note 1 states that “creating multiple/interim claims on a single encounter is not a new concept and that these instructions will apply to relatively few claims that span this single implementation date (October 1, 2014) will be impacted.” This could impact 1/6th of all claims for 2014 impacting over 1 million Medicare episodes alone, so this would not affect a “relatively few claims”.

There is a potential that CMS would fall back to the logic stated in Note 2 and treat the episode as a single service; however not likely because of the problems this causes. If an episode starts before October 1, 2014 and the resumption of care is completed after, which code set would you use? ICD-10 should be used, then the diagnosis data will not be consistent across the episode. If ICD-9 is used, then agencies will be required to code certain claims under each of the ICD data sets during an extended period. This would result in increased confusion amongst coders and potential errors.

CMS also needs to clarify which OASIS data set (M item), is tied to the DOS; M0030 (Start of Care (SOC) Date) or M0090 (Date Assessment Completed). CMS has implemented different program changes based on each item depending on the circumstance. M0030 makes sense except in the case of recertification, since that is not used. M0090 can be beneficial, as it allows a few days of wiggle room around the October 1st implementation date. In the case of SOC, this would allow for SOC to be completed as early as September 27th, considering that October 1st will occur mid-week. This could be helpful especially if all Medicare and Medicaid patients will need to be discharged and readmitted.

Either scenario would not be pleasant. Ideally, there should be a 60 day window on either side of October 1, 2014 to allow for entering ICD-9 or ICD-10 codes. This would put the burden on the government. The agencies would have the ability to do what is best for their staff and the patients. The government would need to handle processing both types of claims during this time.  This would decrease the burden on the agencies.  There has not been any talk of this and it does appear the burden will fall onto the agencies.


Friday, May 17, 2013

Four cooperating parties approved statements clarifying the use of external cause and unspecified codes in ICD-10-CM

The four cooperating parties responsible for the ICD-10-CM/PCS and ICD-9-CM Coding Guidelines, which includes AHIMA, along with the American Hospital Association, the Centers for Medicare & Medicaid Services, and the National Center for Health Statistics, have approved two statements clarifying the use of external cause and unspecified codes in ICD-10-CM. Read the statements.
From AHIMA E-Alert 5/16/2013

Wednesday, April 10, 2013

New Home Health Claims Data Requirements

CMS announced plans to require home health agencies to report new claims data. See Transmittal 2680.

For episodes beginning on or after July 1, 2013, HHAs must report where home health services were provided. The following codes are used for this reporting:

Q5001: Hospice or home health care provided in patient’s home/residence

Q5002: Hospice or home health care provided in assisted living facility

Q5009: Hospice or home health care provided in place not otherwise specified (NO)

The location where services were provided must always be reported along with the first billable visit in an HH PPS episode. In addition to reporting a visit line using the G codes as described above, HHAs must report an additional line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). If the location where services were provided changes during the episode, the new location should be reported with an additional line corresponding to the first visit provided in the new location.

Thursday, April 4, 2013

Nurse Recognition Program Seeking 2013 Nominations

HHNA is currently accepting nominations to honor and recognize home care and hospice nurses from across the country. Agencies may nominate any registered nurse to represent their state for 2013. Nominations will be reviewed by the Nurse Recognition Program Selection Committee and one nurse will be recognized from each state.
To see examples of stories from previous issues of CARING, you can click here. To fill out the online nomination form click here. The deadline for submission has been extended to April 8, 2013.