Home Health & Hospice Week

Do you know the ropes for billing daily skilled nursing visits?

You'd better pinpoint your endpoint problems now before medical reviewers do it for you--and deny your claims.

Medical reviewers frequently deny claims because home health agencies fail to include an endpoint statement for daily skilled nursing care, regional home health intermediary Palmetto GBA notes in its "Medical Review Topic of the Month" for January.

Medicare regulations require the home care benefit to be intermittent, Palmetto notes in the article. That means daily skilled nursing visits for more than 21 days disqualify a patient from the benefit, unless the record includes a statement of a "finite and predictable" endpoint for the daily nursing care.

Other exceptions: Daily nursing visits are also OK (1) if therapy is also furnishing services at the same time or (2) if there are orders for the nurse to administer daily insulin injections and documentation of why the beneficiary can't or won't inject.

Crafting a valid endpoint statement can be tricky. The statement should specifically address nursing visits and should offer a timeframe for when they will cease being daily. You can state the timeframe in number of weeks or months, or just use a specific date, the RHHI advises.

Pitfall: Using general phrases like "wound care will decrease to less than daily in three months" or "daily visits to decrease when wound heals" won't cut it, Palmetto warns. You must include nursing visits spe-cifically and predict a finite and predictable endpoint.

Resource: For more endpoint dos and don'ts, see Palmetto's article at www.palmetto.gba --click on "RHHI", "What's New" and scroll down to the endpoint article. Or email editor Rebecca Johnson at rebeccaj@eliresearch.com with "Palmetto Endpoint Article" in the subject line to receive a free copy of the article.

• If you think your Medicare provider number will stay intact even if you don't serve Medicare patients for a while, think again. In a Dec. 31 opinion, an administrative law judge ruled that the Centers for Medicare & Medicaid Services could terminate the provider agreement of United Medical Home Care Inc. of Panorama City, CA, which hadn't served a Medicare patient in six months.

Gray area: CMS has the discretion to decide what timeframe is too long to go without serving Medicare patients for enrollment purposes, says the decision from ALJ Keith Sickendick.

"We remain concerned about agencies that put their provider agreement 'on the shelf' and later resume operations, or try to sell their 'agency,'" NAHC warns in a message to members. Such agencies could see terminations, enrollment problems or revoked billing privileges. Rather than ceasing operations, HHAs would be safer to continue limited operations, even to just a few Medicare patients, NAHC counsels.

• Connecticut should put more resources into home care, says a new report from the Center on Aging at the University of Connecticut Health Center. The state legislature commissioned the report to assess the state's long-term care strategy, reports the Associated Press.

About 32 percent of Connecticut's Medicaid spending goes to home and community-based services, placing it 26th among the states, AP says. In contrast, Oregon spends about 70 percent of its Medicaid budget on home and community programs.

"It's a win-win for the state if we can keep people out of nursing homes for as long as possible," says state Sen. Paul Doyle (D-Wethersfield). "That care is more expensive, and that's not usually the option that people want for themselves."

• Home health agencies seeking answers to questions about changes of ownership (CHOWs) can look to a new CMS transmittal on the topic. Medicare counts a buyer that acquires an agency but moves it to a new location with new personnel as a new applicant for Medicare enrollment purposes, the CMS transmittal makes clear. "This change clarifies a situation that has been questioned by providers frequently," the National Association for Home Care & Hospice notes in an article for members.

And quick ownership turnarounds could see additional delays under the new CHOW rules. If an agency submits CHOW papers to the intermediary and then submits a second set of papers before the first set processes, the intermediary will refer the case to CMS. "CMS may not like the fact that such ownership flips impose additional work on CMS and its intermediaries when they are both overwhelmed by provider enrollment processing," NAHC says. "Whatever CMS does, it is clear that this additional CMS review will lengthen the processing time for these transactions."

• If you're looking for a way to present some basic hospice payment facts to your referral sources, patients or internal staff such as marketers, you can check out a new resource from CMS. The agency has issued a four-page hospice payment fact sheet that goes over benefit basics and 2008 payment rates. CMS issued a similar summary sheet for home health PPS a few weeks ago (see Eli's HCW, Vol. XVII, No. 2).

The hospice fact sheet is at www.cms.hhs.gov/MLNProducts/downloads/hospice_pay_sys_fs.pdf.

• Suppliers of home medical equipment seem to be taking CMS' accreditation deadlines to heart. "Inquiries and applications have both increased, and we have increased staff to accommodate this increase in activity," Bob Floro of The Joint Commission tells Eli. Other accrediting organizations also re-port an increased volume of applications.

All existing suppliers of home medical equipment must be accredited by Sept. 30, 2009 (see Eli's HCW, Vol. XVII, No. 4).

• Medicare's crackdown on hospice caps is hitting some providers hard. Advantage Hospice & Homecare based in Lumberton, NC has filed Chapter 11 after receiving an assessment for a $13 million overpayment due to the hospice caps, reports The Fayetteville Observer. CMS was demanding immediate repayment of $4.9 million from 2006, but backed down in the face of the hospice's bankruptcy, the paper reports.

"People don't automatically die at six months," owner Autry Butler told the paper. Advantage employs 350 staff and serves 370 patients.

CMS incorrectly computed hospice caps for 2003 and 2004 and sent corrected overpayment letters last summer (see Eli's HCW, Vol. XVI, No. 16). And CMS asked at least one intermediary to perform a hospice cap project and require corrective action plans from providers that exceeded the per beneficiary limit (see Eli's HCW, Vol. XVI, No. 30).

Serious consequences: Exceeding the cap may now result in a post-pay review or a referral to the CMS Regional Office for possible suspension of Medicare payments, according to RHHI Palmetto GBA.

• You had better get a handle on etiology codes or risk your reimbursement under the prospective payment system refinements that took effect Jan. 1. Medicare now awards case mix points to a patient's episode only if you list a case mix manifestation code after a specified etiology code.

But read the chart included in the pseudocode carefully to see which codes qualify. The list doesn't appear in the PPS final rule, only the pseudocode.

Old way: Old PPS didn't check what code a manifestation code followed.

New way: Under the refinements, the PPS grouper doesn't recognize a manifestation code "unless it's directly following an appropriate and complete etiology code," Abt Associates' Henry Goldberg emphasized in a conference last November.

Example: The manifestation code 336.2 (Sub-acute combined degeneration of spinal cord in disease classified elsewhere) will count toward case mix and payment only if it is preceded by 266.2 (B-complex deficiency NEC), 281.0 (Pernicious anemia) or 281.1 (B12 deficiency anemia NEC) on the same line in M0230/ M0240/M0246 in the OASIS assessment. (Note: This example is corrected from the original article in Eli's HCW, Vol. XVI, No. 40.)

This could be a reimbursement drain if agencies fail to pair manifestation codes with the appropriate etiology codes, experts caution.

• West Virginia's tightening of its Medicaid home care program didn't send home care patients into nursing home care, says a state audit released this month. The 2005 changes reduced the number of slots for the home care program from 4,900 to 3,400.

The audit found the changes implemented in 2005 didn't save any money, and the modifications were rescinded in 2007, reports the Charleston Gazette.

The state legislature increased funding for the state's share of the program, so currently there is no backlog of individuals waiting to enter the program.

It is "shortsighted" to limit participation in the home care program, since it is much less expensive than the costs of nursing home care, State Sen. Dan Foster (D-Kanawha) told the newspaper. According to the audit, West Virginia spends about $19,145 a year for each home care participant, while the average cost for a Medicaid patient in a nursing home is $34,569 a year.