Home Health & Hospice Week

Check these claims to make sure you can back up your patients’ therapy visits and OASIS scores.

Some of your high-dollar episodes may also bring you high-level scrutiny.

HH Medicare Administrative Contractor Palmetto GBA has announced "service-specific prepay probe reviews" on three HIPPS codes that "have been identified as major risk services," it says on its website. The codes are 5CHK*, 5CGK*, and 5BHK*.

Those codes represent "very high therapy utilization patients with high clinical and functional scores, high case-mix weights, and high payments," explains billing expert M. Aaron Little with BKD in Springfield, Mo. Specifically, Little notes:

• 5CHK*: 20-plus therapy visits, highest clinical score (3) and highest functional score (3). It has a 2014 case-mix weight of 2.2292 — the highest possible — with a $5,514 episode payment for the Springfield, Mo., CBSA (after sequestration reduction).

For this HIPPS code, Palmetto will select 100 claims to review from each of these states: Florida, Illinois, Louisiana, and Texas, the MAC says. It also will choose 100 claims total from all other states in its jurisdiction.

• 5CGK*: 20-plus therapy visits, highest clinical score (3) and mid-functional score (2). It has a 2014 case-mix weight of 2.1325 — the second-highest possible — with a $5,276 episode payment for the Springfield, Mo., CBSA (after sequestration reduction).

For this HIPPS code, Palmetto will select for review 100 claims each from Florida and Texas, 100 claims from the overall state group of Illinois, Louisiana, and Mississippi, and 100 claims total from all other states in its jurisdiction.

• 5BHK*: 20-plus therapy visits, mid-clinical score (2) and highest functional score (3). It has a 2014 case-mix weight of 2.0230 — the fifth-highest possible — with a $5,006 episode payment for the Springfield, Mo., CBSA (after sequestration reduction).

For this HIPPS code, Palmetto will select for review 100 claims each from Florida and Texas, 100 claims from the overall state group of Illinois, Louisiana, and Mississippi, and 100 claims total from all other states in its jurisdiction.

"There must be a higher-than-average amount of such episodes in the states subject to review," Little muses.