Home Health & Hospice Week

If the Centers for Medicare & Medicaid Services doesn't steer home health agencies clear of dangerous V code waters, agencies could sink come October.

The looming problem is with patient episodes that will span the Oct. 1 implementation date for use of V codes as primary diagnoses, noted Mary St. Pierre with the National Association for Home Care & Hospice in the May 7 Open Door Forum for home health and durable medical equipment.

HHAs could find themselves with patients who have one primary diagnosis on a request for anticipated payment (RAP) before Oct. 1, then a V code as the primary diagnosis on the final claim after Oct. 1. CMS currently doesn't allow agencies to use V codes for aftercare on OASIS, but the Health Insurance Portability and Accountability Act requires HHAs to use them by October.

CMS and the intermediaries must work out the problem in the Medicare claims processing system, notes consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD.

Even if Medicare claims processing systems allow for claims split on the V code implementation date, many providers' billing systems won't allow that split, St. Pierre maintained.

But having a different diagnosis code on the RAP and final claim shouldn't hold up claims in the billing process, says M. Aaron Little, supervising consultant in BKD's Springfield, MO office. And "intermediaries actually do accept V/E codes on billing transactions, so I wouldn't foresee any significant billing processing problems," Little tells Eli.

Indeed, the claims processing system doesn't edit as "far down" as diagnosis codes, agrees consultant Rose Kimball with Med-Care Administrative Services in Dallas. "Unless it changes the HIPPS code" with a significant change in condition (SCIC), any diagnosis coding changes before and after Oct. 1 "don't matter" billing-wise, she reassures agencies.

Many HHAs haven't thought far enough ahead to anticipate V code billing problems, says coding consultant Prinny Rose Abraham with Minneapolis-based HIQM Consulting. Agencies have been focusing on furnishing V and E code training to their staff instead of billing issues.

But it's likely providers will get confused when the October date rolls around, worries Little.

A CMS official promised in the forum that the agency is aware of the problem and is working on a solution with other HIPAA staffers.

Little hopes the regional home health intermediaries will "release some information in their monthly provider publications to proactively address any potential misunderstandings" surrounding the V code switch.

HHAs bracing themselves for the coming recoupments for partial episode payment (PEP) adjustments don't have much to look forward to. One member of the Home & Health Care Association of Massachusetts saw more than $400,000 withheld for 338 PEP'd episodes when intermediary Associated Hospital Service of Maine accidentally made a little more than half of its expected PEP takebacks last month, reports the association's Tim Burgers.

"No agencies have been told exactly how large their recoupment will be," Burgers tells Eli, and the final figure could reach even higher.

Some association members had more than $100,000 held up in the accidental recoveries, Burgers noted in the forum. "Agencies around the country could expect some pretty sizable recoveries under this project," he warned. The average recoupments in the accidental "sneak preview" from AHSM were about $1,300 per claim, Burgers added.

That figure sounds about right, a CMS official noted in the forum. The official also stressed that the AHSM recoveries were an accident, and that the funds will be recouped gradually over up to a year to lessen the financial hardship to providers (see Eli's HCW, Vol. XII, No. 16 article "Reimbursement" ). CMS has asked the intermediary to restore the payments.

Most Massachusetts agencies seem to have gotten their funds back, although a few say not all of the funds were returned, Burgers says.

A dispute resolution process is in place for those adjustments, the CMS official maintained. However, a bigger volume of disputed claims will probably mean a bigger backlog for the process.

CMS fixed the PEP problem back in April, so PEPs will be recouped from the beginning of the prospective payment system in October 2000 until April 2003, the CMS official added.

Meanwhile, the newest problem to crop up with the Home Health Compare Web site, which compares 11 patient outcomes for home health agencies in eight pilot states, is in regards to agencies' service areas. Agencies have found they are listed on the site for areas they don't service.

That's probably because CMS wanted to cast a wide net, said a CMS official in the forum. CMS "wanted to err in showing too many HHAs versus not enough," she said.

CMS figured service areas by taking the patient zip code reported in M0060 on the agency's OASIS assessments for the past two years, she explained. CMS now is working with state associations to remedy the problems and plans to tweak the process for the Web site's national rollout for all 50 states this fall.

The information on the site will be updated every four weeks.

Other than the service area issue, the home health quality information launch May 1 went smoothly, CMS officials said. The biggest question CMS received was why agencies weren't listed in the newspaper ads that compared three patient outcomes. The ads had room for only the largest 40 HHAs or so in a given area.

The gray area of hospice volunteer rules received some clarification in the forum. Regulations specify hospices must use volunteers in administrative support or direct patient care roles, a CMS staffer detailed.

That means time spent on general orientation and training, training on hospice philosophy and training on employee issues can't count as volunteer hours. However, time spent orienting a volunteer to a specific patient's care or training a volunteer on specific office tasks would count, the CMS official explained.