Home Health & Hospice Week

Your grace period for nonroutine supplies billing mistakes is almost over, and its end will bring payment delays if you don't know the NRS ropes.

Home health agencies must report NRS on claims under the prospective payment system revisions that took place Jan. 1, the Centers for Med-icare & Medicaid Services noted in Nov. 2, 2007 Transmittal No. 1371 (CR 5776). When an agency doesn't furnish supplies, the agency shows that by using a number instead of a letter in the fifth position of the HIPPS code.

Starting this April, the intermediaries implemented informational claims edits that checked for supplies codes. Currently, if a claim has a HIPPS code that indicates the agency furnished supplies by using a letter in the fifth position, the claim must also include a line item for NRS and related charges.

If the claim includes a HIPPS code ending in a number, which shows the submitting agency did not furnish NRS to the patient, then the claim does not undergo the NRS edit check.

When an agency submits a claim with an alphabetic fifth HIPPS code digit (S-X) but doesn't report supplies charges on that claim, the system places codes M50 and N59 on its remittance advice. RA remark M50 says "Missing/incomplete/invalid revenue code(s)" and RA remark N59 says "Alert: Please refer to your provider manual for additional program and provider information."

About to change: As promised in the PPS revisions final rule, on Oct. 1 the claims system will begin returning to provider (RTPing) claims with that problem instead of merely supplying the informational edits, a CMS official confirms to Eli.

This will be a shock for many agencies, who haven't really noticed the NRS edits up to this point, expects billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN. "They never look at those codes unless the claim rejects," Gaboury maintains.

Providers haven't exactly ignored the edits, believes reimbursement consultant Michelle Enger with Optimal Reimbursement Strategies in Clear-water, FL. But "with the amount of clinical and bil-ling changes that occurred with PPS 2008 as well as the numerous Regional Home Health Intermediary (RHHI) claim processing issues that providers have experienced, October 1st is coming sooner than anticipated," Enger observes.

The change could be an unwelcome surprise for HHAs mired in other PPS billing issues. "I believe there are a ton of agencies that still aren't billing supplies and have no clue" that the NRS edit will begin returning claims Oct. 1, Gaboury says.

Agencies shouldn't take long to learn about the problem, depending on how much they deal with it. "The volume of claims that a provider submits will determine how quickly they will catch on," Enger predicts. "Fifty claims being returned to provider for the NRS edit is a lot easier to correct than 500."

Hidden trap: HHA staff will be tempted to take the easy way out and just change the last digit of the HIPPS code to a number, indicating the episode had no NRS used. "There will be many billers that simply change the fifth position so the claim will pay," Gaboury forecasts.

It's easy to do that because the amount of PPS payment doesn't actually depend on whether the claim says the agency furnished NRS to the patient. Under PPS now, the patient is categorized into one of six NRS payment categories based on the answers to OASIS questions and that category's payment amount is added to the PPS payment whether the agency furnished supplies or not.

Fraud alert: But just changing the last digit has major negative implications, Gaboury warns. "It is a huge problem," she tells Eli. "When you change the fifth position you are confirming to Medicare that there are no billable supplies associated with that claim. If there really are supplies associated with the claim, the agency has just filed a false claim," she says.

Agencies would also be undermining their own future payment rates from Medicare. CMS and the Medicare Payment Advisory Commission use the claims information to set future payment rates, calculate HHA profit margins, and influence policy decisions.

Remember: Plus, "the claim is a reflection of the care that was given to the patient and should be consistent with the clinical documentation," Eng-er counsels.