CMS Adds New Data Reporting Requirements for Home Health Claims

Effective July 1, 2013, home health agencies will be required to report data so that the Centers for Medicare & Medicaid Services (CMS) can capture the following:

  • Where home health services were provided
  • When a physician, other than the certifying physician, orders additional visits

Site of Home Health Services

The location where services were provided must be reported along with the first billable visit in an episode. Further, changes in the location during an episode must be reported on the corresponding line to the first visit in the new location.

HCPCS: Code Definition

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 current HCPCS definitions for these codes, which are presently confined to hospice, will be revised to include home health.

Non-certifying Physician Changes to Plan of Care

In addition, home health agencies will be required to identify any “changes/additions to the plan of care by a physician other than the certifying physician” by adding a HCPCS modifier. The physician change modifier, which is now identified as XX, will be assigned to the code set in the March 31, 2013 HCPCS update.

Clarification from CMS

The National Association for Home Care & Hospice has been in discussions with CMS about these new requirements and received clarification on some points to date. First, in response to a NAHC inquiry as to whether CMS is seeking site of service information as an indicator of duplicative services (e.g. personal care services at an ALF), CMS responded that they are not interested in level of care. Rather they wish to collect the data to determine the nature of the patient’s home in which home health services are provided in response to inquiries from other government agencies.

Site of Service: Since a requirement to report site of service has been in place for hospice providers since 2007, NAHC is seeking information about their experiences and problems they have encountered collecting and reporting site of service data. NAHC is also interested in learning whether providers would find it useful to have CMS further define “assisted living facility” to include only those setting that are licensed by the state. Finally, NAHC would like to know whether a definition should be requested for “otherwise non-specified” locations.

Physician Modifier: CMS responded to a NAHC request for further clarification of the requirement to report a modifier for services ordered by a non-certifying physician as follows:

The purpose was to capture situations where there are additions/changes to the plan of care that result in an increased number of visits/increased services or a change in the type of services (which, in essence would be an increase in visits/services). NAHC can certainly look to reissue this CR to clarify when we would expect to have a modifier reported next to G-codes that reflect additional visits/services which were ordered by a physician other than the certifying physician.

NAHC will urge CMS to issue additional instructions so that it will be clear to home health agencies that the new coding requirement is limited to additional visits made solely to deliver care ordered by a non-certifying physician.

Resources

Detailed information on the new requirements was offered in a February 1, 2013 MedLearn Matters article.

Guidance to CMS MACs and update to the Medicare Claims Processing Manual issued via Transmittal 8136 is available here.

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