CMS Responds to Inquiry on HHA PECOS Status

Centers for Medicare & Medicaid Services (CMS) in April published the final rule “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement.”

Provisions of this final rule included an announcement of plans to develop and activate home health edits for enrollment of ordering and referring physicians. The full text of the final rule can be accessed here.

After analysis of the Federal Register notice, the National Association for Home Care & Hospice (NAHC) posed a series of questions to CMS in its efforts to help home health agencies to be prepared for the eventual initiation of edits of claims for Medicare enrollment status of ordering and certifying physicians. First, NAHC asked CMS whether a date has been determined on which it expects its contractors to activate Ordering/Certifying physician edits. CMS responded that no date to activate edits has been set but they would provide a minimum advance notice of 60 days before doing so.

In response to NAHC’s inquiries about the status of physician enrollment efforts, CMS reported that the majority of physicians are in PECOS and they will continue to monitor for this. Enrollment was facilitated by requiring physicians not in PECOS to revalidate during the first phase of the Medicare revalidation effort. In regards to “opt-out” physicians, the Medicare Administrative Contractors (MAC) were instructed to register “opt-out” physicians in PECOS.

NAHC expressed concern that the final rule language implies that order date, certification date, and the date of service are the same day, explaining to CMS that home health agencies initiate services based on verbal orders issued by physicians prior to the first visit of each episode of care, while certification includes a Face to Face encounter and may take place a much as 30 days after the first visit.

In response, CMS stated that the enrollment requirement is “based on the date of the order and date of certification for home health.” Further, CMS explained that the ordering physician must be enrolled for the entire episode of care. CMS added: “The regulation at 424.516(f)(2) requires that records must be maintained for these orders/certifications. It wouldn’t matter if it were on the claim or not (meaning it was verbal). The provider (HHA) and supplier (physician) must maintain a record for 7 years.” The implication of this response is that, although claims editing will not verify physician status from initial order throughout the episode, medical review will.

In another question NAHC asked whether, in cases where an inpatient stay resulted in the conduct of a face-to-face encounter and certification by one physician and responsibility for the plan of care by another physician, CMS responded that both physicians be enrolled in Medicare. NAHC also asked which physician’s name must appear on the home health claim when the certifications and plans of care are by two different physicians, CMS responded that “The doctor who orders the home health or the certifying physician should be listed on the claim.”

In its final question, NAHC asked whether, once initiated, the edits would be applied to the date an episode starts (i.e. any episodes that start on or after the activation date) or be applied to all RAP and claims submitted to Medicare on or after the edit activation date. In its response, CMS stated that: “We will not be retroactively denying claims. We will deny from the dates of service on or after the implementation of the denial edits.” This response suggests a lack of understanding of home health episode billing which could include visit span dates prior to and after the edits are initiated. NAHC will work with CMS to resolve this concern and share any new information with members.

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