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Posts tagged ‘home health face to face’

Change on the Horizon

The 2015 update to  Home Health PPS is considerable and provides for major and minor changes, plus a lot of interesting information.  Here’s the bullet points.

Reduction in Payment

No news here.  Everyone was expecting a decrease in payment.  It comes to approximately $81.00 subtracted from the standard episode rate.  The standard episode rate is that dollar amount which is adjusted by OASIS and other factors to find the final payment rate.  In contrast, the per visit rate has gone up slightly. 

Face to Face documentation requirements

A face-to-face document is still required but the narrative section has been removed effective January 1, 2015.  Within the regulations the effect of the Face-to-Face requirement has been described as follows:

  • The error rate for home health claims was calculated to be 17.5 percent.
  • The majority of home health improper payments were due to “insufficient
    documentation” errors. “Insufficient documentation” errors occur when the medical documentation submitted is inadequate to support payment for the services billed or when a specific documentation element that is required (as described above) is missing. Most “insufficient documentation” errors for home health occurred when the narrative portion of the face-to-face encounter documentation did not sufficiently describe how the clinical findings from the encounter supported the beneficiary’s homebound status and need for skilled services, as
    required by §424.22(a)(1)(v).
    • CMS-1611-F  Page 37

ImportantAll episodes beginning with an OASIS Start of Care assessment will require  Face-to-Face documentation.  While the risk of denial related to the narrative has been reduced, agencies will have far more opportunities to make an error.  This includes patients who return to service after being discharged and patients who were in the hospital over day 60 of an episode and must be readmitted for purposes of billing. 

MD/hospital documentation:  The regulations state that if requested, an agency must cough up the hospital’s documentation if the patient was admitted directly from the hospital or the physician’s notes that demonstrates eligibility.  This should be happening already but from reading clinical records, it is obvious that often the nurses caring for the patient are not reading the hospital documentation.  Do not wait until 2015 to add getting the MD records in the chart prior to billing.

Interesting and Important:  I think the following excerpt is saying that if agencies provide the physician with the information to support eligibility, the physician may use it if he or she signs off on it.   This is in stark contrast to not being able to help the physician compose the narrative.  Read for yourself and feel free offer your own opinion.

The initial assessment visit must be done to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The Medicare CoPs, at §484.55(b), require a comprehensive assessment to be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care, and for eligibility for the Medicare home health benefit to be determined, including homebound status. We would expect that the findings
from initial assessment and/or comprehensive assessment of the patient would be communicated to the certifying physician.

The certifying physician can incorporate this information into his/her
medical record for the patient and use it to develop the plan of care and to support his/her certification of patient eligibility. The certifying physician must review and sign off on anything incorporated it into his or her medical record for the patient that is used to substantiate the certification/re-certification of patient eligibility for the home health benefit.

End in Sight

Twice in the Federal Regs, there is a directive that all patients whose care extends into a second episode, must be recertified with a documented estimated end in sight for skilled care.  I really thought I missed something in the proposed regs but Lisa Selman-Holman did not see it, either.  Regardless of who saw what, the directive is in place.  Be careful of ‘statutory’ reasons for denial.  This has the potential to be like dates, signatures, etc.  Once it is identified that a recertification did not meet requirements, a full denial can be issued.


There are some changes to the payment calculations.  I am hoping that someone with a better head for math than myself with go through all the numbers and explain to us the difference.  Consider that a cry for help.

Data Submission

There has always been a provision in the Prospective Payment System for a 2 percent penalty for those agencies that did not submit OASIS data.  Nobody knew what that meant.  Did it mean penalties for no data submission or less than 100% data submission?  It has finally been clarified for agencies as 70% of qualifying episodes in 2015 with gradual increases over the next several years. 

Since it is now a requirement for payment that the OASIS data used to determine payment be in the state repository prior to billing, this new definition strikes us as ‘late’ for lack of a better word.  If you are not sure of your data submission status, call us now. You need help.

Value Based Purchasing

Value Based Purchasing is recycled Pay-for-Performance.  The actual indicators that will factor into any payment adjustments have yet to be determined which was common theme in the P4P predecessor.  Although this is not our first rodeo with the concept of Value Based Purchasing, this one may stick.  Keep your ears to the ground for more information.

These regulations run through 259 pages but like most, there is a lot of fluff and stuff inserted between the good stuff.  Take some time and read through the comments and look at some of the data.  We will be doing so as well and posting anything interesting or important we find.

Good luck.  It’s always an adventure when the regulations are changed.


But Our Survey was Perfect!

The state has come through and scrutinized every piece of paper in your office, gone on multiple home visits and even complimented you on your Infection Control Program.  There’s absolutely no reason to be concerned when some ADRs are received from Medicare.  How could an agency as perfect as yours be denied payment?

It happens every day.  Trust me.  I hear about perfect surveys and denials in the same sentence almost every day.

State regulations often follow the Medicare Conditions of Participation.  If your survey was perfect or even just good, you have likely met the CoP’s.  However, off to the side, in another area of the manual are the Medicare Conditions for Payment.  They are separate and apart from the CoP’s because not all payor sources have these requirements for payment. 

They are:

  • The patient is confined to the home
  • The patient is under the care of a physician (or as we say in the south, under the doctor)
  • The patient has a need for recurring, intermittent skilled care.
  • A Face-to-Face Encounter must occur within a designated time frame
  • The patient is an eligible beneficiary
  • OASIS data has been collected and submitted.
  • The agency is certified by Medicare.

Most patients meet the homebound criteria but many patients do not have homebound criteria documented well enough to warrant payment.  In case you missed it, here is a post about how to document homebound status.   

The patient is under the care of a physician should be obvious, right?  Not so fast, grasshoppers.  Not just any physician counts.  It has to be one that is licensed in your state or your state must allow physicians from nearby counties in another state to write orders.  Each state is different so read your physician practice acts and call the board of medicine if you still aren’t clear. 

The way that Medicare determines that a patient is under the care of a physician is by looking at signatures.   For years, we were told that if the physician failed to date his or her signature, we could simply enter the date the signed plan of care was received by the agency.  They changed their minds on that one a few years ago but not everyone got the memo, apparently.  Everyone in the agency who sees plans of care on a regular basis should be taught to look for dated signatures.  The earlier you find an undated signature, the more likely the physician will be able to sign an attestation statement with confidence.

Recurring, intermittent services sounds like someone is trying to confuse you.  In short, you may not see a patient indefinitely and you may not arrange to see a patient only once.

Daily nursing visits must have a written ‘end in sight’ to daily skilled nursing care included in the documentation.  The single exception to this rule is daily visits for insulin injections.   You can document this anywhere but I like to see it under the frequency or in the goals section.  Similarly, you may not plan to visit a patient once.  Physicians may call and ask for you to go to the house to remove sutures or administer a flu vaccine.  These visits would not be covered under the Medicare home care benefit although you can give a flu shot.  If a patient dies, moves out of town or refuses services after the admission visit, you may bill for it because you fully expected to see the patient again.

I think we have covered, recovered and stripped bare the Face-to-Face documentation requirements in prior posts.  If you continue to have questions, read here

Skilled care is defined in the Medicare Benefits Manual, chapter 7.   I always have a copy on my iPad and my desktop but whenever I can, I go to the online version because changes are fairly frequent.  You can identify the changes by the red font.

Everyone checks eligibility right?  I seldom see a problem with that but when one occurs, it occurs in a very big way.  Usually, an unfortunate soul without Medicare or insurance will borrow someone else’s card.  Although you are completely clueless, it is still non-billable.  That means you have to give the money back.  If you find out about it before Medicare does, you have 60 days before the money is considered fraudulent (that applies to all overpayments).  Whenever possible, check identification on admission.

It seems that until recently, agencies sent OASIS data in one direction and claims in another and the two never met up and the penalty for not submitting OASIS data was very scarcely enforced.  At some point, the OIG got wind of this and jumped all over Medicare in a long and boring report last year.  Now now you will be denied on an ADR if the OASIS data has not been submitted. 

I think you will know if ever your agency becomes decertified so let’s just skip that one.  (Hint:  one big clue is the lack of payment.)

Your state surveyors do not know much at all about billing.  The Face-to-Face requirement is not a requirement for licensure.  In all likelihood, you probably know more about OASIS and coding than a surveyor does because they do not do it every day.  The state really doesn’t survey your length of stay.  The state wants to know if you meet the basic requirements to provide care for patients.  If you are still confused, consider that the state employees are paid by state taxes to protect the citizens of the state.  Medicare pays contractors to protect the trust funds (large piles of money) used to pay for the care.

If you have a perfect survey, it means that you are doing many things right.  In fact, if you get in trouble with your state agency, there will come a point in time where they will communicate with Medicare and your provider number will be at risk.  I’ve only seen that happen a few times by people who do not read stuff like this. 

Now think about all the reasons agencies have claims denied.  They are not included in your state survey.  And that is how you can have a perfect survey and still get denials or worse. 

Now you know. 

Questions and comments are always welcome.

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