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 [...]