Home Health & Hospice Week

Add these 2 newly revealed problems to your billing to-do list.

You'll have to do some extra PPS billing legwork if you want to get all your rightful reimbursement come Jan. 1.

On Dec. 18, the Centers for Medicare & Medicaid Services disclosed two problems with the new prospective payment system billing system: 1) Wound items. The grouper isn't awarding all points for M0 items on wounds (M0440 through M0488), CMS says in the notice. The problem applies only to recertification (RFA 4) or other follow-up (RFA 5) episodes. This scoring issue could affect 6 to 7 percent of assessments, CMS estimates.

The cost: The failure could result in lower Non-routine Supply (NRS) level assignment, underpaying you by $35 to $230 an episode. 2) Diagnosis code combinations. The grouper is also scoring certain diagnosis code combinations incorrectly, CMS explained. The episode will score incorrectly if 1) the primary diagnosis is one that has different points in a secondary position; 2) the primary diagnosis is in M0246a3 or M0246a4 and 3) another code in the same PPS diagnosis group appears as a lower-listed diagnosis in M0230.

What happens: If those three criteria are met, the grouper scores the episode as if the primary diagnosis were an "other" diagnosis, CMS reveals. The error will affect about 1 percent of cases overall--0.3 percent for case mix scoring and 0.7 percent for NRS scoring. It applies to start of care, resumption of care, recert and other follow-up episodes. PPS contractor Abt Associates is working on a software patch. When that work is complete, "we will be releasing the revised grouper, HAVEN, and associated pseudo code as soon as possible in 2008," CMS says.

Medicare Won't Correct Your Claims If the system pays you incorrectly before the fix is in place, it will be up to you to obtain your rightful reimbursement after the patch is complete ...quot; the claims system won't go back and auto-correct underpaid claims.

Your choice: You can leave your underpaid claims as is, CMS says. Or you can investigate your claims to see which ones were underpaid, then cancel and resubmit the requests for anticipated payment (RAPs) for them.

But identifying those claims, especially for the diagnosis codes, will be a huge headache. "This really upsets me," laments billing consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN. CMS' error notice doesn't even list the diagnosis codes that will trigger the error or the possible reimbursement impact.

Many agencies won't even see CMS' notice about the problems and know to check for the errors, Gaboury predicts. "Agencies are just relying on their software to be right," she tells Eli.

Take action: Don't just leave your PPS money on the table, urges consultant Tom Boyd with Rohnert Park, CA-based [...]