Home Health & Hospice Week

Home health agencies can't seem to get it right when it comes to claims with a primary diagnosis of Parkinson's disease (332.x) -- and the mistakes can be costly.

Regional home health intermediary Cahaba GBA is continuing edit 5THCD, which selects claims with Parkinson's disease as the primary diagnosis, a length of stay greater than 60 days, and no billed therapies, according to Cahaba's September newsletter for providers.

Problem #1: Cahaba medical reviewers denied many of the claims caught up in the edit "because the documentation did not support the continued need for skilled nursing," the newsletter says. "To be covered as skilled nursing services, the services must require the skills of a nurse, and must be reasonable and necessary to the treatment of the patient's illness or injury."

Providers must adhere to strict standards for observation and assessment to qualify for Medicare payment, Cahaba instructs. O&A "are reasonable and necessary skilled services 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 ... Plan of Care until the patient's treatment regimen is essentially stabilized."

Don't count on fluctuating vital signs and other changes to meet that requirement. O&A "is not reasonable and necessary where these indications are part of a longstanding pattern of the patient's condition, and there is no attempt to change the treatment to resolve them," Cahaba says.

Problem #2: Cahaba reviewers downcoded many claims because agencies inappropriately used Parkinson's as the primary diagnosis in M0230. "Parkinson's disease is a chronic disorder, and although it greatly affects a patient's health, it may not be the most specific skilled reason home health is currently seeing the patient," Cahaba cautions.

Cahaba's September Newsline is online at http://www.cahabagba.com/rhhi/news/newsletter/200809_rhhi.pdf.

• A Texas home health agency owner has pled guilty in a Medicare scam centering on her false identity. Irene Anderson, owner of AG Total Care Home Health Services Inc. in Dallas, pled guilty to one count of mail fraud on Aug. 21, says U.S. Attorney Richard Roper of the Northern Dis-trict of Texas.

Anderson owned a second HHA in Sulphur Springs, TX, called New Dimension Healthcare Services, but she did so under a fictitious identity she created, Iya Edwards. Anderson obtained a separate social security number and driver's license for the ID.

Edwards and New Dimension were issued a Medicare provider number in March 2005 and billed Medicare fraudulently until April 2008, according to the release. Medicare paid them $1.2 million during that time.

As part of the guilty plea, Anderson agreed to repay nearly $2.3 million and forfeit a 2006 Hummer, a 2002 Suzuki and $8,500 in cash that was found in her car when she was arrested in April.

• Oxygen suppliers are clamoring for de-tails as implementation of the 36-month cap nears. The American Association for Homecare and the National Association for Independent Medical Suppliers each have submitted laundry lists of questions to the Centers for Medicare & Medicaid Ser-vices for clarification.

"Oxygen is the most significant issue facing DME providers in the next few months," NAIMES claims.

Suppliers want to know things like how CMS will develop payment rates for oxygen maintenance and how CMS will reimburse for parts and labor after the rental period ends, AAHomecare notes.

"The policy and fees for services after the cap must be provided in time for suppliers who wish to opt out of service [to] comply with the 60-day notice to patient requirements," NAIMES says.

• If you have a question for your contractor or CMS, get ready for some more red tape. CMS and Medicare contractors soon will require you to provide three data elements before proceeding: your National Provider Identifier (NPI) number, your Provider Transaction Access Number (PTAN), and the last five digits of your tax ID number, CMS says in a newly revised MLN Matters article.

3 strikes and you're out: "You will only be allowed three attempts to correctly provide your NPI, PTAN, and last 5-digits of your TIN," CMS stresses in the article.

The change will take place in March 2009, CMS notes in Aug. 8 Transmittal No. 6139.

• Benjamin Franklin said "In this world nothing is certain but death and taxes," and the Internal Revenue Service has a new way to enforce the latter. Starting Oct. 1, the IRS can deduct up to 15 percent from your Medicare payments if you owe taxes, CMS says in MLN Matters article 6125.

"When such adjustments occur, your Medi-care remittance advice will reflect the code of 'WU' in the PLB03-1 data field," CMS says. "In addition, a 10 digit toll-free IRS number ... will appear in the PLB03-2 data field."

Providers must contact the IRS directly about the problem and not their Medicare contractor, CMS says. "Under current privacy rules and regulations, only the IRS may discuss the tax issue with you."

• Your personal care services billing could get tougher if the HHS Office of Inspector Gen-eral gets its way. The OIG conducted an audit of five states' PCS payments in the first quarter of 2006 and found about a half-million dollars in errors.

The errors indicate the states may have made $11 million in incorrect PCS payments for the time period, the OIG says in its report (OEI-07-06-00620). The errors occurred when the Medicaid programs paid for PCS that were billed on the same days that beneficiaries were in institutional care.

The report is online at http://www.oig.hhs.gov/oei/reports/oei-07-06-00620.pdf.

• Medicare plans a "transparent" system update to the Fiscal Intermediary Shared System Aug. 31, but history has proven that providers should be on the lookout for any resulting problems.

The upgrade will expand the field sizes in the Part A processing system, explains contractor National Government Services in a message to providers. The change will prepare the system for the new UB-04 claim format, ICD-10 diagnosis codes, and new CMS requirements. "These expanded fields will also allow space for future growth of unknown CMS changes," NGS adds.

"This system upgrade should be transparent to the provider community, as there are no new provider entry requirements or changes," NGS expects.

• You will now see a specific claim adjustment reason code (CARC) if your claim gets denied due to Stark reasons. Contractors will use CARC #213 when denying a claim for non-compliance with the Stark law's self-referral prohibitions for physicians and their family members, CMS says in Transmittal No. 1578.

Contractors will begin using the new code Jan. 1, CMS notes in MLN Matters Article 6131.

• Rep. Allyson Schwartz (D-PA) has reintroduced legislation that would allow nurse practitioners, clinical nurse specialists, nurse midwives and physicians' assistants to order home care and certify patients as homebound.

"For many patients, their NP or PA is the primary provider engaged in direct patient care because a physician is simply not available," the American Academy of Nurse Practitioners noted when the bill was introduced last year. "Therefore the requirement that only a physician can order necessary home care increases administrative burdens and creates more paperwork and unnecessary steps before a beneficiary can get the home health care they need."

• When Medicare's interim payment system hit in 1997 and decimated the industry, foresightful home health agency companies were praised for their diversified payor mix. Now under the more favorable prospective payment system, companies are eager to shed their non-Medicare business.

Gentiva Health Services Inc. is selling a controlling interest of its CareCentrix managed care business to Chicago-based private equity firm Water Street Healthcare Partners. Melville, NY-based Gentiva will receive $84 million in cash and a $25 million interest-bearing seller note upon the closing of the transaction, the company says in a release. It will also retain 31 percent of Care-Centrix's stock, valued at $26 million.

"Separating CareCentrix enables us to devote Gentiva's full resources and attention to the extraordinary growth potential in our home care business," Gentiva CEO Ron Malone says in the release. "Going forward Gentiva will generate 95 percent of its revenues from home health and hospice services."

• CMS appears to be getting its feet wet in pay-for-performance, announcing high marks for the participants of its physician incentive program. The program could provide a model for future P4P programs for home care and other providers, industry observers predict.

Each of the 10 groups participating in the Physician Group Practice (PGP) program "improved the quality of care delivered to patients with congestive heart failure, coronary artery disease and diabetes mellitus during performance year two of the demonstration," CMS announced in a release.

Because the participating groups met their pre-set benchmarks, they collected bonus payments totaling $16.7 million.

"We are paying for better outcomes and we are getting higher quality and more value for the Medicare dollar," CMS Acting Administrator Kerry Weems says in the statement.

Weems also appears to confirm what many analysts had already suspected -- that the pilot program is simply an "audition" for a move to pay-for-performance.

"These results show that by working in collaboration with the physician groups on new and innovative ways to reimburse for high quality care, we are on the right track to find a better way to pay physicians," he says.