CMS Issues Several Change Requests Specific To Home Health Agencies

The Centers for Medicare & Medicaid Services (CMS) has issued four Change Requests that provide guidance to the Medicare Administrative Contractors (MACs) on several home health policy and claims processing issues.

Change request 8699Preventing Duplicate Payments When Overlapping Inpatient and Home Health Claims Are Received Out of Sequence

CMS has instructed the MACs to implement edits that will prevent home health claims from processing with dates of service that overlap an inpatient stay. In response to a 2012 Office of Inspector General report that exposed claim vulnerabilities, CMS has identified two conditions where a home health claim could process that overlap with an inpatient claim:

The edit that rejects home health claims when they have dates overlapping an inpatient stay – other than the admission date, discharge date, or a date during an occurrence span code 74 period indicating a leave of absence – does not consider inpatient stays in a swing bed (Type of Bill 018x), and

Medicare systems only identify overlaps with inpatient stays when the inpatient hospital or skilled nursing facility claim was received before the home health claim.

Effective January 1, 2015, If an HH Prospective Payment System (PPS) claim is received, and CWF finds dates of service on the home health claim that falls within the dates of an inpatient, SNF or swing bed claim – not including the dates of admission and discharge, and the dates of any leave of absence – Medicare systems will reject the home health claim. The HHA may submit a new claim removing any dates of service within the inpatient stay that were billed in error.

If the home health PPS claim is received first and the inpatient hospital, SNF or swing bed claim comes in later, but contains dates of service duplicating dates of service within the home health PPS episode period, Medicare systems will adjust the previously paid home health PPS claim to non-cover the duplicated dates of service.

For more on this change request, please click here.

Change Request 8710PreventingPayment on Requests for Anticipated Payment (RAPs) When Home Health Beneficiaries are Enrolled in Medicare Advantage (MA) Plans

Current Medicare systems edit reject claims for home health episodes when a beneficiary is enrolled in a Medicare Advantage plan.  However, Requests for Anticipated Payment (RAPs) for such episodes are currently being paid.

Effective January 1, 2015, edits will be put n place to ensure that RAPs with “From” dates falling within Medicare Advantage enrollment periods are processed, but are paid at zero percent. If a final claim is received it will be rejected, as is currently the process.  Additionally, the requirements add remittance advice coding to zero-paid RAPs processed in Medicare Secondary Payer situations, so that the two situations can be distinguished. In the future, CMS will seek a new alert remittance advice remark code to specifically identify the Medicare Advantage cases also.

For more on this change request, please click here.

Change Request 8813Diagnosis Reporting on Home Health Claims

Effective January 1, 2015, the MACs will implement edits to reject HH claims that list a manifestation code as a primary diagnosis.

An analysis of Outcome Assessment and Information Set (OASIS) records and claims for CY 2011 revealed that some agencies were not complying with the coding guidelines when reporting the primary diagnosis, in particular with regards to certain codes that require the underlying condition be sequenced first followed by the manifestation.

The principal diagnosis reported on the home health claim shall be the ICD-9-CM code that is most related to the current home health plan of care. HHAs shall not submit manifestation codes as the primary diagnosis.

For more on this change request, please click here.

Change Request 8818 –Clarification of the Confined to the Home Definition in Chapter 15, Covered Medical and Other Health Services, of the Medicare Benefit Policy Manual

In the calendar year 2012 Home Health PPS Final Rule published on November 4, 2011, CMS finalized its proposal to provide clarification to the Benefit Policy Manual language regarding the definition of a patient being “confined to the home.”

In October 2013, CMS issued change request 8444 to clarify the definition of “confined to the home” to more accurately reflect the definition articulated in Sections of 1814(a) and 1835(a) of the Social Security Act. At that time, chapter 2 of the Medicare Benefit Policy Manual was revised. Change request 8818 also updates chapter 15 of the Medicare Benefit Policy Manual to reflect the clarification of “confined to the home” definition.

For more on this change request, please click here.

Source: NAHC

 

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