Home Health & Hospice Week

If you're not attempting to change the treatment, don't attempt to get paid.

Are your claims for COPD patients destined for trouble?

Regional home health intermediary Cahaba GBA denied more than 45 percent of claims it recently reviewed that had a primary diagnosis of Chronic Airway Obstruction (ICD-9-CM 496) and a length of stay greater than 120 days, it says in a posting on its Web site. In a widespread edit, the RHHI selected 169 recertification claims from January through March to review.

The problem: Of the denied claims, Cahaba shot down more than half due to lack of documentation to support ongoing skilled nursing in the home, the intermediary explains.

"Observation and assessment of the patient's condition are reasonable and necessary ... when the likelihood of change in a patient's condition requires a skilled nurse to identify and evaluate the patient's need for possible modification in the patient's plan of care until the patient's treatment regimen is essentially stabilized," Cahaba says.

The solution: "Indications such as abnormal/fluctuating vital signs, weight changes, edema and respiratory changes may justify further observation and assessment," the intermediary suggests. When such indications show a likelihood that skilled observation and assessment will result in changes to the patient's treatment, Medicare would cover the services.

On the other hand, observation and assessment aren't necessary when the patient's condition is longstanding and there is no attempt to change the treatment to resolve such indications, Cahaba concludes.

• The Centers for Medicare & Medicaid Services could add more diagnosis codes to the categories that receive extra payment under the prospective payment system. After earlier discussion at PPS Technical Expert Panel (TEP) meetings, PPS contractor Abt Associates has been analyzing home health episodes to determine whether certain diagnoses correspond with higher or lower costs, reports the American Association for Homecare.

Abt is looking at diagnoses including gastrointestinal disorders, cancer, neurological disorders, stroke, hypertension, heart failure, diabetes, pulmonary diagnoses, wounds, Alzheimer's disease, psychiatric disorders, and blindness, AAH says.

CMS will propose any additions to the case-mix codes under its PPS refinement rule, slated for November (see Eli's HCW, Vol. XV, No. 18).

• Suppliers of power mobility devices have gained ground in their battle against the PMD final rule, reports the Power Mobility Coalition. The House Government Reform Subcommittee on Regulatory Affairs released a May 19 letter calling on CMS to reevaluate the impact of the rule, which takes effect June 6.

The subcommittee is "greatly concerned" that CMS failed to "seriously evaluate the additional burden that the final rule imposes on suppliers of PMDs," Chair Candice Miller (R-MI) says in the letter.

• If you want to enroll in Medicare or make changes to your enrollment information, you'd better obtain a National Provider Identification (NPI) number in a hurry. Although the NPI due date isn't until May 2007, CMS is requiring an NPI for the new enrollment 855 form that took effect May 1, CMS says in a release.

"No initial application can be approved and no updates to existing enrollment information can be made without this NPI information," CMS says. "All health care providers and suppliers who bill Medicare are required to obtain their NPI in advance of enrolling in or changing their Medicare enrollment data."

Even if you aren't enrolling or changing enrollment information, CMS encourages you to apply for your NPI soon. "You should begin sharing this information ... to make the transition to NPI as smooth as possible," the agency urges. Information on NPIs is online at www.cms.hhs.gov/apps/npi/01_overview.asp.

• The Program Safeguard Contractors should withdraw their nebulizer draft local coverage determination, says the American Association for Homecare in its written comments on the LCD proposed in March (see Eli's HCW, Vol. XV, No. 16).

"The decision to pay no more for Xopenex and DuoNeb than the Medicare payment amount for different, cheaper generic drugs is misguided and confuses a payment determination with Medicare coverage for these drugs," says the trade group.

• If you furnish outpatient therapy, you may get some valuable information about the $1,740 therapy cap through your DDE access.

"Outpatient therapy cap amounts can be found on Page 1 of both the Health Insurance Query A (HIQA) and the Health Insurance Query for Home Health Agen-cies (HIQH)," regional home health intermediary Palmetto GBA says in its April Frequently Asked Questions. "The full cap amount is shown for both physical therapy (also includes speech therapy) and occupational therapy. When Medicare pays for services, these amounts will decrease until the entire cap has been met."

The therapy cap applies only to Part B therapy, not therapy furnished under a home health plan of care.

• RHHI Associated Hospital Service is asking providers to conduct some of their own medical review. Under a new educational campaign, AHS will identify possible incorrect clinical billing or coding through data analysis.
 
Then the intermediary will mail providers a letter containing "education about the issue, a list of claims that may have been paid incorrectly and a verification form," AHS explains. Providers must assess their own billing and coding of the services, make corrections if necessary, and return the form.

• A higher dose of flu vaccine increases the immune response in the elderly, shows a new study sponsored by the National Institutes of Health's National Institute of Allergy and Infectious Diseases.

In a clinical trial conducted by researchers from Baylor College of Medicine in Houston and vaccine maker sanofi pasteur, four equal-sized groups of subjects age 65 or older received the normal dose of vaccine (15 micrograms); twice the normal dose (30 micrograms); four times the normal dose (60 micrograms); or a placebo. Participants in the high-dose group (60 micrograms) had 44 to 79 percent higher levels of antibody than did those who received the normal dose of vaccine, NIH says in a release describing the study.

Subjects tolerated the dosages well at all levels, although higher-dose patients did have more mild side effects at the injection site, says the study published in the latest issue of the Archives of Internal Medicine.

• Option Care Inc. saw nearly flat income but increased revenues in the quarter ended March 31. The Buffalo Grove, IL-based home infusion and specialty pharmacy company reported net income of $4.8 million on revenues of $155.3 million for the quarter, compared to a $4.7 million profit on $120.8 million in revenues for the same period in 2005. Option Care attributes the figures partly to Medicare Part D implementation problems and the pending sale of its Portland, OR home health agency, according to a release.

The company also has purchased its New Jersey franchise. It's the sixth franchisee acquisition since early 2005, Option Care says.

• Amedisys Inc. will pay $3.4 million to buy West Virginia Home Health Services Inc. in that Certificate of Need state, Amedisys says in a release.

WVHHS is the state's largest HHA, reports the Charleston Gazette. The agency had been getting purchase offers for a long time, but Amedisys "made us an offer we couldn't refuse," Dave McWatters, CEO of the agency's hospital parent Highland Hospital Asso-ciation Inc., tells the newspaper.