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.



 

OIG Finds 20% Of Home Health Claims Coded Improperly, Resulting In $462M In Improper Payment

Some concerning news hit the home health community last week.

The Department of Health and Human Services’ (HHS) Office Inspector General (OIG) released a report that showed home health agencies submitted nearly 22% of claims in error because services were either not medically necessary (2.1%) or were coded improperly (20.2%).

This is the first time OIG has significantly addressed home health’s coding on claims. They stated that one of the factors for this review was the fast rise in Medicare home health spending—84% from $8.5 billion in 2000 to $15.7 billion in 2007—which “leads to concerns about the potential for improper payments due to fraud and abuse.”

More than 10 percent of claims (a value of $278 million) were considered up-coded, and 9.8% of claims (a value of $184 million) were found to be down-coded. This equates to a net loss of $94 million for the 
Medicare system.

While the report did not go into extensive details on scenarios that they found problematic, they did give an example of the frequent inappropriate use of GERD 530.81. We plan to discuss this further in our next blog post.

The results of this report are very significant and should be taken seriously by home health agencies. Whether the error is unintentional or not, agencies can get themselves into a lot trouble. CMS is cracking down and “has begun using technologies and analytic tools to prevent fraudulent payments and identify risky providers and claims.”

On the bright side, just 2% of claims did not show medical necessity. Agencies are doing a great job ensuring the services they provide are medically needed. 

Here at Daymarck, we have a very strict compliance stance. It is our first and foremost priority. We never up-code or use filler codes, and we code every agency the same. We also stay up to date with the constantly changing rules and regulations to ensure our clients are 100% compliant.

Now more than ever it’s critical that you are submitting accurate claims. If you’d like someone to give your agency an audit to see how you are doing, we can help. Contact us to discuss a coding “check up.”

To learn more about our view on compliance, visit here.

Call to Action: Stop Co-Pays and Across-the-Board Cuts

An offer put forth by a majority of the Democrats on the Joint Select Committee on Deficit Reduction (the “supercommittee”) has caused a firestorm of criticism from many Democrats on the Hill, along with senior and disability advocates. Their $3 trillion deficit reduction blueprint includes $400 billion in Medicare savings, equally divided between provider and beneficiary cuts, and $100 billion in Medicaid savings over 10 years. This offer is a “grand bargain” with Republicans who would have to agree to match spending cuts with new tax revenues. Republicans have countered with a $2.2 trillion proposal, which reportedly would include substantial Medicare and Medicaid cuts. Republicans have not yet agreed to increase taxes, so members of the supercommittee appear to be at a stalemate. However, they may strike a deficit reduction deal by their November 23 deadline.

The Leadership Council of Aging Organizations (LCAO), a national coalition of more than 60 senior groups including NAHC that opposes increased Medicare cost shifting to seniors, is planning to conduct a briefing for Hill staff this Friday at November 4, at 11:00 AM, on the theme of Medicare and  “Skin in the Game.” This refers to the often-heard comment by some on the Hill that seniors need to pay more for Medicare services so they will have more “skin in the game.”  As we all know, seniors already have a lot of skin in the game, including the fact that their families and friends are already providing an estimated $450 billion in unpaid services a year to enable them to remain in their homes—costs that Medicare would have to pick up if they were in nursing homes or hospitals. 

In order to stop copays and across-the-board cuts, you can help blanket the Hill with our message. To send a message, go here. There you will find numerous studies, talking points, and a sample message that you can edit to include your experience and the negative impact home health and hospice cuts and copays would have on your patients. You can also call your elected officials. Find the phone numbers for elected officials in your state here. When calling, ask the receptionist to connect you with the person who handles Medicare issues.

Thanks for helping to making a difference! 

Patients' Right to Choose Providers

By Elizabeth E. Hogue, Esq.

The right of patients to choose providers who will render care to them is currently based upon three key sources:
 

• Court decisions that establish the right of all patients, regardless of payor source and the setting in which services are rendered, to control treatment, including who provides it.
• Federal statutes for both the Medicare and Medicaid Programs that establish the right of patients whose care is paid for by these programs to choose providers who render care in the absence of a waiver.
• The Balanced Budget Act of 1997 (BBA), which currently requires hospitals only to provide a list of home health agencies to patients.  According to the BBA, the list must meet the following criteria:

1. Agencies that provide services in the geographic area in which patients reside, are Medicare-certified, and request to be included must appear on the list given to patients.
2.  If hospitals have a financial interest in any agency that appears on the list, this interest must be disclosed on the list.

    * Conditions of Participation (COP’s) of the Medicare Program that are the same as the provisions of the BBA described above.

Despite the existence of these requirements that are intended to protect the right of patients to choose providers, there is a lingering perception, however unfair it may be, that hospitals give “lip service” to patients’ right to freedom of choice, but still operate based upon a culture that emphasizes ownership of patients and the need, and perhaps even the right, to go to great lengths to keep patients “within the system.”  Case managers/discharge planners are likely to see more enforcement actions by state survey agencies with regard to the rights of patients to choose their providers.

Action taken by a provider in Indiana is instructive.  Specifically, the provider documented instances of alleged violations and reported them to the state survey agency.  Surveyors treated the reports like a complaint and conducted a complaint survey of the hospital's practices.  Surveyors concluded that the hospital violated its own policies and procedures and the provisions of the Balanced Budget Act in the process of making referrals for home health services.  The hospital received a statement of deficiencies and was required to submit and follow a plan of correction (POC).

This action opens the door for clear enforcement action against hospitals and other providers who violate patients' right to freedom of choice.  If violations are at the condition level of deficiencies, providers could, at least in theory, lose their right to participate in the Medicare/Medicaid Programs.

The right of patients to choose providers has generated considerable conflict within the provider community.  This right is likely to be tested and reinforced.  Case managers/discharge planners need a thorough understanding of the issues in order to stay out of the fray.
 
(To obtain more information about the fraud issues discussed above in a book entitled Medicare/Medicaid Fraud and Abuse: A Practical Guide for Providers, send a check to Elizabeth Hogue for $30.00 including shipping and handling to: Fulfillment, 107 Guilford,Summerville, SC  29483.) 

©2011
Elizabeth E. Hogue, Esq.  All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.