Home Health & Hospice – What's New Ask-the-Contractor Teleconference (ACT)
View the handout for the December 19, 2017, Home Health & Hospice – What's New Ask-the-Contractor Teleconference (ACT).
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- Can you clarify the face-to-face homebound status requirements and supporting eligibility with home health agency clinical notes? Will this be a requirement?
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Yes, homebound status on face-to-face is a requirement. If your face-to-face encounter documentation does not sufficiently address the homebound status of that individual patient, you can use documentation you have that the certifying physician may not have access to, and submit that documentation to the certifying physician. Supporting documentation can be visit notes, history and physical, the Start of Care (SOC) Outcome and Assessment Information Set (OASIS) or many other examples which contain the necessary information.
For example – send the pages from the SOC OASIS that specifically address the homebound status including the pages that pertain to the activities of daily living (ADLs). The level of independence in performing ADLs is a good indicator of whether or not the patient meets the homebound status. Send these pages to the certifying physician. The certifying physician then would indicate that he/she agrees with them and the documentation will be included in their medical record for that patient. The physician accomplishes this by putting his/her dated signature on the documentation you have sent.
You would then get a copy of the documentation with the dated signature returned to you and send that along with the rest of your face to face encounter documentation.
Added: 01.19.18
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- What physician code should be used when a beneficiary is in an inpatient hospice stay and their level of care is GIP? Likewise, what physician code should be used when a beneficiary is in a residential status in a facility?
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Unfortunately, Medicare Administrative Contractors (MACs) can't give coding advice. We do have a couple of great resources that will help you in answering these questions.
- Billing Hospice Physician and Nurse Practitioner (NP) Services Web page
- Hospice Medicare Billing Codes Sheet
- Hospice Physician Billing Frequently Asked Questions
We also encourage providers to seek coding advice from the following: American Academy of Hospice and Palliative Medicine (AAHPM) and the American Academy of Professional Coders (AAPC).
Added: 01.19.18
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- I understand that effective January 1, 2018; we will no longer be using the crosswalk to or for the NPIs to show active or not active. We actually have some NPIs that have fallen off of the crosswalk, because of closed locations. How will we get the NPIs back on the crosswalk?
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The provider was advised to contact the Provider Enrollment Customer Service Team at 1.877.299.4500, Option 3. However, additional research after the call indicates the current FISS crosswalk currently removes terminated NPI's and PTAN's from the crosswalk, as well as old owner Changes of Ownership (CHOWs) NPI and PTAN information. In these cases, claims will end up back in the Return to Provider (RTP) status with a reason code of 32103 due to the NPI and PTAN combination not being on the FISS crosswalk. This process changed in January 2018. Please refer to the article, NPI PTAN Not Present in the Crosswalk to explain the process prior to December 31, 2017, and the process as of January 2018.
Added: 01.19.18
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- Is there an estimate time when the next run of ADRs will be?
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The ADR process/analysis is ongoing and there's no specific timeframe. We're always doing data analysis that could trigger an ADR for a provider. Regarding the Targeted Probe and Educate (TPE) process, letters could be sent at any point.
Added: 01.19.18
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- Regarding probe and educate, how is the percentage calculated? How do you know what percentage is good?
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This will vary depending on what the specific edit is and what that particular edit entails. The notification letter you would receive if you were being placed on targeted probe and educate will give you the specifics. It would describe the percentage of either the error rate or what it is that we're looking for.
Added: 01.19.18
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- If we're currently entering our NOEs and NOTRs through the FISS system, do we have to do an application for the EDI?
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In order to have access to the FISS/DDE system, providers do have to complete the necessary application process with EDI. However, there is not an additional application to submit NOEs via EDI. If you are fine with the way you're submitting your NOEs now, you can continue to do that. If you want to move to the EDI process that's completely optional and up to you. It will require additional data elements and a different billing method. Please check the Hospice Claims Filing Web page and the Submitting a Hospice Notice of Election (NOE) via EDI, TOB 8XA quick resource tool to assist with billing.
Added: 01.19.18
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- Can you further address the home health agency with regards to the subunits no longer being available and having to choose the branch versus the free-standing home health agency (HHA)?
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Further development of the response was required and indicates the following: New HHA Conditions of Participation, which will be effective January 13, 2018, no longer contain a definition for home health agency Subunits. The Subunits existing at the time of the effective date of the regulations will become freestanding HHAs unless they notify the State Survey Agency (AS) and the Medicare Administrative Contractor (MAC) that they wish to become a Branch of the Parent. Please refer to the CMS Home Health Agency (HHA) Subunits memorandum for additional details.
Added: 01.19.18
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- Regarding the denial of home health payments based on either late OASIS assessments or having not been received, the original MLN article earlier this year, SE17009, the reinforcement of the regulation required that the assessment needed to be submitted within 30 days, but the initial implementation of this process would allow 40 days. Are we at 30? Are we at 40? Is it a random sampling of claims that are being done or is it going to be 100% of all the claims? So are we still within the 40 days or is that done?
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Yes, you still have the 40 days. CMS has issued the following since Change Request (CR) 9585 was implemented in April 2017: Until matching errors are corrected, Medicare systems will Return to Provider (RTP) home health claims when no Outcome and Assessment Information Set (OASIS) is found. When these claims are returned with reason code 37253, use the F9 function to resubmit your claim after taking one of these actions:
- Update the Health Insurance Claim (HIC) number on the OASIS assessment to match the current information
- Correct the assessment completion date reported in the claim treatment authorization code to match the OASIS assessment
- Resubmit for denial using condition code 21 and Type of Bill 320 if the assessment was not submitted
(No matching OASIS found and the claim receipt date is more than 40 days after the OASIS completion date)
Medicare regulations require the Outcome and Assessment Information Set (OASIS) be transmitted to the state repository, known as the Quality Improvement Evaluation System (QIES), within 30 days of the date the OASIS is completed. Change Request (CR) 9585 was implemented with the April 2017, quarterly systems release and applies to all home health claims with episodes that end on or after April 1, 2017. In accordance with CR 9585, home health claims with dates of service on or after April 1, 2017, that are submitted for payment will deny with Reason Code 37253 when a corresponding OASIS cannot be found in the CMS repository and the claim receipt date is more than 40 days from the OASIS completion date reported on the claim. Positions 5 to 8 of the Treatment Authorization Code on the claim represent the OASIS completion date as reported in item set M0090.
Effective with claims received on or after October 6, 2017, when a corresponding OASIS is not found, the claim will Return to the Provider (RTP) for correction. Please refer to the following resources for additional assistance:
- Update to Home Health Claims Being Returned with 37253 (No OASIS Found) Article
- October 12, 2017, CMS mlnconnects
- Home Health Claims Will Be Returned When No OASIS Is Found Article.
Added: 01.19.18
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- In terms of Probe and Educate – it's my understanding that there's a 2 1/2 to 3-year delay on anything coming back from Administrative Law Judge (ALJ) that's been challenged from the first round of probe and educate.
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Unfortunately, the delay will remain for the immediate future. The ALJ is a separate entity from CGS. The ALJ is working to do their best to clear the backlog. But, there is no definite information available for a specific time period.
Added: 01.19.18
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- My question is in regards to the targeted probe and educate. I understand the medical review, so if you would get selected for a long length of stay in GIP, 20 charts would get pulled, but it wouldn't necessarily be long length of stay GIP charts. It would just be a basket sample even though you stuck out, because of that reason?
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The selection would be for the reason you mentioned. It wouldn't be just a basket pull of any charts or claims that you submit. It would be claims that are submitted with the specific criteria. The letter you would receive if you were placed on TPE would offer further explanation as well. There could be a sample between 20 and 40 charts as directed by CMS.
Added: 01.19.18
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- In terms of TPE, it would only be for prepayment, right? So it would be once we bill, like, a month's worth of claims. It just doesn't seem like there's going to be 20 claims in a month that would have the outlier status.
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Yes, it is all prepayment review and it may not be within a month status. The time period would vary depending on how long it would take to get the sample size from the provider.
Added: 01.19.18
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- Is there any difference between accepting a face-to-face from a hospital and a face-to-face from a skilled nursing facility or can we even take the face-to-face from the skilled facility?
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The face-to-face is valid as long as it meets all of the requirements. Chapter 7 of the Medicare Benefit Policy Manual, Section 30.5.1.1 states the face-to-face must be performed by either the certifying physician, the physician who cared for the patient in an acute or post-acute care facility, or an allowed non-physician practitioner (NPP). Regulations state the face-to-face must be timely and must relate to the reason the patient came to you for services.
Added: 01.19.18
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- If the skilled facility has sent the patient out to the doctor's office, they have the doctor's office visit, they have their nursing assessments and it supports all homebound definitions, is signed by the certifying physician, it is okay to accept that?
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Yes, that's correct.
Added: 01.19.18
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- My question is regarding the targeted probe and educate process and relates to the early question about the backlog with ALJs. Can you help reconcile for me, if we are selected for TPE, because of denial rates, but we've appealed those denials and the system is backlogged and through the appeal process, then our denial is overturned, are we already into the educate part of the process before it turns out that our denial statistic wasn't accurate. Can you help reconcile that for me?
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Based on the direction that we have been given, we don't go back to adjust that initial ADR decision based on appeal decision. If that initial ADR was denied, the original decision would stand for whether or not you would be considered into the targeted probe and educate.
Added: 01.19.18
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- I have a question about submitting the NOEs electronically. Will there be an exception, say, the client activity be from our third-party provider that we use to submit our claims electronically so when we go submit the claims – the NOEs electronically and say that client activity breaks down, would that be granted as an exception since this is out of the provider's control?
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Additional research indicates, for computer issues, CGS will only grant exceptions for matters where we (Medicare Administrative Contractors and other CMS affiliates) are at fault. CGS will not grant exceptions for providers' billing system issues or their billing administrators. Please refer to our website for additional information.
Added: 01.19.18
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- Regarding the TPE process, it says three rounds up to 20 to 40 claims. Is it going to be a minimum of 20 to 40 claims?
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Yes, it is a minimum of 20 claims up to 40. That is for each round of the targeted probe and educate.
Added: 01.19.18
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- Are you recording this, so we can listen to it?
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We won't have a recording available. What we will offer are the Q&As and the handout that was used, which will be posted to our website as quickly as possible (within 30 business day of the call).
Added: 01.19.18
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- My question is regarding ADRs. If our claim selected for the ADR, how long does it take to resolve?
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Once CGS received your documentation from the ADR request, then we have 30 days to review it and to respond back to you.
Added: 01.19.18
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