Targeted for ADRs


Every so often, Palmetto posts a list of the claims that will be of interest to them on their website. This is the list that was published on August 4.

Note the last letter of the HIPPS code. The letter ‘L’ indicates 16 – 17 therapy visits and the dreaded ‘K’ means that 20 or more therapy visits are scheduled. Only one of the edits is for therapy below 14 visits. In that edit, Palmetto GBA is looking for the lowest clinical and functional scores together with therapy.

Palmetto is asking why a patient who appears to be clinically stable and can walk, talk, bathe, transfer and dress themselves needs any therapy. It’s a good question. There could be a perfectly legitimate explanation but if it is not documented well, you are looking at a denial.

Pretty much all episodes with 20 or more therapy visits are being scrutinized. These are the expensive claims and people who are ‘gaming’ the system will often use high utilization as a method to do so. This does NOT mean that a patient should not receive 20 therapy visits if needed. For most agencies, these episodes will be few and far between.

16 and 17 visits are very profitable as well even if the dollar amount is not the same. The profit starts to drop off at 18 and 19 visits until 20 visits are made.

All clinical documentation should support the services billed but in an agency where staff is limited or compromised at time of billing, claims with these HIPPS codes might be prioritized for review prior to dropping claims.

1BGP* 0 – 13 Visits, Lowest Scores in the Clinical and Functional Domains and Maximum Score in the Service Domain
2BGL* 16-17 Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
2CGL* 16-17 Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
2CHL* 16-17 Therapy Visits, High Score on Clinical Domain, High Score on Functional Domain
5AFK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Low Score on the Functional Domain
5AGK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Moderate Score on the Functional Domain
5AHK* 20 or More Therapy Visits, Low Score on the Clinical Domain and High Score on the Functional Domain
5BFK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Low Score on the Functional Domain
5BGK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
5CGK* 20 or More Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
5CHK* 20 or More Therapy Visits, High Score on the Clinical Domain and High Score on the Functional Domain
All Aggregate Length of Stay and Disbursement/Beneficiary
All Home Health Services

 

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Home Health Conditions for Payment


We have looked and have been unable to find specific guidance on the new CoPs.  There was a phone conference scheduled with NGS that was cancelled and nothing so far from Palmetto GBA.  Help us out if you know anything.

Meanwhile, some people who are very knowledgeable and well respected in the industry differ from us in how we interpret what ‘estimating how much longer the patient will be on service at the time of recertification’ means.  Look for it below in larger bold text.

§424.22   Requirements for home health services.

Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.

(a) Certification—(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s eligibility for the home health benefit, as outlined in sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, as follows in paragraphs (a)(1)(i) through (v) of this section. The patient’s medical record, as specified in paragraph (c) of this section, must support the certification of eligibility as outlined in paragraph (a)(1)(i) through (v) of this section.

(i) The individual needs or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services as defined in §409.42(c) of this chapter. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification form, in addition to the physician’s signature on the certification form, the physician must sign immediately following the narrative in the addendum.

(ii) Home health services are or were required because the individual is or was confined to the home, as defined in sections 1835(a) and 1814(a) of the Act, except when receiving outpatient services.

(iii) A plan for furnishing the services has been established and will be or was periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)

(iv) The services will be or were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.

(v) A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in paragraph (a)(1)(v)(A) of this section. The certifying physician must also document the date of the encounter as part of the certification.

(A) The face-to-face encounter must be performed by one of the following:

(1) The certifying physician himself or herself.

(2) A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health.

(3) A nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(4) A certified nurse midwife (as defined in section 1861(gg) of the Act) as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(5) A physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

(B) The face-to-face patient encounter may occur through telehealth, in compliance with section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.

(1) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.

(2) [Reserved]

(2) [Reserved]

(b) Recertification—(1) Timing and signature of recertification. Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Recertification should occur at the time the plan of care is reviewed, and must be signed and dated by the physician who reviews the plan of care. Recertification is required at least every 60 days unless there is a—

(i) Beneficiary elected transfer; or

(ii) Discharge with goals met and/or no expectation of a return to home health care.

(2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the recertification form, in addition to the physician’s signature on the recertification form, the physician must sign immediately following the narrative in the addendum.

(c) Determining patient eligibility for Medicare home health services. Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. This documentation shall be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described in paragraphs (a)(1) and (b) of this section. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.

(d) Limitation of the performance of physician certification and plan of care functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of care may not be established and reviewed, by any physician who has a financial relationship as defined in §411.354 of this chapter, with that HHA, unless the physician’s relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements.

(1) If a physician has a financial relationship as defined in §411.354 of this chapter, with an HHA, the physician may not certify or recertify need for home health services provided by that HHA, establish or review a plan of treatment for such services, or conduct the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act unless the financial relationship meets one of the exceptions set forth in §411.355 through §411.357 of this chapter.

(2) A Nonphysician practitioner may not perform the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act if such encounter would be prohibited under paragraph (d)(1) if the nonphysician practitioner were a physician.

[53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70334, Nov. 21, 2005; 72 FR 51098, Sept. 5, 2007; 74 FR 58133, Nov. 10, 2009; 75 FR 70463, Nov. 17, 2010; 76 FR 9503, Feb. 18, 2011; 76 FR 68606, Nov. 4, 2011; 77 FR 67163, Nov. 8, 2012; 79 FR 66116, Nov. 6, 2014]

This Just (snuck) In!


Hospice Providers, take note

To be quite honest, I have never seen a ‘no code’ list in hospice.  If anything, I would expect to see a ‘full code’ list as any code status besides DNR would be the exception.

And yet, there is a new list of codes that hospices may not use when determining the primary reason for hospice care.   A list of codes at the end of this document will be automatically returned to providers when used as a principle code for hospice for claims billed after October 1.

This information comes from CMS change request 8877 which also contains very important information about the Notice of Election.

Home Health Providers:

An updated Local Coverage Determination has been published by Palmetto GBA for Alzheimer’s Dementia.  Among the insightful gems included in this guidance is the following passage begging the question of, ‘does someone have too much time on their hands?’

Behavioral disturbances often complicate the medical management of beneficiaries with Alzheimer’s disease. At baseline many individuals with Alzheimer’s disease manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline – resulting in sub-optimal clinical outcomes.

Wow.  I’m glad we cleared that up.  Seriously, look how often the word, ‘baseline’ is used.  If you really want to get paid, consider using the FAST scale to stage Alzheimer’s on admission and recert.  There are also numerous documentation requirements.  Please review and document accordingly.

If you recall, numerous claims once denied for Face-to-Face documentation are now being denied for lack of both long and short term goals.  The reference to short and long term goals is listed as the Physical Therapy LCD.  I am quite certain that the Alzheimer’s documentation LCD will be used in the same way.

Both of these regulations will take place on October 1.  Be ready.

 

The Hospice No Code List

290.0 Senile Dementia Uncomplicated
290.10 Presenile Dementia Uncomplicated
290.11 Presenile Dementia With Delirium
290.12 Presenile Dementia With Delusional Features
290.12 Presenile Dementia With Delusional Features
290.13 Presenile Dementia With Depressive Features
290.20 Senile Dementia With Delusional Features
290.20 Senile Dementia With Delusional Features
290.21 Senile Dementia With Depressive Features
290.3 Senile Dementia With Delirium
290.3 Senile Dementia With Delirium
290.40 Vascular Dementia Uncomplicated
290.41 Vascular Dementia With Delirium
290.42 Vascular Dementia With Delusions
290.43 Vascular Dementia With Depressed Mood
290.8 Other Specified Senile Psychotic Conditions
290.9 Unspecified Senile Psychotic Condition
293.0 Delirium Due To Conditions Classified Elsewhere
293.1 Subacute Delirium
293.81 Psychotic Disorder With Delusions In
293.82 Psychotic Disorder With Hallucinations In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.89 Other Specified Transient Organic Mental Disorders Due To Conditions Classified Elsewhere
294.20 Dementia, Unspecified, Without Behavioral Disturbance
294.21 Dementia, Unspecified, With Behavioral Disturbance
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
310.0 Frontal Lobe Syndrome
310.1 Personality Change Due To Conditions Classified Elsewhere
310.2 Postconcussion Syndrome
310.89 Other Specified Nonpsychotic Mental Disorders Following Organic Brain Damage
310.9 Unspecified Nonpsychotic Mental Disorder Following Organic Brain Damage