Home Health & Hospice Week

Beware denials that result in LUPAs.

When you submit a claim with one nursing and four therapy visits, you'd better be ready to defend it.

Regional home health intermediary Cahaba GBA has been reviewing claims with that visit mix for nearly a year, it notes in a June 27 posting to its Web site. And in the quarter spanning January through March, Cahaba denied 239 of 313 such reviewed claims.

Top denial reason: For 132 claims, the intermediary denied the skilled nursing visit as medically unnecessary due to lack of documentation.

Beware: Denying just one visit in a five-visit episode pushes the claim into the rock-bottom per-visit low utilization payment adjustment (LUPA) rate.

"Generally, if the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba says in the notice at www.cahabagba.com/part_a/whats_new/20060627_denials.htm.

• Missouri is wrong to deny coverage of medical equipment under Medicaid, a federal appeals court says in a June 22 ruling.

The decision by the 8th U.S. Circuit Court of Appeals gives new life to a lawsuit over last year's Medicaid cuts in Missouri (see Eli's HCW, Vol. XIV, No. 32). It was unreasonable of Missouri to deny coverage of certain equipment to most low-income adults, the court suggests. Specifically, the appeals court says Missouri's policy of covering some DME items but not others appears unreasonable under federal Medicaid rules and court precedent.
 
States have discretion to determine the optional services in their Medicaid plans, the ruling says. But "failure to provide Medicaid coverage for non-experimental, medically necessary services" within a Medicaid category is both "unreasonable and inconsistent with the stated goals of Medicaid," according to the decision.

• New legislation approved by the Senate Budget Committee could lead to home care cuts. The Stop Overspending Act of 2006 (S. 3521) calls for across-the-board spending cuts in Medicare if certain spending levels are reached and other mechanisms for cutting Medicare and Medicaid spending.

The SOS bill may not have much chance of passage in this election year but could be "a harbinger of things to come," warns the National Association for Home Care & Hospice. Consideration of "dramatic cuts in Medicare underscores the continuing need for grassroots action by the home care community to protect the Medicare market basket inflation update for home health care and hospice," NAHC warns.

• A lawsuit by House Democrats that seeks to nullify the Deficit Reduction Act should be dismissed, the U.S. Justice Department says.

The lawsuit rests on the fact that the House and Senate failed to approve identical versions of the bill. The Senate version stipulated that Medicare could pay to rent some items of medical equipment for 13 months, while the House passed a version that erroneously stated "36 months" for the capped rental period.

• Providers completing an electronic National Provider Identifier (NPI) application should be able to obtain their new NPI number within 10 days, expects RHHI Palmetto GBA. However, "we cannot predict the amount of time it will take to obtain [an NPI] because several factors come into play," including how many applications are being processed at the time and whether the application is completed correctly, Palmetto says in a posting on its Web site.

• A home health agency is heading to federal court to fight CMS for its rightful therapy reimbursement. As expected, the CMS Administrator overturned the Provider Reimbursement Review Board's favorable ruling for The Medical Team in Reston, VA, according to the recent Administrator's decision.

The agency plans to appeal the reversal in federal court, confirms attorney John Jansak with Harriman & Jansak in Towson, MD. The decision is the latest in a string where the CMS Administrator reverses the PRRB's stance on compensation for therapists paid per visit (see Eli's HCW, Vol. XV, No. 15).

• You can expect some close scrutiny of claims including a diagnosis of 344.61 (Cauda equina syndrome with neurogenic bladder). RHHI Cahaba GBA is initiating a widespread probe review of such home health prospective payment system claims, it says in a June 22 posting to its Web site. The topic code for this medical review will be 5THCZ.

• Fiscal intermediaries may be improperly denying claims that use the KX modifier to indicate exceptions to the outpatient therapy caps, CMS admits. "These improper denials occur when some services on the claim are below the therapy cap and not billed with the KX modifier, and other services on the same claim are above the therapy cap, and billed with the KX modifier," the agency explains.

Information on properly using the KX modifier to avoid these problems is in a new MLN Matters article (SE0637) at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0637.pdf.

• CMS is offering pdf files of the 855 enrollment form, it says. The forms "can be filled out online and saved for future reference or to notify CMS of any future changes," a CMS spokesperson says. "This presents a significant savings in terms of time and energy for the practitioner."

Download the forms at www.cms.hhs.gov/CMSForms/CMSForms/list.asp --search for "855".

• A number of home care providers are on the acquisition trail. Gentiva Health Services Inc. has acquired the assets of Lazarus House Hospice Inc. in Cookeville, TN. Lazarus furnishes hospice services in 15 counties in the certificate-of-need state, Gentiva says in a release.

Gentiva also acquired the assets of Carolina Vital Care, a home infusion pharmacy located in Charlotte, NC. The price for both deals was $4.5 million in cash, the Melville, NY-based giant says.

Almost Family Inc. has acquired the assets and business operations of Baptist Home Health Care, a Birmingham-based HHA affiliated with the Baptist Health Care System of Alabama for undisclosed terms. Baptist generated about $1.7 million in Medicare revenues in the last year, the Louisville, KY-based Caretenders parent says in a release.

And LHC Group Inc. has agreed to acquire the Kentucky assets of Somerset, KY-based Lifeline Home Health Care. The pending transaction doesn't include Lifeline's operations located outside of the certificate-of-need state, Lafayette, LA-based LHC clarifies in a release.

LHC will pay about $15 million cash for the operations that generated $23 million in revenues in 2005, it says. The deal, covering 2,400 patients and 350 employees, will be the regional chain's largest to date and is expected to close July 31.