Home Health & Hospice Week

Pointer: Start checking HETS reports for hospital billing ASAP.

Not only does the new case mix factor on institutional versus community admission source complicate reimbursement levels, it also complicates the billing process itself. And mistakes could mean you miss out on hundreds, if not thousands, of dollars per episode.

In the 2019 HH PPS final rule, the Centers for Medicare & Medicaid Services explains some of how the billing process that will capture qualifying institutional stays will work, but it also defers some details to a future transmittal on the topic.

Here’s what we know now, based on the final rule published in the Nov. 13 Federal Register:

• Claims-based. The reimbursement designation will be based on claims data, not OASIS data.
• Automatic adjustments. The Medicare claims system will automatically adjust home health agency claim payment for the institutional case mix factor by checking for a qualifying institutional stay (see story, p. 330, on which stays qualify).
• Retroactive adjustment. If a claim for a qualifying institutional stay comes in after a relevant HHA claim is paid, the claims system will automatically adjust the previous claim and payment level in accordance with the new status.
• RAPs. “For the purposes of a RAP, we would only adjust the final home health claim submitted for source of admission,” CMS finalizes in the rule. “For example, if a RAP for a community admission was submitted and paid, and then an acute or PAC Medicare claim was submitted for that patient before the final home health claim was submitted, we would not adjust the RAP and would only adjust the final home health claim so that it reflected an institutional admission. Additionally, HHAs would only indicate admission source occurrence codes on the final claim and not on any RAPs submitted.”
• Non-Medicare stays. To receive an institutional case mix increase for a qualifying non-Medicare stay — for example at a Veterans Admin istration hospital — HHAs must manually include an occurrence code indicating the non-Medicare stay occurred. HHAs can submit the code on their initial claims, or adjust claims with the code after payment, if they learn of a qualifying stay.
• Other occurrence code uses. HHAs also can use the occurrence code to trigger an institutional adjustment if the institution for the Medicare stay fails to bill timely, or at all, the final rule advises. The procedures and timelines providers will need to use this function remain unclear at this time, notes billing expert M. Aaron Little with BKD in Springfield, Missouri. “Right now we don’t know the answers for this level of detail,” Little observes. “We will need to assess the answers to those questions pending additional CMS guidance.”

But you can expect that you’ll want to do so sooner rather than later, predicts Sandy McCleve with Advantage Healthcare Consulting Cost Report & Reimbursement in North Salt Lake, Utah. “In most instances, an HHA should pull the trigger on billing a manual occurrence code for a qualifying stay as soon as possible,” McCleve believes. “It does make the process faster and easier if the prior hospital/facility had already billed the qualifying stay,” he concedes. But “if the HHA waits too long before billing for the qualifying stay, they run the risk of not submitting that payment before the deadline and therefore getting their claim denied.”

• Stay documentation. For both non-Medicare stays and stays that Medicare providers fail to bill, HHAs must maintain documentation. “Regarding the usage of discharge summaries as evidence of a prior institutional stay, such summaries may be considered in the assessment of the appropriateness of the usage of an occurrence code indicating admission to HH from an institutional setting and determinations will be made based upon the evidence gathered,” CMS indicates.

HHAs may find securing and maintaining this documentation a hassle. But the hefty payment boost that comes with the institutional case mix designation definitely will be “a good incentive to be thorough,” notes Diane Magrady, compliance lead with Morton Grove, Illinois-based Pragma-IT, creator of the therapyBOSS therapy documentation software solution.

Tip: “Agencies are going to have to be more diligent in reviewing Medicare HETS eligibility reports to ensure that the facility has billed their stay,” Magrady advises. “Agencies should get into the habit of reviewing the HETS report for facility stays now, so it is routine when it counts.”

• Dependence on institutions. You’ll be out of luck if the hospital or other facility does a 180 on the patient’s stay. “Regarding a scenario where an institutional provider determines post-discharge that an admission did not meet inpatient criteria but the discharge summary utilized by an HHA indicated that the patient was being discharged to home health following a qualifying inpatient stay, the home health agency would not be left with a non-covered claim,” CMS says in the final rule. “However, the home health claim may be paid as non-institutional rather than institutional, given the source of the admission.”

Stay tuned: CMS promises multiple times in the final rule to furnish more instructions and education on billing related to this case mix factor as PDGM approaches. Providers should be ready to act on the instructions quickly.

Software vendors, too, will be waiting anxiously for the official instructions, so they can formulate their software accordingly, experts note.

Rough seas ahead: Don’t be surprised to see more billing complications than you might expect related to this policy, McCleve warns. “Knowing when a qualifying institutional stay has or has not taken place means that the HHA must determine what healthcare setting was utilized in the 14 days prior to home health admission,” he points out.

On the surface, that may not seem too difficult. “But there are some exceptions to the rule,” McCleve warns — particularly post acute care admissions without a discharge (see related story, p. 330).