Home Health & Hospice Week

Feds could make billing for home health certs and recerts harder that it should be.

If you and your physician referral sources think billing for home health certifications and recertifications is just a matter of sending in the claims, you need to think again.

In a recent report, the HHS Office of Inspector General denied 148 of 151 home health cert and recert claims billed by a Texas physician in 2001 and 2002.

The OIG also denied 88 claims for home health care plan oversight (CPO) from another Texas physician in the same report (see Eli's HCW, Vol. XIV, No. 27). The total overpayment for the two docs came to nearly $16,000.

The physician billing for certs and recerts admitted that 146 of the 151 services he claimed were accidentally billed, either due to biller or software errors. But of the five services that the doc actually did furnish, the OIG - through Medicare carrier TrailBlazer Health Enterprises - denied three.

TrailBlazer denied the three services for cert (HCPCS code G0180) and recert (HCPCS code G0179) because the physician failed to document the cert and recert services in the patient record, the OIG says. In fact, the physician didn't have one patient's record on file at all and couldn't locate any cert or recert "logs" for the other patient at issue.

No Documentation Required?

The Centers for Medicare & Medicaid Services hasn't set out documentation requirements for home health cert and recert, maintains Constance Row with the American Academy of Home Care Physicians. "There is no guidance ... from CMS requiring specific documentation," Row tells Eli.

"The codes were created by CMS in response to a reported physician backlash and unwillingness to sign home health agency orders," says Dr. Peter Boling, professor of medicine at Virginia Commonwealth University in Richmond. "They did not want the codes to be perceived as laden with hindrances and rules."

Burden imposed: But it looks like the feds and carriers are putting those hindrances and rules on the services anyway. In the report, the OIG admits that the cert/recert HCPCS code definitions "did not contain clearly defined documentation requirements."

But because CMS established the codes as Level II HCPCS codes, the OIG applies the Level II documentation requirements to the codes. Those requirements are "that there should be documentation in the patient's office record per certification period to support the services rendered and billed," the OIG argues.

No OASIS Review

The OIG also lays out these services for the cert/recert codes: The physician should

(1) review the initial or subsequent reports of a patient's status that the HHA provides,

(2) review the patient's OASIS,

(3) contact the HHA to ascertain the implementation of the initial plan of care, and
 
(4) document the services provided in the patient's office record.

Not so fast: "The original guiding language ... did NOT specify review of the OASIS in care cert/recert as implied by the OIG report," Boling protests. "CMS did say that IF the physician reviewed the OASIS, that would count toward care cert or recert, rather than toward CPO, if both care cert and CPO were to be billed in the same time interval."

Physicians shouldn't feel like they have to look over the OASIS to claim cert and recert services. "It is vanishingly rare for a physician to see an OASIS form," Boling notes. "Most physicians have never heard of OASIS."

TrailBlazer, which is the carrier for Delaware, the District of Columbia, Maryland and Virginia as well as Texas, also tried to require OASIS review in its original requirements for cert and recert, Boling reports.

TrailBlazer's original local coverage determination (LCD) in 2002 on the codes "had some requirements very similar to CPO that were not appropriate," agrees Heather Vasek with the Texas Association for Home Care. After some haggling, TrailBlazer backed down on some of the stiffer requirements in its LCD in 2003, including the OASIS review standard.

However, TrailBlazer and some other Part B carriers around the nation still hold physicians to stricter standards for coverage of G0180 and G0179. Trail-Blazer's LCD specifies that the physician must participate in the plan of care. "This code should not be billed if a physician merely rubber stamps the plan of care actually developed by someone else," the carrier says in the determination.

The policy also requires the physician to have a face-to-face encounter with the patient within six months before signing the cert. There is a loophole, however: "Medicare recognizes that in rare circumstances, this may not always be possible because of practice patterns in certain physician group practices," the LCD acknowledges.

CPO-Cert Mix-Up Common

Tougher criteria for cert and recert billing may be on the rise because of the confusion about the services and care plan oversight. In its report, the OIG seems to lump cert/recert and CPO billing together into one service type.

"There is no connection between CPO and certification or recertification," Row stresses.

"There has been some confusion related to CPO and cert/recert for some time," Boling says. "Imprecise direction from CMS headquarters to regional carriers, resulting in varied implementation" is partly at fault, according to Boling. Lack of physician awareness about these codes and their proper use is another contributing factor, he judges. 

Note: The OIG report is at www.oig.hhs.gov/oas/reports/region6/60400083.pdf. The TrailBlazer LCD is at www.trailblazerhealth.com/lmrp.asp?ID=1861&lmrptype=tx.