If the State requesting a demand bill for the services within the original Medicare 60-day episode does not require a new OASIS assessment, home health agencies should submit an adjustment to the previously paid Medicare claim, using Type of Bill (TOB) 3×7. In addition: Add condition code 20 to the adjustment claim;
Full Answer
How does home health care work with Medicare?
Usually, a home health care agency coordinates the services your doctor orders for you. Medicare doesn't pay for: 24-hour-a-day care at home. Meals delivered to your home. Homemaker services. Custodial or personal care (like bathing, dressing, or using the bathroom), when this is the only care you need.
What are the coding instructions for home health care?
“All of these coding instructions state to include any conditions that exist at the time of home health admission or that develop during the course of a home health period of care and that affect patient care planning.”
How is the case mix adjustment determined for Medicare claims?
Certain OASIS items describing a patient’s condition, and other information reported on Medicare claims are used to determine the case-mix adjustment to the national, standardized 30-day payment rate. 30-day periods are categorized into 432 case-mix groups for the purposes of adjusting payment under the PDGM.
Why are there billing errors on my Home Health final claim?
When this occurs, billing errors can arise because the dates of service submitted on the final claim may not fall within the beneficiary's episode/period of care history posted to the Common Working File (CWF). Reason codes 79079 and U5386 may both be assigned to the home health final claim when this occurs.
In which of the following circumstances would a partial episode payment pep adjustment be applicable?
A partial episode payment (PEP) adjustment is made when a patient elects to transfer to another HHA or is discharged and readmitted to the same HHA during the 60-day episode.
What is a Lupa adjustment?
A LUPA stands for Low Utilization Payment Adjustment and is a per visit reimbursement to a home health agency when they do not meet a minimum visit threshold. This differs to the traditional reimbursement model for home health, which reimburses at a lump sum per 30 days.
What is episodic billing?
Episodic, or bundled payments, is a concept now familiar to most in the healthcare arena, but the models are often misunderstood. Under a traditional fee-for-service model, each provider bills separately for their services which creates financial incentives to maximise volumes.
What constitutes an early episode of home health under PDGM?
Under the PDGM, the first 30-day period is classified as early. All subsequent 30-day periods in the sequence (second or later) are classified as late. A sequence of 30-day periods continues until there is a gap of at least 60-days between the end of one 30-day period and the start of the next.
How can Lupa be avoided in home health?
One of the biggest factors on avoiding LUPA is to have accurate diagnosis coding and OASIS review. That is essential to make sure the LUPA is correct so you're going off the best information! One of the unintended consequences of the No Pay RAP in 2021, is that OASIS does not have to be completed to submit the RAP.
What is a Lupa episode?
If an HHA provides four visits or less in an episode, they will be paid a standardized per visit payment instead of an episode payment for a 60-day period. Such payment adjustments, and the episodes themselves, are called Low Utilization Payment Adjustments (LUPAs).
What is an episode in home health?
Defining the Episode. For the demonstration, an episode of care will be defined as all services delivered during a period of 120 days following the initial admission of a beneficiary to Medicare home health care at a demonstration provider.
What counts as an episode of care?
Definition. An episode of care is an inpatient episode, a day case episode, a day patient episode, a haemodialysis patient episode, an outpatient episode or an AHP episode. Each episode is initiated by a referral (including re-referral) or admission and is ended by a discharge.
What is a Medicare episode of care?
CMS is applying episode grouping algorithms specially designed for constructing episodes of care in the Medicare population. An episode of care (“episode”) is defined as the set of services provided to treat a clinical condition or procedure.
What is comorbidity adjustment?
High comorbidity adjustment: There are two or more secondary diagnoses that are associated with higher resource use when both are reported together compared to if they were reported separately. That is, the two diagnoses may interact with one another, resulting in higher resource use.
What is a HHRG score in home health?
HHRG—Home Health Resource Group (pronounced 'Herg'). Also known as the case mix score, it is determined by answering certain OASIS data items in the clinical severity, functional status and service utilization domains.
What is late episode in home health?
Late episode of care – Third episode and beyond in a sequence of adjacent covered episodes. Two period timing categories used for grouping a 30-day period of care. Early period of care - First 30-days. Late period of care - Second or later 30-day period. Admission Source.
Limitation on Recoupment (935) Overpayments
The limitation on recoupment (935), as required by Section 935 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) changes the process by which CGS can recoup an overpayment resulting from a post payment adjustment, such as a denial or Medicare Secondary Payer (MSP) recovery.
Resources
Refer to the Claims Correction Menu (Chapter 5) of the Fiscal Intermediary Standard System (FISS) Guide for information about how to submit claim adjustments or cancellations using FISS.
What is HH probe and educate?
Throughout this document, the term “HH probe and educate reviews” will be used to refer to reviews conducted by Medicare review contractors to determine if the requirements for certification/recertification, patient eligibility, coding and medical necessity (CM S-1611-F requirements for home health services) were met. The primary purpose of this HH Probe and Educate process is to ensure that HHAs understand the new patient certification requirements implemented in CMS-1161-F. CMS will direct Medicare review contractors to apply CMS-1611-F and any additional guidance issued by CMS, when conducting HH Probe and Educate reviews. Eligible claims will be those submitted by HHAs for episodes that start on or after August 1, 2015, through an end date to be determined.
Does Medicare review contractors review certification?
The Medicare review contractors shall review the certification documentation for any episode initiated with the completion of a start-of-care OASIS assessment. This means that if the subject claim is for a subsequent episode of care, the HHA must submit all certification documentation as well as recertification documentation.
What is an ABN for home health?
The home health agency should give you a notice called the Advance Beneficiary Notice" (ABN) before giving you services and supplies that Medicare doesn't cover. Note. If you get services from a home health agency in Florida, Illinois, Massachusetts, Michigan, or Texas, you may be affected by a Medicare demonstration program. ...
Who is covered by Part A and Part B?
All people with Part A and/or Part B who meet all of these conditions are covered: You must be under the care of a doctor , and you must be getting services under a plan of care created and reviewed regularly by a doctor.
What is intermittent skilled nursing?
Intermittent skilled nursing care (other than drawing blood) Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition.
Does Medicare cover home health services?
Your Medicare home health services benefits aren't changing and your access to home health services shouldn’t be delayed by the pre-claim review process.
Do you have to be homebound to get home health insurance?
You must be homebound, and a doctor must certify that you're homebound. You're not eligible for the home health benefit if you need more than part-time or "intermittent" skilled nursing care. You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services.
Can you get home health care if you attend daycare?
You can still get home health care if you attend adult day care. Home health services may also include medical supplies for use at home, durable medical equipment, or injectable osteoporosis drugs.
When did the Home Health PPS rule become effective?
Effective October 1, 2000, the home health PPS (HH PPS) replaced the IPS for all home health agencies (HHAs). The PPS proposed rule was published on October 28, 1999, with a 60-day public comment period, and the final rule was published on July 3, 2000. Beginning in October 2000, HHAs were paid under the HH PPS for 60-day episodes ...
When will HHAs get paid?
30-Day Periods of Care under the PDGM. Beginning on January 1 2020, HHAs are paid a national, standardized 30-day period payment rate if a period of care meets a certain threshold of home health visits. This payment rate is adjusted for case-mix and geographic differences in wages. 30-day periods of care that do not meet ...
What is PPS in home health?
The Balanced Budget Act (BBA) of 1997, as amended by the Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) of 1999, called for the development and implementation of a prospective payment system (PPS) for Medicare home health services.
Is telecommunications technology included in a home health plan?
In response CMS amended § 409.43 (a), allowing the use of telecommunications technology to be included as part of the home health plan of care, as long as the use of such technology does not substitute for an in-person visit ordered on the plan of care.
OASIS to HHRG
Home health agencies are paid under the Home Health Prospective Payment System which uses a complex model to calculate episodic payment for up to 60 days of skilled home care services. The rates for each certification period are calculated using the OASIS document, a set of questions used to perform a comprehensive assessment.
Rates and Amounts Set by CMS
At the end of every year the Department of Health and Human Services and the Centers for Medicare and Medicaid Services release the Final Rule outlining changes to the Medicare and Medicaid Programs for the following year. Information includes any policy related changes, new program requirements and rate changes.
Per Visit Rates
The last character of the HIPPS score is the severity level calculation which indicates the Non Routine Supply add on amount. There are 6 severity levels, each with its own amount calculation. This is what CMS expects you will be paying for supplies for the episode based on the patient's condition as described in the OASIS.