Home Health & Hospice Week

Don’t let the confusing PPS refinements trip up your billing.

If you don’t keep on top of your PPS payments,your bottom line is likely to suffer. But you need to know the prospective payment system ropes to figure out whether your payments are accurate under the complicated system.

The host of PPS errors that intermediaries are making adjustments for now are proof that mistakes occur all the time. And for many errors Medicare requires you to bring the correction to intermediaries’ attention yourself.

Because PPS methodology is so confusing under the refinements that took effect Jan. 1, 2008,it’s tempting to let unexplained payment differences slide, especially if the dollar amount isn’t huge.

Don’t fall into that trap, warned consultant  M. Aaron Little with BKD in Springfield, Mo. in a recent Eli-sponsored audioconference, “Smart Easy Ways to Reconcile Medicare Home Health Billing Adjustments.”

“PPS refinements has been very, very complex,”Little told attendees. “We’ve had a number of challenges with our claims getting paid correctly.” The Centers for Medicare & Medicaid Services has acknowledged at least one known error that continues today (see Eli’s HCW, Vol. XVIII, No. 6, p. 44).

“This … makes it very important that we always take the time to make sure that the amounts that we are paid on our claims are correct,” Little urged. “Even a couple of hundred dollars difference very likely could be due to an error [with the PPS claims processing system] that may not even be identified at this point.”

Put On Your Detective Hat

Home health agencies need to carefully look at their claims payments to see if they pay differently than expected, Little advised. If so, you need to figure out why -- legitimate claims adjustment or an error.

There are three basic reasons that the Medicare system pays claims differently than anticipated,Little explained: a change in early/late episode status, a change in the number of therapy visits billed, or an error. An error can occur in the Medicare claims system or can be an error on your part, such as data entry typos.

Your job is to look at your incoming claims payments and see if they are different than the amount you billed. If so, you need to reconcile that claim to determine whether the payment is accurate.

What you’ll need: To reconcile your PPS claims, you’ll need five key elements:

1) the claim’s OASIS matching string,

2) your originally billed HIPPS code,

3) current Medicare Common Working File (CWF) information on the patient’s early/late episode status,

4) the number of therapy visits billed, and

5) the HIPPS code the system actually paid.

“Whenever an upcode or downcode occurs,Medicare is actually changing the HIPPS code at which you are being paid,” Little explained. Every time you see a claim paid a different amount than what you expected, “the first thing I would encourage ou to do is find out what is the paid HIPPS code and then you can work backwards from there.” You can find the paid HIPPS code online through Direct Data Entry/the Fiscal Intermediary Shared System.

Remember These Reconciliation Tips

Once you have those five pieces of information,you can start going through the reconciliation process for the claim. (For those steps, see worksheet,p. 51).

Using the worksheet Little provided, you can double-check your billing elements and the system’s recoding accuracy. “Any time you have one of those payment differences, step through these questions to help get you to the ultimate answer -- did episode pay correctly?” Little counsels.

Key: To work through the reconciliation process, you’ll need to understand the relationship between HIPPS codes and OASIS matching strings,Little stressed. When the system recodes your claim,it will use the OASIS matching string you submitted on the claim to generate a new HIPPS code and payment amount.

You should also be sure to double-check the number of therapy visits, Little exhorted. “Don’t just presume that the number of therapy visits billed is correct,” he said. “Go back to your source documentation and just confirm that the number of therapy visits that should have been billed actually were billed.Many times you’ll find it worthwhile to do that.”

Pitfall: If you have savvy software, it will auto-adjust the amount you expect to get paid based on the number of therapy visits you bill, Little noted.But it can’t do the same for the early/late episode sequencing information that’s contained in the CWF.

M0110-related upcodes or downcodes are the most common legitimate adjustments to claims that you’ll see, Little expected. Your billing software only knows the information you enter into it.

Be sure to confirm any episode sequencing changes in the CWF directly, he urged.