Home Health & Hospice Week

The PPS revisions are complex, but you can use this tool to get a handle on downcodes.

Home health agency billers have a heavy responsibility to track payments under the prospective payment system, but now you have help.

Adjustments to claims you bill are very common under the PPS revisions that took effect Jan. 1, cautioned billing expert M. Aaron Little in his recent Eli-sponsored audioconference, “Crash Course: Crucial Lessons Your HHA Billing Staff Must Know For 2008.”

Do this: HHA billers must investigate differences between billed and paid claims to ensure accurate payment, urged Little, with BKD in Spring-field, MO.

“That is a pretty heavy responsibility to investigate those differences,” Little acknowledged. But “it is extremely critical that we investigate those claims.” That’s especially true of downcodes, which could be costing your agency its rightful reimbursement based on simple errors.

Step 1: Billers should know what each position in the five-digit HIPPS code represents, Little advised listeners. The first digit shows the payment grouping based on M0110--early or later episodes. The second and third positions represent the clinical and functional dimension scores, respectively.

The fourth digit indicates the service utilization score, which is now completely determined by the number of therapy visits. The last digit shows Nonroutine Supplies (NRS) level.

Step 2: When Medicare pays a claim, check the submitted HIPPS code versus the paid HIPPS code. The electronic remittance advice should give you that information.

“What did the HIPPS code actually mean?” Little asks. “What is it trying to tell us?”

By looking at the two codes, you should be able to tell where the claims system adjusted your payment. For example, when the first digit is different, the system up- or downcoded your claim based on episode sequence of “early” or “later.” When the fourth digit is different, it changed your payment based on therapy utilization.

Resource: Use this one-page HIPPS code tool Little furnished in the conference to quickly pinpoint HIPPS code differences.

Example: If you bill a claim with HIPPS code 2CFKT in the Oklahoma City area, you’ll re-ceive payment of $4,491.28, Little noted in the conference. But if the claims system adjusted your HIPPS code to 3CFPT, your PPS episode payment would drop to $3,945.84.

You can tell the adjustments were made in the episode sequence and therapy areas because the first and fourth positions are different, Little advised conference attendees.

Step 3: Your job as a biller is now to investigate whether those differences were valid, Little instructed. You don’t want to lose money based on faulty data.

To determine the correct M0110 sequence, you’ll need to look up the patient’s history in the Common Working File, he counseled. You can use the “APP DATE” field on the CWF inquiry screen to get back to the timeframe that matters for early and later episodes--up to 60 days before your patient’s episode begins.

If the information in the CWF appears to be incorrect, you’ll have to enlist the help of your regional home health intermediary to get it changed, Little says.

To determine therapy accuracy, look on your claim and see how many visits you billed, Little says. If you have orders for 14 to 15 visits and billed 2CFKT, then received payment for 11 to 13 therapy visits under 3CFPT, look into why the extra visit or visits aren’t on the claim. Did the agency fail to make the visits, or did the visits just not make it onto the final claim?

“We want to make sure it was not just some kind of an error that those extra visits did not get put onto our claim,” Little noted. “Obviously it made a difference in our payment.”

Step 4: If the adjusted payment is valid, you can accept it and follow up with any internal changes necessary. If the adjusted payment is incorrect, you must adjust the claim once the final payment is finalized, Little tells Eli.

“It’s a little overwhelming to get used to this data,” Little acknowledged of the vastly more complicated PPS system. There are now 918 possible payment levels and twice that many HIPPS codes, thanks to the dual NRS codes for furnishing or not furnishing supplies. Under “old PPS,” there were only 80 HHRGs and HIPPS codes.

Despite the complexity, “if you are in the role of billing or billing oversight, it’s really critical for you to have a good working knowledge of this information,” Little urged. “We are the gatekeepers for our organization’s cash flow.” 

Note: To order a recording of Little’s recent audioconference which also covers PPS payment drivers, NRS payment and more, go to www.audioeducator.com/industry_conference.php?id=750.