Home Health & Hospice Week

As CMS fixes old claims problems, new ones crop up, CMS admits in forum.

Major changes to a payment system are never smooth, and home health agencies are still experiencing a bumpy PPS ride into March.

The Centers for Medicare & Medicaid Services and its contractors have fixed the majority of the claims systems problems that arose in the transition to prospective payment system refinements Jan. 1, noted CMS' Wil Gehne in the Feb. 20 Open Door Forum for home care providers.

For example: A Feb. 4 claims system update fixed errors regarding upgrades for episodes with exactly 20 therapy visits, wage index adjustments for low utilization payment adjustment (LUPA) add-ons and supplies add-ons being applied to 2007 episodes, Gehne recounted. "We're whittling away at the number of problems," he told the 377 forum attendees.

But as a result of the fix, new problems cropped up. "We fixed one thing and actually then ... broke something else," Gehne said. "Sometimes it happens that way."

The first problem involved 2007 episodes with the first date of service in 2008 returning to provider (RTP'ing) in error. Regional home health intermediaries Cahaba GBA and Palmetto GBA reported the problem in February (see Eli's HCW, Vol. XVII, No. 7).

CMS expected RHHIs to implement the date-spanning fix "as soon as possible" after receiving the correction Feb. 21, Gehne said.

The second problem occurs with LUPA add-ons, Gehne explained. Instead of applying just one LUPA add-on for an appropriate claim, the system is applying the add-on to every service line item in the claim. CMS and its contractors were still testing a correction for that at the time of the forum, so there was no deadline for its fix to take effect.

Reconciliation Confusion Plagues Providers

One Michigan provider called into the forum and asked CMS to furnish more remittance advice codes to pinpoint the reasons for claims adjustments. CMS is considering the addition, Gehne said.

The problem: Agencies have difficulty, for example, distinguishing when the claim is up- or downcoded due to early/late episode sequence, the caller said.

The solution: The electronic RA should have the billed HIPPS code and the paid HIPPS code both on the advice, Gehne advised. Agencies can look at the first digit and see whether it changed from a 1 or 2 to a 3 or 4, or vice versa, to determine whether the adjustment is due to an early/late episode change. "A glance at those codes in combination will tell you if the adjustment is related to episode sequence," he explained.

Other adjustments, such as those for therapy, can confuse the matter, the caller said. More accurate RA codes would help agencies identify them, she urged.

Other issues addressed in the forum include:

• HAVEN. CMS issued HAVEN 8.1 software Feb. 1, CMS' Kim Jasmin told the forum. That version includes the new grouper version 2.02 and OASIS data specifications version 1.60. The new version encompasses fixes identified from HAVEN 8.0.

Chip in: If you identify any HAVEN 8.1 er-rors, report them to the HAVEN helpdesk at 1-877-201-4721 or haven_help@ifmc.org, Jasmin urged.

• Hospice reporting. Hospices are still befuddled by the requirement to report visit data when patients reside in inpatient facilities. CMS reiterated its stance that hospices and contracting facilities must work out how they count visits on their own terms.

But callers insisted that CMS' vague guidance isn't good enough. After reading the agency's Q&As, "I'm really struggling with that issue," said a caller who identified herself from San Diego Hospice. This dilemma has been a recurring issue in previous forums.

CMS' Lori Anderson promised to review CMS' Q&A guidance on the issue to try to help hospices figure out how to count inpatient visits accurately.

An out: CMS also reissued the transmittal (CR 5567) requiring hospice visit data on claims. It now includes a statement saying CMS requires the data for research purposes only, not for payment, Gehne said. That should let hospices off the hook for any False Claims Act liability related to inaccurate visit reporting.

• Homebound status. CMS reiterated that homebound status for patients must be considered on a case by case basis. Palmetto recently pulled back a medical review article stating that driving would disqualify a patient for the home care benefit (see Eli's HCW, Vol. XVII, No. 3).

But if your patient drives, you'll certainly have your work cut out for you in defending her eligibility. "If the net effect of driving indicates that the individual has the capacity to get their health care routinely outside of the home, then it could challenge their eligibility," CMS' Katie Lucas said in the forum, reading from a letter the agency sent to the National Association for Home Care & Hospice. "The fact that a patient is fit enough to drive raises questions as to whether the basic statutory requirement is met."

• Enrollment. Some home care providers are seeing major delays to their enrollment paperwork at the CMS Regional Office level, reported NAHC's Denise Bonn. CMS will look into the issue, staffers said.

• Hospice budget neutrality rule. A CMS proposed rule implementing President Bush's administrative proposal to strip $2.29 billion from hospice payments over five years is in the clearance process, said CMS' Randy Throndset in response to a question from Larson-Allen's Ron Clitherow.

"Keep your eyes peeled over the next few months and you should be seeing something," Throndset told attendees. CMS recently announced the budget measure, to the surprise of many in the industry (see Eli's HCW, Vol. XVII, No. 8).