Home Health & Hospice Week

Warning: Separate submission will mean duplicate documentation process.

The Review Choice Demonstration has become at least a little bit easier under PDGM, indicates a newly updated frequently asked question set about the medical review demo currently operating in Illinois and Ohio.

Problem: When the Centers for Medicare & Medicaid Services nailed down Patient-Driven Grouping Model specifics on the 30-day billing periods, indications were that home health agencies would have to submit all their documentation for the 60-day episode (plan of care, face-to-face physician encounter documentation, etc.) twice — once for each 30-day billing period covered in the 60-day episode (see Eli’s HCW, Vol. XXVIII, No. 36).

Solution: Now CMS says that’s no longer the case for the thousands of HHAs that will eventually go under the demonstration, according to a series of new FAQs on RCD. “If a provider is requesting more than 30 days of services, the provider can select the multiple episode/billing period option and submit two or more 30-day billing periods at the same time,” CMS says in Question #105 released Jan. 6. In Palmetto GBA’s “eServices, you can select multiple episode(s)/billing periods once you complete all the tasks for episode/billing period 1. For multiple episodes/billing periods, you will need to enter the episode/billing period start and end dates, the type of bill, HCPCS codes and upload the POC, if changed, or refer back to the POC (Task 3) for episode/billing period 1. Each 30-day request will generate a separate UTN” or Unique Tracking Number, the FAQs add.

Furthermore, “providers are encouraged to use the multiple episode/billing period feature to avoid having to submit the same information multiple times,” CMS says in Question #110.

If you don’t: When you submit a pre-claim review (PCR) request for the two 30-day billing periods at separate times, you will have to upload the same documentation separately for each period, CMS confirms.

But there are cases where the second 30-day period will require different documentation and thus double the upload time, CMS cautions in the Q&As. “If the POC uploaded with the first pre-claim review request only covers the first 30-day billing period, a new POC would be needed for the second 30-day billing period,” says Question #110. “In that case, the new POC should be uploaded for Task 3.”

Don’t assume that the patient will need a new POC just because her diagnosis changes between the first and second 30-day billing periods, though. “There are many times that a diagnosis changes in the middle of the 60-day episode,” CMS reassures HHAs in Q&A #108. “This should be reflected in the skilled notes from the HHA.”

The home health episode of care “is still 60 days and the certification/recertification is viable for that length of time,” CMS elaborates. “If a provider submits a PCR and the diagnosis changes mid-way through the episode, a new POC or recertification would not be expected until the start of the new 60-day episode. The same POC (as long as the dates cover the entire 60 days) and certification elements used for the first 30-day billing period would be used, as well as current skilled notes and valid orders to render a determination for the second 30-day billing period.”

Upon recert: “When recertification occurs, the new diagnosis is reflected on the POC and any relevant information such as updated evaluations, skilled visit notes, orders, goals, etc., are all updated to accommodate the change in diagnosis,” CMS advises.

Note: The 118-FAQ set is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Choice-Demonstration/Downloads/RCD-FAQs.pdf.