Home Health & Hospice Week

Watch out: PHE waivers may turn into reimbursement-killers.

The COVID-19 Public Health Emergency continues, but some of the related relief Medicare has provided during it does not.

The Centers for Medicare & Medicaid Services has announced that it will fire up post-payment medical review for claims that providers submitted during the COVID era. “Beginning August 2020, Medicare Administrative Contractors (MACs) resumed post-payment reviews of items and services with dates of service before March 2020,” CMS explains in a message to providers. “MACs may now begin conducting post-payment medical reviews for later dates of service,” the agency says.

“It’s a big deal,” emphasizes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri.

“This could potentially be really bad,” agrees consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tennessee.

“I am concerned that agencies have let some elements of compliance slide while managing the pandemic and are not as prepared as they should be for audits to resume,” Cindy Krafft, founder of Kornetti & Krafft Health Care Solutions, tells AAPC.

Pitfall: The main concern is “that the review period will now cover the time in which the pandemic began, with all the waivers in place during this time,” Little points out. “The pandemic and the waivers really add several layers of complexity to this period of time,” he observes.

Waivers that pose the most risk to claims newly allowed to undergo review include:

• Face-to-face. On March 17, 2020, CMS announced an expansion of telehealth benefits for physicians and their patients under the PHE, and on March 23 CMS clarified in a COVID-19 Frequently Asked Question set that “under the expansion of telehealth under the 1135 waiver, beneficiaries are able to use telehealth technologies with their doctors and practitioners … for the face-to-face encounter to qualify for Medicare home health care” (see HCW by AAPC, Vol. XXIX, No. 11). CMS confirmed the same for hospice F2F encounters in an interim final rule released March 30 (see HCW by AAPC, Vol. XXIX, No. 12-13).

In a number of different guidance documents, CMS made clear early on that F2F encounters with physicians or other qualified non-physician practitioners must include both an audio and visual component. “This means that physician (or allowed practitioner) face-to-face encounters must be doubly checked that they meet the home health CMS requirement of audio and visual components as well as the continuing content requirements,” emphasizes appeals expert Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan.

And as with anything in Medicare, if it’s not documented, it’s not considered done. Agencies must “get the F2F encounter note (when conducted via telehealth) where the physician documented that the encounter was audio and video,” Gaboury stresses. “This applies to both home health and hospice,” she points out.

The cost: If a reviewer knocks out the F2F encounter, the whole episode or stay will be knocked out too — and its payment.

• NPPs. One of the many clauses in the Coronavirus Aid, Relief, and Economic Security (CARES) Act signed into law March 27, 2020, broadens home health ordering under Medicare. The law amends Section 1814(a) of the Social Security Act (42 U.S.C.1395f(a)) to add nurse practitioners, clinical nurse specialists, and physician assistants to the list of clinicians who can order home health. In a COVID-19 interim final rule released April 30, 2020, CMS implemented the change in regulation and made it retroactive to March 1 (see HCW by AAPC, Vol. XXIX, No. 17).

This will be one of the most relevant waivers for medical review, Little expects.

There may be “agencies that started accepting orders from NPPs when it was not yet legal in their state,” Gaboury cautions.

The cost: Again, NPP errors will eliminate payment for an entire episode.

• Telehealth. HHAs may not have gotten everything they wanted when it comes to telehealth — namely direct reimbursement for telehealth visits and/or the ability to count them toward low utilization payment adjustment thresholds — but they did see liberalization in the area.

Direct reimbursement for telehealth visits is out of its hands, CMS insists in the 2021 final rule published in the Nov. 4, 2020 Federal Register. “By law, services furnished via a telecommunications system cannot be considered a home health visit for purposes of eligibility or payment,” CMS says in the final rule.

As required in the March 2020 COVID–19 interim final rule with comment period (IFC), “any provision of remote patient monitoring or other services furnished via telecommunications technology … or audio-only technology … must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment,” CMS says in the final rule (see HCW by AAPC, Vol. XXIX, No. 41).

“The providers need to make certain they didn’t bill for a technology-based visit on a Medicare claim,” Little urges. “On the medical review side, it will be interesting to see how the reviewers assess those services in relation to the overall plan of care,” he adds.

HHAs must be wary of “telehealth visits that the agency performed that wound up on the claim that made the agency cross the LUPA threshold,” Gaboury cautions.

The cost: “How this may affect payment is unclear, since any telehealth visits or service are non-billable service to start with,” Osentoski offers. But if an agency accidentally billed a telehealth visit as an in-person one, it could knock the period down to a much-lower-paying LUPA.

• Homebound definition. Homebound criteria have long been one of reviewers’ favorite bases for denials. That won’t change with COVID-era claims, and may get more complicated due to the associated waiver.

The March 2020 COVID–19 IFC specified that “the definition of ‘confined to the home’ ... allows patients to be considered ‘homebound’ if it is medically contraindicated for the patient to leave the home.” That applies when a physician has determined that it is medically contraindicated for a beneficiary to leave the home because (1) they have a confirmed or suspected diagnosis of COVID-19 or (2) they have a condition that may make the patient more susceptible to contracting COVID-19, according to the rule.

This is “another potential issue to monitor at the medical review level,” Little recommends.

Note: Links to the March 2020 IFC and COVID-19 FAQs are at www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers.