Palmetto GBA Review of Results for Targeted Medical Review of Home Health HIPPS Codes 2CGK* and 1BGP* in Four Regions

The J11 Medical Review Department performed a service-specific prepay targeted medical review on claims for 2CGK* and 1BGP* (variable last digit of HIPPS Codes.) These edits were set for four regions within the J11 Home Health jurisdiction: Midwest (including IL, IN and OH); Southeast (KY, NC, SC and TN); Southwest (AR, LA, NM, OK and TX); and Gulf Coast (AL, FL, GA and MS). The results for the Gulf Coast claims processed May – July 2013 are presented here.

2CGK* – Gulf Coast Results
Of the eight claims reviewed, three were either completely or partially denied, resulting in a claim denial rate of 38 percent. A total of $17,985.98 charges was reviewed with $7,962.14 denied, resulting in a charge denial rate of 44 percent. The major denial reasons identified were:

Percent of Total Denials
Denial Code
Denial Description
74.5%
      5FF2F
Face to Face Encounter Requirements Not Met
25.5%
5FNOA
Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted

1BGP* – Gulf Coast Results
Of the 1355 claims reviewed, 809 were either completely or partially denied, resulting in a claim denial rate of 60 percent. A total of $4,492,516.24 charges was reviewed with $2,572,126.84 denied, resulting in a charge denial rate of 57 percent. The major denial reasons identified were:

Percent of Total Denials
Denial Code
Denial Description
82.2%
5FF2F
Face to Face Encounter Requirements Not Met
3.9%
56900
Requested Medical Records Not Submitted Timely
3.6%
5FNOA
Appropriate OASIS Not Submitted
3.1%
5F012
Physician’s Plan of Care and/or Certification Present – Signed but Not Dated

Denial Reasons and Prevention Recommendations

5FF2F/5TF2F-Face-to-Face Encounter Requirements Not Met
The services billed were not covered because the documentation submitted for review did not include (adequate) documentation of a face-to-face encounter.

How to Avoid a Denial
The face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.

Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

  • The certifying physician must document that he/she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter
  • The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services
  • The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification
  • The certifying physician may dictate the face-to-face encounter documentation content to one of the physician’s support personnel to type. The documentation may also be generated from a physician’s electronic health record.

For more information, refer to:

  • CMS Manual System, Medicare Benefit Policy Manual Chapter 7, Section 30.5.1.1

5ANOA/5FNOA – Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted
The services billed were not covered because the home health agency did not submit the Outcome and Assessment Information Set (OASIS) for the HIPPS code billed on the claim. To avoid denials for this reason, the provider should ensure that the OASIS that generated the HIPPS code for the claim is submitted with the medical records in response to an Additional Development Request (ADR).

Under the Prospective Payment System (PPS), an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations Sections 484.20, 484.55 and 484.250
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 10.1, 10.9 and 20.1.2
  • Outcome and Assessment Information Set IMPLEMENTATION MANUAL

5F012/5T012 – Physician’s Plan of Care and/or Certification Present – Signed but Not Dated
The service(s) billed (was/were) not covered because the physician signed but did not date the plan of care and certification prior to billing Medicare.

In order to avoid unnecessary denials for this reason, the provider should verify that the physician has dated his/her signature.

The physician must certify that:

  • The home health services were required because the individual was confined to his/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 further information on the above Medicare coverage issue regarding the plan of care, references include, but are not limited to, these resources:

  • 42(CFR) Code of Federal Regulations, Sections 424.22 and 409.43
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30
  • Date Stamps No Longer Accepted: Physicians Must Date Signatures article

For further information on the above Medicare coverage issue regarding the certification, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations, Sections 409.41, 409.42, 409.43 and 424.22
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30
  • Date Stamps No Longer Accepted: Physicians Must Date Signatures article

5F011/5T011 – Certification Not Signed
The service(s) billed (was/were) not covered because the physician did not ‘sign’ the plan of care prior to billing Medicare.

In order to avoid unnecessary denials for this reason, the provider should ensure that the attending physician has signed and dated the plan of care prior to the claim being submitted for payment. The form may be signed by another physician who is authorized by the attending physician to care for his/her patients in his/her absence. Electronic signatures are acceptable if entries are appropriately authenticated and dated. Authentication must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry. The home health agency must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records upon request from the intermediary, State surveyor, or other authorized personnel or in the event of a system breakdown.

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations, Sections 424.22 and 409.43
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30
  • Date Stamps No Longer Accepted: Physicians Must Date Signatures article

Also, the service(s) billed (was/were) not covered because the documentation submitted did not include the physician’s signed certification/recertification. To avoid denials for this reason, ensure that the attending physician has signed and dated the certification/recertification.

The physician must certify that:

  • The home health services were required because the individual was confined to his/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 further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations, Sections 409.41, 409.42, 409.43 and 424.22
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30
  • Date Stamps No Longer Accepted: Physicians Must Date Signatures article

56900 – Requested Medical Records Not Submitted Timely
The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Development Request (ADR). When an ADR is generated, the provider has 30 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied or an overpayment will be collected.

Tips to Prevent the Denial of Claims for Untimely Response to ADRs:

  • Be aware of the ADR date and the need to submit medical records within 30 days of the ADR date
  • Submit the medical records as soon as the ADR is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is bound securely with one staple in the upper left corner or a rubber band to ensure that no documentation is detached or lost. Do NOT use paper clips.
  • Do not mail packages C.O.D.; we cannot accept them

For more information, refer to the following article on the Palmetto GBA J11 Part A website: Medical Review Progressive Corrective Action (PCA) Process.

5A041/5F041 – Information Provided Does Not Support the Medical Necessity for This Service
The skilled nursing visit(s) (was/were) not covered because the documentation submitted in response to the Additional Development Request did not support medical necessity for continuation of skilled services.

Initially skilled nursing services were required to observe and assess the beneficiary’s medical condition and response to the plan of care. 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 service.

Skilled observation and assessment beyond a three-week period may be justified when documentation supports the likelihood of further complications or an acute episode. However, observation and assessment are not reasonable and necessary when the documentation indicated that the abnormal findings are part of a longstanding pattern of the patient’s condition and there is no attempt to change the treatment to resolve them.

Documentation that may be helpful to avoid future denials for this reason may include, but is not limited to, the following:

  • New and/or changed prescription medications
  • ‘New’ medications are those that the patient has not taken recently, i.e. within the last 30 days
  • ‘Changed’ medications are those that have a change in dosage, frequency or route of administration within the last 60 days
  • New onset or acute exacerbation of diagnosis
  • Hospitalizations (include the date and reason)
  • Acute change in condition
  • Changes in treatment plan as a result of changes in condition (e.g. physician’s contact, medication changes)
  • Changes in caregiver status
  • Complicating factors (e.g. simple wound care on lower extremity for a patient with diabetes)
  • Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals

In addition, the skilled nursing visits for teaching and training activities are reasonable and necessary where teaching or training is appropriate to the patient’s functional loss, illness, or injury. Teaching and training for an appropriate period of time may be medically necessary when the documentation reflects why the teaching and training is required. When it becomes apparent after a reasonable period of time that the patient, family or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary.

To avoid future denials for this reason, documentation should reflect a need for one or more of the following:

  • Initial teaching and training of a patient, a patient’s family or caregiver on how to manage the patient’s treatment regime
  • Reinforcement of previous teaching when there is a change in physical location (e.g. discharged from hospital to home)
  • Re-teaching due to a significant change in a procedure, the patient’s condition or the patient’s caregiver is not properly carrying out the task
  • Other reasons that may require skilled teaching and training activities

For further information on the above Medicare coverage issues, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations, Sections 409.32, 409.33 and 409.44
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 40.1.2.1 and 40.1.2.3

5F013/5T013 – Physician’s Plan of Care and/or Certification Present – Signed but Dated Untimely
The service(s) billed (was/were) not covered because the physician either signed the plan of care after the claim was billed or did not date his/her signature on the plan of care.

In order to avoid unnecessary denials for this reason, the provider should verify that the physician has dated his/her signature prior to billing the claim to Medicare.

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42(CFR) Code of Federal Regulations, Sections 424.22 and 409.43
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30
  • Date Stamps No Longer Accepted: Physicians Must Date Signatures article

Also, the service(s) billed (was/were) not covered because the physician signed the Home Health Certification and Plan of Care after the claim was billed or did not date his/her signature on the Home Health Certification and Plan of Care.

The physician must certify that:

  • The home health services were required because the individual was confined to his/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 are or 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 further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations, Sections 409.41, 409.42, 409.43 and 424.22
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30

Next Steps
All of the service-specific HIPPS Code edits will be continued at the targeted medical review level. The HIPPS Code 2CGK* has been identified as a major risk area for J11, the results demonstrate high impact severity errors, and the charge denial rate in all four regions is greater than 33 percent. If significant billing aberrancies are identified, provider-specific medical review may be initiated.

The HIPPS Code 1BGP* has been identified as a moderate risk area for J11, the results demonstrate high and medium impact severity errors, and the charge denial rate in all four regions is greater than 33 percent. If significant billing aberrancies are identified, provider-specific medical review may be initiated.

Source: Palmetto GBA

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