Posts Tagged ‘Palmetto GBA’

Palmetto Issues Guidance on Demand Letters for Claims Adjusted with Reason Code 7INAP

November 26, 2013

Please see the following outreach from Palmetto regarding demand letters for claims adjusted with reason code 7INAP. If you have any questions, please feel free to reach out to HCAF. Thank you for your continued support.

HOME HEALTH PROVIDERS RECEIVING DEMAND LETTERS FOR CLAIMS ADJUSTED WITH REASON CODE 7INAP

Some home health providers are receiving overpayment demand letters as a result of adjusted claims with reason code 7INAP. The adjusted claims are based on the Office of the Inspector General’s (OIG) final report, ‘Inappropriate and Questioning Billing by Medicare Home Health Agencies’ (PDF, 3.54 MB) (OEI-04-11-00240).

As explained in the overpayment demand letter, the provider does have the right to appeal the overpayment. Providers filing an appeal should do the following:

1. Submit the request using the Redetermination Request Form either through the Online Provider Services (OPS) application, by fax (803) 699-2425 or by mail

2. All documentation related to the services billed should be submitted with the request for a redetermination of the claim

3. Providers should ensure that the dates of service submitted on the original claim do not overlap a hospital or Skilled Nursing Facility (SNF) stay. If the claims contain dates of service that overlap with a hospital or SNF inpatient stay, a UB04 must also be submitted with a type of bill XX7 to remove the overlapping dates of service.

Providers should also know that the redetermination process includes a full review to ensure that the services billed are supported in the documentation submitted with the request for a redetermination. Therefore, the provider may be subject to denials on the claim for medical necessity reasons.

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Ordering and Referring Denial Edits Will Be Implemented on January 6, 2014

November 8, 2013

CMS will instruct contractors to turn on Phase 2 denial edits on  January 6, 2014. These edits will check the  following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid:

  • Claims from clinical laboratories for ordered tests
  • Claims from imaging centers for ordered imaging procedures
  • Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS
  • Claims from Part A Home Health Agencies (HHAs)

For more information:

  • MLN Matters® Article #SE1305 (PDF, 122 KB), ‘Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)’

Source: Palmetto GBA

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Palmetto GBA October 15, 2013 J11 Home Health and Hospice “Ask the Contractor” Questions and Answers Posted

November 8, 2013

Palmetto GBA has posted the questions and answers from their Oct. 15, 2013 Ask The Contractor segment. They provide this helpful session to help answer some of the critical questions many providers have for the MAC. This installment focuses on many questions related to face2face documentation.

Question
Can the physician dictate the information for the face-to-face documentation?

Answer
The physician is able to dictate the documentation of the face-to-face encounter, but it has to be dictated to his/her staff and the physician will have to be the one who signs and dates it.

Question
I need the phone number for Palmetto GBA’s consolidated customer service center please?

Answer
The number is 855-696-0705.

Question
In the Palmetto 2013 home health workshop series, there were examples of the face-to-face documentation that the physician could provide. One of them is what my client is using with the small tweak of not specifying the leaving home as a considerable taxing effort like the example shows. My client also lists the diagnoses the patient has but doesn’t identify which of the diagnoses requires the home health service. He doesn’t actually detail anything out about why the patient is homebound or how those diagnoses require skilled nursing per se. He’ll mark it skilled nursing or he’ll mark the patient needs lab work or education but he doesn’t give any detail. Is that something that would not qualify for a face-to-face?

Answer
We would have to look at the individual documentation in order to tell you if we think it meets the face-to-face documentation requirements. If you’re saying that you are looking at their documentation and feel it’s not meeting the Centers for Medicare & Medicaid Services (CMS) face-to-face requirements, then you would be correct to advise them not to leave it in that format and to be more detailed.

Question
If the documentation does not meet medical necessity for the face-to-face, does that make the entire home health episode null and void?

Answer
Yes, because the face-to-face encounter documentation is a requirement for the initial certification for home health.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 44 (PDF, 171 KB)

Question
This question is on the home health visit recertification of care. I am a consultant and I have a provider who missed the five-day window by doing the recertification two days too early. They did not go back and redo the assessment during the five-day window as instructed by Palmetto GBA and the Centers for Medicare & Medicaid Services (CMS), if you do the recertification too early. They billed the visit as if it had been done during the five-day window, which obviously is incorrect. What are they going to do to the second episode of care that does not have a valid certification exam to support its’ medical services? Because this is a retroactive audit, they cannot go back and redo that recertification assessment during the five-day window. Is the provider allowed to change the service from a recertification to a teaching service, if that was documented? If so, that visit then becomes a non-chargeable visit and I don’t believe you can just downgrade to a different type of visit?

Answer
If the recertification was not valid, then the episode cannot be billed. If it was already billed, the claim should be cancelled and the money repaid to Medicare. For questions on OASIS assessments and reassessments, please contact your State OASIS Coordinator for assistance.

Reference: A listing of State OASIS Coordinators (PDF, 82 KB) may be found on the CMS website.

Question
Does the primary care physician or the person who is signing the 485 home health plan of care also need to co-sign the face-to-face, if that was done by the hospitalist?

Answer
The hospitalist is able to certify the need for home health, do the face-to-face and initiate the plan of care. The hospitalist can then hand off the patient to the community physician.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013 Question 20 (PDF, 171 KB)

Question
We have home health referrals where the physician gives us the referral based on the office visit completed that day.  We admit the patient, send the 485 and the face-to-face to the physician to complete. The physician signs and dates the 485 and on some occasions signs and dates the face-to-face on a different date, so that they have two separate dates. I think we’ve gotten denials because the dates on the 485 and the face-to-face don’t match. Does that matter?

Answer
There’s nothing in the Medicare regulations that say they have to be the exact same date.

Question
Some of our physicians who are failing to date the face-to-face at the time they’re doing it. So what we’re doing is sending it back to their offices and of course, saying that we must have a date on there. We have a face-to-face where the encounter date was February 13, 2013 and then the physician later dated the face-to-face document on March 13, 2013. We’re being told that the date he entered on the face-to-face is outside the compliance timeline.

Answer
The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care. As per the CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013 Question 17, “HHAs are allowed to title and date the face-to-face encounter documentation. The content requirements must be that of the certifying physician, the documentation must be signed by the certifying physician, and the documentation cannot be otherwise altered/changed by the HHA in any way. In most cases, the expectation is that the certifying physician signs, titles, and dates the face-to-face encounter documentation. Prior to billing, a home health agency should ensure that the certification is complete. The certification is not complete without a face-to-face documentation that has been clearly titled and dated and signed by the certifying physician.”

References: Medicare Learning Network (MLN) Article SE1038 (PDF, 73 KB) and CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 17 (PDF, 171 KB)

Question
A physician who attended the patient in acute or post-acute setting may certify the need for home health. Previously, the several questions about the co-signing was very helpful. My question is about the certification. If the hospitalist signs a face-to-face that has everything on it, the skilled need, the homebound, and there is a certification statement that says, “I certify the patient as confined to their home and needs intermitted skilled nursing care, physical therapy, and/or speech therapy.” That certification statement is on the face-to-face, in addition to the narrative for clinical necessity and homebound. Does that then – would the possibly list signature on that face-to-face, with all the pieces and the certification statement. Then he hands it over to the community physician who signs the 485. In that situation, you have two different physicians signing, no co-signature, no anything else is necessary. Is that correct?

Answer
Yes, you are correct. The hospitalist would be signing and dating their own face-to-face and then the community physician would be signing and dating their own plan of care.

Reference: CMS Home Health Face-to-Face Encounter Question& Answers Revised February 28, 2013, Question 22 (PDF 171 KB)

Question
If the certification statement just says, “I certify the patient as confined to his or her home,” and it doesn’t also specifically say, “and needs intermittent skilled nursing, physical therapy, and /or speech,” would that be considered an incomplete certification statement? Do both components have to be present in a certification statement?

Answer
You need to make sure the certification statement is complete and meets all the requirements for a valid home health certification.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 27(PDF, 171 KB)

Question
My question is about once you get a denial from an Additional Development Request (ADR) or Recovery Audit Contractor (RAC). What recourse do you have if they determine the documentation was not adequate to meet the face-to-face requirement? Can we get documentation from the doctor? What can we do?

Answer
If you’re asking whether or not you can submit a redetermination request for face-to-face documentation denials, the answer is yes. Anything additional that you can provide from the physician as further documentation of the physician’s findings concerning the patient’s condition during that face-to-face encounter would be beneficial.

Reference:
CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 5 (PDF, 171 KB)

Question
Are the physicians allowed to use checkboxes?

Answer
As far as the checkboxes are concerned, there is not a requirement that says that you cannot use the checkboxes or incorporate them in some way.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 24 (PDF, 171 KB)

Question
Sometimes the physician does not complete the section on our form. Our form says, “I certify that my clinical findings support that this patient is homebound.” The doctor doesn’t write anything specific on there. Is that good? What if we have a statement that says you’re certifying your clinical findings support that the patient is homebound?

Answer
I don’t think that would be sufficient. I think that you would really want to make sure that you’re explaining what about the patient makes them homebound. They’re looking for that extra piece of information that speaks specifically to this patient’s condition and not simply a restating of the Medicare requirements home homebound status.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 28 (PDF, 171 KB)

Question
We received quite a few face-to-face documents that have as the reason for the visit the listing of the diagnosis number only. Is that sufficient as long as the rest of the clinical documentation is there as the necessity for home health?

Answer
There isn’t a problem with the diagnosis code being on the face-to-face document. However, if that’s the only information that’s given, that wouldn’t be enough information to meet the requirements. If in your example you’re saying they gave that diagnosis code but then they also gave other clinical documentation such as information about why the patient is considered homebound and why they need these skill services, then that should be sufficient.

Question
CMS says that they don’t specify a form or format for the communication documentation. So would it be acceptable if the physician sends us two different documents that together address all the required elements? Would that satisfy a face-to-face or does it all have to be contained in a single document?

Answer
The face-to-face can be multiple documents. However, the documentation must be clearly titled and dated and signed by the certifying physician that it is to serve as documentation of the face-to-face encounter.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 6 (PDF, 171 KB)

Question
We get a lot of orthopedic patients where they’re only homebound during the time directly after their surgery. We get a lot of the homebound statuses from the doctors that are just “status post-surgical procedure, can’t drive” and obviously those aren’t acceptable. For patients that are seen for orthopedic procedures, like a total hip or a total knee, what exactly are you looking for, for the homebound status?

Answer
Providers may consider details such as the date of surgery; type of surgery and if there were any complications; presence or absence of staple sutures; condition of the surgical site and whether or not wound care is needed. Please note that Medicare guidelines do not provide for a pre-authorization or pre-approval process. The decision as to whether or not certain pieces of information would be accepted should the claim be reviewed, has to be done in conjunction with the review should the claim be selected. It is the provider’s responsibility to determine whether or not the documentation they submit contains all the required elements to ensure that the regulations are met.

Question
As long as the hospitalist is certifying the home health services completely, and the information that they’re putting on the face-to-face documentation is what we’re turning around to see the patient for, then it’s ok that they sign the face-to-face and the patient’s primary care physician signs the plan of care?

Answer
That’s correct.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 26 (PDF, 171 KB)

Question
We have a physician in our area that does send back the face-to-face with “See progress notes” written all the way across. He does sign and date it and sends in his progress notes from the visit that he documents with the face-to-face visit.  Is that acceptable or not? The whole entire visit is from the physician himself.

Answer
Yes, that’s fine. Just assure the progress notes are signed, dated and clearly titled as the face-to-face documentation.

Reference: CMS Home Health Face-to-Face Encounter Question & Answers Revised February 28, 2013, Question 4 (PDF, 171 KB)

Source: Palmetto GBA

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Clarification to Benefit Policy Manual Language on ‘Confined to the Home’ Definition

November 1, 2013

MLN Matters® Number: MM8444
Related Change Request (CR) #: CR 8444
Related CR Release Date: October 18, 2013
Effective Date: November 19, 2013
Related CR Transmittal #: R172BP
Implementation Date: November 19, 2013

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (Regional Home Health Intermediaries (RHHIs and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8444 which requires Medicare contractors to be aware of the clarification of the definition of “confined to the home” as stated in the revised section 30.1.1 of Chapter 7 of the “Medicare Benefit Policy Manual”. CR8444 clarifies the definition of the patient being “confined to the home” to more accurately reflect the definition as articulated at Section 1835(a) of the Social Security Act (the Act). In addition, the Centers for Medicare & Medicaid Services (CMS) removed vague terms, such as “generally speaking”, to ensure the definition is clear and specific.

These changes present the requirements first and more closely align the CMS policy manual with the Act. This will prevent confusion, promote a clearer enforcement of the statute, and provide more definitive guidance to HHAs in order to foster compliance.

Background
In the Calendar Year (CY) 2012 Home Health (HH) Prospective Payment System (PPS) proposed rule published on July 12, 2011, CMS proposed their intent to provide clarification to the Benefit Policy Manual language regarding the definition of “confined to the home”. In the CY 2012 HH PPS final rule published on November 4, 2011 (FR 76 68599-68600), CMS finalized that proposal. In order to clarify the definition, CMS is amending its policy manual as follows:

For purposes of the statute, an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria-One
The patient must either:
Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence

OR

Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.

Criteria-Two:
There must exist a normal inability to leave home;

AND

Leaving home must require a considerable and taxing effort.

Additional Information
The official instruction, CR 8444 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R172BP.pdf on the CMS website.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

Source: Palmetto GBA

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Enrollment Denials When Overpayment Exists

October 25, 2013

The following article is from Palmetto GBA and lists changes that may affect home health agencies regarding enrollment denials when an overpayment has not been repaid in full:

 

Related Change Request (CR) #: CR 8039 
Related CR Release Date: August 1, 2013 
Effective Date: October 1, 2013 
Related CR Transmittal #: R479PI 
Implementation Date: October 7, 2013 

Note: This article was revised on October 17, 2013, to reflect the revised CR8039 issued on August 1. Several examples and clarifying statements have been added. In addition, the transmittal number and the Web address for accessing CR8039 were revised. 

Provider Types Affected 
This MLN Matters® Article is intended for physicians, providers, and suppliers, including current owners of an enrolling provider or supplier or the enrolling physician or non-physician practitioner, submitting enrollment applications to Medicare contractors (Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Carriers, Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs), and A/B MACs). 

What You Need to Know 
This article, based on Change Request (CR) 8039, informs you that Medicare contractors may deny a Form CMS-855 enrollment application if the current owner of the enrolling provider or supplier or the enrolling physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time an application for new enrollment or Change of Ownership (CHOW) is filed. 

Background 
Under 42 Code of Federal Regulations (CFR) Section 424.530(a)(6), an enrollment application may be denied if the current owner (as that term is defined in 42 CFR Section 424.502) of the applying provider or supplier, or the applying physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time the application was filed. 

(Under 42 CFR 424.502, the term “Owner” means any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of the provider or supplier as defined in Sections 1124 and 1124A(A) of the Social Security Act) of the applying provider or supplier) 

Overpayments are Medicare payments that a provider or beneficiary has received in excess of amounts due and payable under the statute and regulations. Once a determination of an overpayment has been made, the amount is a debt owed by the debtor to the United States Government. 

Upon receipt of a CMS-855A, CMS-855B, or CMS-855S application, the Medicare contractor will determine –whether any of the owners listed in Section 5 or 6 of the application has an existing or delinquent Medicare overpayment. 

Upon receipt of a CMS-855I application, the Medicare contractor will determine whether the physician or non-physician practitioner has an existing or delinquent Medicare overpayment. (For purposes of this requirement, the term “non-physician practitioner” includes physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals.) 

If an owner, physician, or non-physician practitioner has such an overpayment, the contractor shall deny the application, using 42 CFR 424.530(a)(6) as the basis. 

Consider the following examples: 

Example #1: Hospital X has a $200,000 overpayment. It terminates its Medicare enrollment. Three months later, it reopens as Hospital Y and submits a new CMS-855A application for enrollment as such. A denial is not warranted because §424.530 (a)(6) only applies to physicians, practitioners, and owners. 

Example #2: Dr. John Smith’s practice (“Smith Medicine”) is set up as a sole proprietorship. He incurs a $50,000 overpayment. He terminates his Medicare enrollment. Six months later, he tries to enroll as a sole proprietorship; his practice is named “JS Medicine.” A denial is warranted because §424.530 (a)(6) applies to physicians and the $50,000 overpayment was attached to him as the sole proprietor. 

Example #3: Dr. John Smith’s practice (“Smith Medicine”) is set up as a sole proprietorship. He incurs a $50,000 overpayment. He terminates his Medicare enrollment. Six months later, he tries to enroll as an LLC of which he is only a 30 percent owner; the practice is named “JS Medicine, LLC.” A denial is not warranted because the provision applies to “all” owners collectively and, again, the $50,000 overpayment was attached to him. 

Example #4 – Jane Smith is a nurse practitioner in a solo practice. Her practice (“Smith Medicine”) is set up as a closely-held corporation, of which she is the 100 percent owner. Smith Medicine is assessed a $20,000 overpayment. She terminates her Medicare enrollment. Nine months later, she submits a CMS-855I application to enroll Smith Medicine as a new supplier. The business will be established as a sole proprietorship. A denial is not warranted because the $20,000 overpayment was attached to Smith Medicine, not to Jane Smith. 

Excluded from denial under §424.535(a)(6) are individuals or entities (1) on a Medicare-approved plan of repayment or (2) whose overpayments are currently being offset or being appealed. 

Note that CR8039 applies only to initial enrollments and new owners in a CHOW. Note also that if the Medicare contractor determines that the overpayment existed at the time the application was filed, but the debt was paid in full by the time the contractor performed its review, the contractor will not deny the application because of that overpayment. 

Additional Information 
The official instruction, CR8039, issued to your Medicare contractor regarding this change, may be viewed athttp://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R479PI.pdf on the CMS website. 

Disclaimer 
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

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Palmetto GBA Reminder: All users must routinely verify their OPS profile per CMS requirements

October 18, 2013

Many agencies frequently ask, “Why am I being asked to complete OPS profile verification?

Answer:

Palmetto GBA and CMS are dedicated to ensuring that access to Medicare data is secure. To do this, CMS requires that all users verify and/or update the information on their Online Provider Services (OPS) profile at least once a year. This includes validating the user’s email address listed on their profile. This must occur at least annually for Palmetto GBA to continue to offer OPS. Users will be prompted in OPS when their account is due to complete profile verification. Palmetto GBA appreciates your effort to help them keep Medicare data secure.
Source: Palmetto GBA

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

October 11, 2013

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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Palmetto GBA Incarcerated Beneficiary Claim Denials: Frequently Asked Questions

August 30, 2013

Palmetto GBA is asking that providers please not resubmit claims denied in error due to incorrect incarceration information in the Medicare Enrollment Database. CMS is working diligently to develop a process to automate the reprocessing of the claims that were denied in error and resubmitted claims complicate the solution.

CMS has posted Frequently Asked Questions (FAQs) about incarcerated Social Security Administration (SSA) beneficiary claims denials on the All Fee-For-Service Providers website. These FAQs will be updated as more information becomes available.

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Palmetto GBA Will Now Take Your Questions!

August 27, 2013

QandA BoxHCAF leadership will meet with Palmetto GBA, Medicare’s fiscal intermediary for Florida, in October to discuss Medicare provider concerns. If your agency has any questions or concerns to express to Palmetto GBA, all questions must be submitted to HCAF no later September 4 by 3:00pm EST. If you have specific questions related to the recent flood of F2F audits, this would be the perfect opportunity for you to present those questions to HCAF so that we may present them to Palmetto on your behalf.

Please be sure to include your name, your contact information and agency information. Past meetings between HCAF and Palmetto GBA have answered many questions for providers. Before submitting your question, click here to review previous Coalition Q&A’s to make sure your question has not already been answered. All questions must be submitted to Patti Heid, HCAF’s Director of Membership Growth & Development, at pheid@homecarefla.org

 

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Palmetto GBA Creates One Contact Number for Home Care

August 23, 2013

Palmetto GBA is excited to announce that beginning on October 1, 2013, all J11 Part A, Part B and Home Health and Hospice providers will have ONE number to contact for all your inquiries. With customer service being very important to Palmetto GBA, the mission of this change is to increase first call resolutions for providers.

The new telephone number will be 855-696-0705. You will dial this number for the:

  • Electronic Data Interchange (EDI)
  • Interactive Voice Response (IVR)
  • Provider Contact Center (PCC)

Your call will start in Palmetto’s IVR. If the call cannot be completed in the IVR, your call will be routed to a Customer Service Advocate (CSA) based on your provider type.

If the CSA needs additional assistance from a functional area, they will be able consult with the supporting area during the call. The functional areas include:

  • Finance
  • Provider Enrollment
  • Medical Review
  • Appeals/Reopening
  • Claims

Please do not attempt to call 855-696-0705 until October 1, 2013. The current contact numbers will be terminated once the new telephone number is activated. The change does not affect fax numbers.

 

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