During January to March of this year, the top reasons for denial for Home Health Palmetto GBA claims were published on their website as listed below. They can be confusing in their meaning and so we have attempted to clarify as we understand them. Without further ado:
56900—Medical Records not received
This has been the number one reason for denials for years. This occurs most often when an ADR is not seen in the system. Alternatively, it is noticed too late to get records together and sent. To avoid this denial:
CGS encourages providers to use the Fiscal Intermediary Standard System (FISS) to check for MR ADRs at least once per week. To check for MR ADRs,
in the FISS system:
In addition to the above, we suggest:
5FF2F Face to Face Requirements not Met
This should be easy by now but it’s still confusing. Our favorite cheat sheet is the PDF on CGS’s website. Additionally, we see denials that can be prevented by being mindful of the following:
5F023 No Plan of Care
It is a rare event that an agency omits the plan of care from an ADR. When an ADR is denied for not having the plan of care, agencies often assume that the mistake is on the part of the reviewer. Look again. Often this means:
5CHG3 Partial Denial of Therapy
A reviewer will often deny visits based upon an arbitrary number of feet that a patient can walk or problems with individual notes. Because therapy adds significantly to the dollar amount of a claim, these services are an opportunity for Medicare contractors to save a few Medicare dollars at your expense. To avoid these denials:
5FNOA – Appropriate OASIS not submitted
This code means that the OASIS was not found in the repository when the claim was billed. Palmetto GBA explains this denial code as follows:
Under the HHPPS, 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.
Since this list was generated from 2018 claims, it is unlikely that agencies would receive this denial code in response to an ADR because they are auto-rejected upon dropping the claim. Yet, this reason for denial is ranked fifth. If you have received a denial for reason code 5FNOA in response to records submitted in response to an ADR, please let us know.
5T072 – No physician Orders for Services
This denial refers to services provided in excess of what the MD ordered, or services provided before an order was obtained. This is frequently seen when a physician orders PT to evaluate the patient but there are no subsequent orders. It may also be related to the date next to the nurse’s signature on the plan of care. Nurses new to reviewing and signing plans of care will often date their signature with the date that the document was signed instead of the verbal SOC date.
To prevent this denial:
5F041-Information does not support medical necessity
This denial is listed twice with the same code. It is also the easiest one to avoid when clinicians understand and appreciate the importance of their documentation. To avoid this denial:
Remember that the best reason to document is to communicate the condition of the patient to other clinicians. You don’t have the luxury of shift change report.
5T070 – Visits/Supplies/DME Billed Not Documented/Not Documented As Used
Although this code includes visits, supplies and DME, Palmetto GBA’s explanation of this denial appears to be limited to visits.
The services(s) billed (was/were) not documented in the medical records submitted in response to the Additional Development Request (ADR). As a result, medical necessity for these services could not be determined.
It looks very similar to a denial for medical necessity. Palmetto GBA advises:
To avoid unnecessary denials for this reason, the provider should ensure that adequate documentation is submitted to substantiate the medical necessity for all the services billed when responding to an ADR. The provider may submit discipline visit notes and/or a summary of the services rendered for the billing period. If a summary is submitted, it should include the following: (1) the information for the dates of service billed, (2) documentation of the services that “were rendered” by each discipline billed, (3) documentation of the patient’s condition, and (4) documentation of the patient’s progress/response to the treatments/services rendered.
This information appears to be outdated as visit notes are specified in the list of documentation required for ADRs. Our advice is to:
5A301 Info Provided Does Not Support the M/N for Therapy Services
The same information that applied to the partial denial for therapy services also applies here so we won’t be redundant and repeat it here.
We hope you don’t need help with appealing denials but we are here for you if you do and to answer any questions about denials you might have received. We would also appreciate any input if you have anything to add, especially about the denial for OASIS and the denial for Visits/Supplies/DME Billed Not Documented/Not Documented As Used. Email us at TheCoders@hhcoding.com.
A notification of the intent to re-implement the Pre-Claim Review process is being published today in the Federal Register. The purpose, as stated in the notice, is to develop and improve methods to investigate and prosecute fraud in the home healthcare services. In other words, Medicare wants you to send them evidence before you are even suspected of a crime. At its onset, agencies in Illinois, Ohio, Florida, North Carolina and Texas with the option to expand.
If there was even a chance that this burdensome, intrusive and expensive process would serve its stated process, my objections might not be so strong (but maybe they would). Assuming that this process involves collecting the same information as the 2016/2017 demonstration, it is not likely identify or help in the prosecution of fraud. For those of you unfamiliar with the process, agencies had to gather and submit eligibility information for patients and submit it prior to billing the final claim. (Palmetto GBA’s Guide to PCR submission) What’s even more amazing is that the United States Congress agrees with me.
Here’s what they wrote in the Final Rule for the 2015 PPS update:
Each year, the CMS’ Office of Financial Management (OFM), under the Comprehensive Error Rate Testing (CERT) program, calculates the Medicare Fee-for-Service (FFS) improper payment rate. For the FY 2013 report period (reflecting claims processed between July 2011 and June 2012), the national Medicare FFS improper payment rate was calculated to be 10.1 percent. For that same report period, the improper payment rate for home health services was 17.3 percent, representing a projected improper payment amount of approximately $3 billion. The improper payments identified by the CERT program represent instances in which a health care provider fails to comply with the Medicare coverage and billing requirements and are not necessarily a result of fraudulent activity.
Worse than being ineffective, the proposed PCR project does not state goals of prevention of fraud, improvement of patient outcomes, or identification of opportunities for innovative approaches to home healthcare. The process focuses on Face-to-Face information, documentation of homebound status, signatures and dates, and care plans. Nothing written here is meant to dismiss the importance of these statutory requirements but agencies who are fraudulently bent are coached by the CMS in how to get paid whether or not visits are being made or if the ordered care is given. Numerous checklists and examples could serve as a Fraud 101 primer. It befuddles me that an undated signature may result in a denial or delay in payment but Medicare doesn’t understand that a fraudulent agency may document homebound status perfectly even when the details are contrary to reality.
But you do have a choice. You can opt out of the PCR process. It’s a condescending choice like when a toddler is told he can eat his vegetables or be sent to bed early with no dessert. Most kids will hold their nose and get the Broccoli down.
Similarly, Medicare is giving agencies a choice to participate in PCR or suffer a 25 percent reduction in payment IF they are paid after a mandatory request for additional records (ADR). So agencies will hold their nose and participate in PCR.
Agencies can also opt for a post payment review. In this scenario, you would submit information after being paid which means any errors found occurred prior to billing. Undated signature? Denied. Then you will have an overpayment which will be recouped. There are few things worse than having money you already earned taken back. But agencies have a choice.
Agencies will be removed from PCR after they reach an unannounced target goal. If the purpose of PCR is accurately stated, how could the goal be less than 100 percent? If a 90 percent target is set, that means that 10 percent of claims meet the categories of fraud, abuse or waste.
What has never happened to the best of my knowledge is anyone being notified by the person reviewing a patient in the pre-claim review process of errors that might cost Medicare money. Just once I would like to see advice to an agency to include therapy because even though it was received in a prior admission, it’s worth another shot because the patient is having pain difficult to manage without opiates increasing the risk of falls and subsequent injury.
Luckily, you don’t have to sit back and wait for the curtain to fall. You have been invited to comment on the PCR process. Before you do, take a look at the document which was to have been included in today’s Federal Register. As of now, it does not appear to be there.
Note that there are multiple ways to submit your comments. Use them all. Tell your co-workers, bosses, employees and mother to read the memo and draw their own conclusions. There is an ethical dilemma if you tell them how to feel about a political matter but providing a stamp won’t draw the attention of anyone.
Also note the title of the gentleman who signed the memo; Director, Paperwork Reduction Staff. I couldn’t make that up if I tried.
The Coders will prepare comments for submission and share them with you. Please feel free to share your comments for or against the reimplementation of the Pre-Claims Review Demonstration. And remember, you have options.
Maybe the most frustrating element of Quality Improvement for us has always been that there is not a clear definition. One agency may ‘QA’ notes as they come in but never go any further. Another may collect data on countless areas of concern but never put into place a plan for improving those areas. There are those agencies with a program that is great but so complex and time consuming that it never gets done.
All of that is changing. Effective January 18, 2018, agencies must meet specific criteria in their Quality Assurance as written into the new Conditions of Participation. The Condition reads as follows:
(484.65) The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS.
The short version:
This is not hard. It does require time and buy in from employees in every department of the agency. Agencies who invest the resources to make this happen will find themselves at the top of the list for star ratings and be every referral source’s darling. But, it will not happen unless and until senior leadership in the agency buys into the process. With Gusto.
The standards that will be surveyed to determine compliance are similarly easy, but they are comprehensive. Here they are (paraphrased):
The agency must be capable of showing improvement in indicators for which there is evidence that health outcomes, care and patient safety will improve when action is taken to address those indicators In other words, the indicators chosen by your agency must be useful.
And agencies must measure, analyze and track indicators, including adverse events and other aspects of performance that enable the agency to assess processes of care, services and operations. Simply put, agencies will review data related to their chosen indicators to determine if their plans are working and the plan must include the frequency at which data is collected. The governing body must approve the frequency of data collection.
Standard – Program Data
The agency must use data from OASIS when applicable as well as other relevant data in the design of its program to:
The governing body is the person or group of persons who assume full legal authority and responsibility for the agency’s overall operations. Ultimately, the buck stops at the governing body. They write checks and approve budgets. They can veto decisions. It may be the owner of a small agency or a group of executives appointed by the boards of publicly traded companies. Think CEOs, CFO’s and any other person with a job title beginning with a capital C.
So, the Governing body approves the data that will be collected as well as the frequency. That means that if the data is not collected or is useless or does not result in improvement; ignorance on the part of the governing body will not be an acceptable excuse. Truly, it never was acceptable but now it is in writing.
Medicare has already given agencies three indicators they expect to see written into the Quality Assurance plan; hospitalizations, emergent care and adverse events. You’re halfway there but to be effective means determining why patients are visiting the hospital and receiving emergent care. You already have much of that information in your transfer assessments. You should know what percentage of your patients are hospitalized because of falls, wounds, medication errors, etc. If more than a quarter of your patients are going to the hospital for unknown reasons, it could be that the clinicians completing the assessment aren’t taking the time to find out. Now is the time to instill the importance of taking the effort to get the information required to complete a transfer assessment.
Potentially Adverse Events must be investigated, and action must be taken to prevent future occurrences. This is not new but is overlooked with an alarming frequency. Adverse Events retrieved in OASIS reports often have diminished value due to of the age of the data, but you can investigate Adverse Events as they happen while all staff involved with care are still employed and memories are still fresh. The names of the Potentially Avoidable Events are self-explanatory, and a list provided to staff who complete discharge assessments or billing audits may be useful for identification prior to generating an outdated report.
Monitored Measures to Demonstrate and Track Sustained Improvement
For all activities undertaken to improve quality of care by the agency, there must be measures that are monitored to demonstrate improvement and track sustained improvements. It is a common occurrence for education to yield immediate results for a brief period of time with a return to baseline after a few weeks.
Performance Improvement Projects
Agencies must conduct performance improvement projects. The number and scope of distinct projects must reflect the scope, complexity and past performance of the agency. Documentation will include a description of the project, the underlying reason for undertaking the project and measurable achievement. The nature of the project is up to the agency but it must be related to data that has been and will be collected.
Governing Body Responsibilities
Finally, the governing body is responsible for ensuring that:
Regarding fraud and waste, the interpretive guidelines go on to say:
In the event that the HHA identifies a possibly illegal action by its employees, contractors or responsible/relevant physicians, it is the responsibility of the HHA to report the actions to the appropriate authorities according to the individual State laws and the nature of the action(s).
I have taken liberties with the actual language. The full text of the new Conditions of Participation can be found here. Ultimately it is the responsibility of each agency to understand the CoP’s and we hope we are able to help you. But we are not now and never will be a substitute for any regulatory body or document.
Next up in the new Conditions of Participation is Infection Control which will be discussed in detail next week. For now, agencies will do well to pull all relevant OASIS reports and outcomes so that a plan can be put in place.
As always, if you need help implementing the new Conditions of Participation, you know who to contact.
Imagine if every one of your Face-to-Face documents and plans of care were scrutinized prior to payment. Would 90 percent of them be found compliant with existent rules? If a non-clinical person determined that your documentation did not meet Medicare coverage guidelines, would you take their word over your nurses’? How would you feel about submitting a perfectly valid claim for eligible services and being paid 25% less than your peers?
Agencies in Illinois do not have to use their imagination. It is already happening through the Pre-Claim Review process. This process involves submitting plans of care, face to face documents, physician and hospital notes and sometimes more to Palmetto prior to dropping a claim for ‘affirmation’. Once affirmed, a secret code is given to the agency which is placed on the claim. Without the code, final claims are reduced by 25 percent.
And while Medicare is reporting a 90 percent ‘affirmation’ rate, it does not report that there were over 80,000 RAPs submitted compared to 23,000 final claims. Agencies are apparently reluctant to submit their pre-claim review documentation.
Because a RaP will be taken back after 120 days if not answered by a final claim, I expect that many agencies are going to drop an enormous number of claims in the coming weeks which means the number of pre-claim reviews will far exceed that ever imagined by Palmetto, GBA. Maybe Palmetto really can process an additional 60k reviews without any interruption in services to the rest of us. Maybe; but I doubt it.
In April, Florida will come on board. Texas, Michigan and Massachusetts will follow at undetermined dates.
Agencies in states other than Illinois might not be impressed with all this stuff and nothing. They are busy with the changes to the OASIS data set, the impending Conditions of Participation and perhaps their own audits or surveys. Hopefully they will take pause and consider the magnitude of this demonstration project to understand the egregious nature of this intrusive and burdensome little project taken on by Medicare.
The new conditions of participation expected in July of this year explain that the prior Conditions focused on identifying agencies with poor performance. The updated Conditions of Participation take a much-needed step away from this punitive approach. As written in the new regulations:
Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.
There is nothing about the Pre-Claim Review process that stimulates broad-based improvements in healthcare. How could the Pre-Claim Review Project be so far removed from the intent of the home health Conditions of Participation?
Consider that the demonstration project is resulting in difficulty meeting the educational demands in Illinois and that resources have already been relocated from Florida to Illinois. Do agencies in other states have the same access to education as the agencies under pre-pay review?
According to the Medicare Pre-Claim Review Q & A:
The demonstration establishes a pre-claim review process for home health services to assist in developing improved procedures for the investigation and prosecution of Medicare fraud occurring among Home Health Agencies providing services to Medicare beneficiaries.
Nobody can deny that a small number of agencies operate without any regard to Medicare rules and only a passing acquaintance with ethics. This inconvenient acknowledgment of fraud amongst the ranks does not justify excessive scrutiny on 100 percent of providers. Somehow it does not seem fair to involve home care agencies in a demonstration project designed to enhance their prosecution.
And yet, agencies who fail to submit documentation for a Pre-Claim Review are put on a 100 percent review – a level of scrutiny previously reserved for agencies operating far outside of Medicare rules for an extended period.
The documentation required for a pre-claim review is reviewed for clerical errors and dare I say, elements that cannot be established with limited documentation by reviewers who are not nurses. The reason for denial given most often per Palmetto GBA is lack of medical necessity. We see care plans daily that are very poorly crafted supported by excellent nursing and therapy notes. Conversely, we see plans of care worthy of a Pulitzer prize supported by 9 visit notes at weekly intervals documenting that a skilled nurse taught meds – presumably meds ordered for the patient but who knows? Nobody asked us if it was possible to determine Medical Necessity without a complete review of the chart.
In the same vein, we see homebound status documented on visit notes that is contradictory to plans of care. In one recent chart, we found that a patient was shopping weekly. On another, a therapist documented the patient was driving. Sufficient documentation on a plan of care that a patient meets the homebound criteria does not make it so.
But, the reviewers are also quick to note when a signature is not dated or the date of encounter is omitted from the Face-to-Face encounter document. I agree that dates are an important step towards compliance but lack of a date is often nothing more than an oversight; not a tell-tale sign of fraud on behalf of the agency, especially since it is the physician who responsible for the dates. If this keeps up, the federal prisons will be filled with healthcare providers who forgot to date a couple of documents.
The burden to the agency is extensive. On a recent CMS conference call, many agencies reported that the PCR process was costing them $25,000.00 per month. Another agency stated it was taking them about an hour per claim. Even if these estimates are overstated, they are still far above Medicare’s estimation that it would take minimal time and expense to get the pre-claim reviews submitted.
If Tom Price is confirmed as the new secretary of HHS, there may be some relief but the Georgia representative will oversee 13 different agencies including CMS, the CDC, the FDA, National Institutes of Health and more. While he has been outspoken against the Pre-Claim Review Process as a senator it is hard to imagine that the Pre-Claim Review process will find its way to the top of his priority list upon confirmation.
So, who benefits from this circus? Is Palmetto being honest when they say the project is going well? Are our patients happier and healthier because of frantic efforts to assemble and transmit paperwork? Could the resources being consumed by The Pre-Claim Review project be put to better use? What can you do?
I can only provide an answer for the last question. The first thing you should do is to contact your elected officials in Washington. After that, get your care plans and Face-to-Face documents in order because there is now an abundance of reviewers at Palmetto who are fluent at reviewing (and finding cause to deny) them. If you are in Illinois and have claims that you believe are non-affirmed due to incompetent reviewers at Palmetto, contact NAHC. Under no circumstances do we recommend ignoring the Pre-Claim Review Process because your state is not in the demonstration project.
Many Thanks to Tim Rowan, founder of the Home Care Technology Report. who has extensively and investigated the Pre-Claim Review process and its effect on providers. His articles are linked within the content of this post and you can find additional information on his website.
And of course we want your comments and questions. You can leave a comment here or email us with questions. We particularly want to hear from Illinois agencies (after you contact your elected officials).
OASIS and Coding Review 