Home Health & Hospice Week

Pass Low Case Mix Edits By Following These 5 Tips

The days when a home health agency could submit a low case mix claim and expect payment to go unchallenged are over.

Claims with low HHRGs and HIPPS codes are under surveillance by HHH Medicare Administrative Contractors, not to mention a variety of other auditors including RACs and ZPICs. These days, Medicare billing is “very adversarial,” observes consultant Betty Gordon with Simione Consultants in Westborough, Mass. “You’re always worried about somebody reviewing your claims.”

To prevent denials of your low case mix claims, heed this expert advice:

1. Know the rules. Start out by learning what Medicare rules apply to your claims, exhorts consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. Read through the Medicare Benefit Policy Manual chapter on home health services (Chapter 7) for the details your care must comply with. The manual chapter is at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//bp102c07.pdf.

“It really is pretty simple,” Laff tells Eli. “Read the book and follow the rules.”

2. Document the details. Denying skilled observation is a major reason MACs shoot down low case mix claims (see related story, p. 74). Be sure to document the condition and/or treatment changes required for coverage of the service.

“The key issue here very often is a lack of sufficient documentation to support the need for home health services,” explains Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. “These are often patients with chronic illnesses that may have a potential for deterioration or complications, but the documentation generally does not support an initial change or evidence of a need for changes in the plan of care during the episode.”

3. Review high-risk cases. MACs and other reviewers are going after the lowest HHRG cases, Gordon stresses. That means you should flag those claims in your workload and make sure to review the related records. You can use a case conference for that review, or at least have a supervisor review and approve such cases, she recommends.

Timepoint: Denials are even more of a risk when low HHRG patients are recertified for subsequent episodes. Make sure the cases go under review before any recerts, Gordon advises.

For low case mix patients in an initial episode, Gordon recommends reviewing the case after the initial start of care and prior to dropping the final claim.

An agency rarely has the time or resources to review record for every single claim it submits. But claims at high risk of review are worth the time to look over, Gordon says.

4. Consider a downgrade. When you review a low case mix case and find it lacking, you may need to consider a downgrade to a low utilization payment adjustment (LUPA) or discharge,

Gordon says. You may even need to eat the cost of an episode without billing it at all. It’s better to not bill than to file a false claim, experts emphasize. And you can use the case for training purposes to avoid such problems in the future, Gordon adds.

5. Benchmark yourself. If you are submitting an inordinate amount of low HHRG claims, you are likely to catch reviewers’ eye. Examine your own stats to see if you fall outside the norm. If so, evaluate your caseload carefully to make sure those cases are justified and really qualify for Medicare coverage.