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 Boyd & Nicholas. "It will be worth it for agencies to track and confirm the 'correctness' of all their billing for the first few months, until CMS and the intermediaries have demonstrated that they can process everything correctly," Boyd advises.

CMS' analysis shows it will likely be worth your trouble to examine your claims for the shortfalls, says Bob Wardwell with the Visiting Nurse Associations of America. "It could be enough money to go looking for in the case of some agencies."

Even the smaller-amount underpayments will add up quickly, Gaboury warns.

Putting the claims resubmission burden on agencies isn't fair. "It's going to be extremely frustrating to identify these underpayments," Gaboury fumes. With all of the legitimate payment discrepancies due to therapy and M0110 changes, the invalid underpayments will be hard to ferret out.

"It certainly would be much fairer for the contractors to be charged with identifying any overpayments," Wardwell tells Eli. "But how long would that take and would you trust them to be right?"

OASIS effect: When you resubmit your RAP, you may need to revise your OASIS to obtain a corrected HIPPS code, CMS says. In that case, you may submit the revised OASIS data to the state if you want to. "The OASIS for these episodes will not be used in any survey or quality-related reporting," CMS promises.

Billing Road Not As Smooth As Anticipated

The problems certainly were an about-face from CMS' recent assurances that everything was ready to go with the PPS billing system, Wardwell notes.

"Having been in their shoes, I would be very embarrassed," says Wardwell, who headed up HH PPS' original implementation for CMS in 2000. "But at least they were honest and fessed up." CMS could have "found" the error later.

More to come? And these billing errors may not be the last, Gaboury worries. In such a complicated reimbursement system, more grouper problems could be buried in the software undetected.

The problems with the new billing system are "a nightmare," Boyd blasts. "The best thing for the industry would be if CMS postponed the effective date by three to six months."

"It's a mess," Gaboury sighs.

Note: The notice of the problems, including instructions on correcting claims and OASIS records, particularly in HAVEN, is at www.cms.hhs.gov/HomeHealthPPS/downloads/GuidanceforHHAs_Posting_12-18-2007.pdf --scroll down to Issue #2.