Home Health & Hospice Week

Reviewers shoot down 20% of claims for physician-related paperwork errors.

The content of your documentation is very important, but so are the technical details supporting your claims.

Many home health agencies are learning that lesson the hard way, judging from the results of edits that review low case mix claims. HHH Medicare Administrative Contractor NHIC denied more than half of claims reviewed for the edit.

Background: In the last half of 2012, NHIC issued ADRs for nearly 5,000 claims under three edits: 5AC01 — billing of the home health resource group (HHRG) 3AFK*; 5AC02 — billing the HHRG 1AFK*; and 5AC03 — billing five to seven visits for full episode payment. Those HIPPS codes selected for review related to an HHRG of C1F1S1, "which is the lowest possible score for a PPS episode," points out Judy Adams with Adams Home Care Consulting in Asheville, N.C.

The number-one denial reason for the edits was skilled observation not reasonable and necessary (see story in Eli’s HCW, Vol. XXII, No. 11 for details and tips on dealing with this denial problem). But the second-most common reason for denials, at 15 percent, was no physician certification, NHIC explains on its website. And physician orders not signed timely was the fourth-most common denial reason at 5 percent.

When auditing charts, consultant Betty Gordon with Simione Consultants sees missing certifications and face-to-face documentation frequently, she tells Eli.

It’s no surprise that this is a top denial reason, Gordon continues. "It’s low-hanging fruit," she observes. It’s a relatively simple matter for reviewers to find missing or incomplete certs and orders, as opposed to parsing the documentation in visit notes for medical necessity. And when the cert or orders aren’t properly signed and dated, Medicare denies the entire claim — and recoups the entire prospective payment system episode amount.

Do this: "No claim should go out without a [physician] signature and date," Gordon stresses. Agencies should work this basic check into their billing procedures.

Face-To-Face Complicates Certification

Reviewers may also be finding certs incomplete due to face-to-face problems. In addition to the physician not signing and/or dating the certification statement, "this denial code could indicate the face-to-face encounter did not meet the guidelines," NHIC says. "The face-to-face encounter must be documented by the certifying physician."

HHAs continue to struggle with the F2F requirement, relates Lynda Laff with Laff Asso-ciates in Hilton Head Island, S.C. "Many agencies still do not have good processes for getting the F2F signed by the appropriate physician," Laff says. "There is still confusion about who the referring physician is versus who will actually be the ‘following’ or certifying physician."

Problem: "Agencies who get lots of hospital referrals often get referrals from hospitalists who do not intend to follow the patient ongoing," Laff explains. Hospitalists may sign the F2F if they get it quickly, but many agencies do not get it out quickly. Then the doc won’t sign it if he gets it weeks later. The HHA then will turn to the attending or following physician in the community, but she often does not even know the patient was hospitalized or that home care has admitted the patient. "Because many agencies are not contacting the following or community physician — as directed by the CoPs — prior to sending out the plan of care/485 for signature, [the physician] will not sign it," Laff says.

Solution: Get your F2F documentation out ASAP, experts advise. And strengthen communication with the physician certifying the patient.

But many HHAs’ F2F problems aren’t over when they get the form back from the certifying physician, Adams notes. Often "it does not meet all the content requirements," she tells Eli. "Many agencies report having to send the form back multiple times before it is acceptable."

Problems HHAs frequently see with F2F statements include incomplete documentation to support a need for skilled home health services and inadequate documentation of homebound status, Laff says. Or the physician simply does not date or sign the form.

Note: NHIC’s article reviewing the results of the low case mix edits is at http://www.medicarenhic.com/providers/articles/HHPrepayResults022013.pdf