Medicare Compliance & Reimbursement

When you get a documentation request from your MAC or another Medicare entity (such as a ZPIC, CERT or RAC auditor), chances are strong that you don’t have the requested paperwork sitting right in front of you — but if you need more time than the standard 45 days to find it, you can say goodbye to your payments.

That’s the word from new MLN Matters article MM8583 entitled “New Timeframe for Response to Additional Documentation Requests,” which goes into effect on April 6. It notes that when an auditor needs additional documentation from your practice, “no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period.” This indicates that the payer will freeze your payments until you come forward with the documentation.

Although that was always the case, the article points out what is new with the policy: Auditors have always expected documentation for pre-payment review within 45 calendar days of the request, but in the past may have granted extensions when warranted on a case-by-case basis. Now CMS says, “The reviewer should not grant extensions to the providers who need more time to comply with the request.”

Not only will you get denied for extra time, but you can expect to collect nothing on the claims if you don’t get your documentation in before the 45 day period expires. “Reviewers shall deny claims for which the requested documentation was not received by day 46,” CMS says.

Resource: To read the article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8583.pdf.

Overlapping Claims Might Cause Unexpected Adjustments for Home Health

If you’re trying to figure out why some of your claims aren’t paying, it may be due to two new Medicare transmittals that took effect Jan. 1. Those transmittals implement procedures that reject claims that overlap with patient stays in hospitals or for patients in managed care plans.

Hospitals: Before Jan. 1, the Medicare system rejected claims with overlapping dates only when the hospital submitted its claim first, noted the Centers for Medicare & Medicaid Services (CMS) in CR 8699 issued Aug. 1. And the system didn’t check inpatient days that occurred in a swing bed.

Now, the system compares incoming facility claims against home health claims. “If any home health visit dates are found to fall within the inpatient claim dates, the contractor shall … create an adjustment to the home health claim and reject the line items for any visits,” CMS said in the CR at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3005CP.pdf.

Medicare Advantage: Medicare doesn’t pay HHA claims when the patient’s episode falls entirely within a Medicare Advantage enrollment period, CMS reviewed in an Aug. 1 CR 8710. But before Jan. 1, the system would still pay requests for anticipated payment (RAPs) for such episodes. The system would then recoup the RAP amount when rejecting the final claim or when no final claim was filed by the 120-day deadline.

Now CMS has resolved the “pay and chase situation” by revising “original Medicare systems to ensure that RAPs with ‘From’ dates falling within Medicare Advantage enrollment periods are processed but are paid at zero percent,” CMS explained in the CR. “This will allow the final claim to be received and rejected appropriately, but will prevent any program vulnerability.”

Plus: “The requirements add remittance advice coding to zero-paid RAPs processed in Medicare Secondary Payer situations, so that the two situations can be distinguished,” CMS added.

“In the future, CMS will seek a new alert remittance advice remark code to specifically identify the Medicare Advantage cases also,” the agency says in the CR at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3010CP.pdf.

HHAs: Get Manifestation Coding Right Or See Returned Claims

Home health agencies had better put a manifestation diagnosis coding refresher on your long to-do list this month. Reminder: On Jan. 1, a new Medicare claims edit kicked in that returns home health agency claims if they list a manifestation code as primary. CMS set the Jan. 1 implementation date in a transmittal issued last August.

“An analysis of Outcome Assessment and Information Set (OASIS) records and claims for CY 2011 revealed that some agencies were not complying with the coding guidelines when reporting the primary diagnosis, in particular with regards to certain codes that require the underlying condition be sequenced first followed by the manifestation,” CMS said in Change Request 8813. “Given the concerns regarding compliance with coding guidelines, CMS is adopting edits to ensure greater compliance of coding guidelines for primary diagnosis codes.”

Do this: “The principal diagnosis reported on the home health claim should be the ICD-9-CM code that is most related to the current home health plan of care,” CMS directs in a MLN Matters article linked to the CR. “HHAs should not submit manifestation codes as the primary diagnosis.”

See the MLN Matters article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8813.pdf.

New CAHPS Exemption Form Available For Small Hospice Providers

Are you small enough to get out of new CAHPS requirements for hospice? If so, you’ll need to fill out a survey participation exemption form. On Jan. 5, CMS posted the Participation Exemption for Size Form at www.hospicecahpssurvey.org. Use the form to request exemption from CAHPS Hospice Survey calendar year 2015 data collection and reporting, CMS explains.

You have until August 12 to submit the form, but “hospices are encouraged to submit this form online via the CAHPS Hospice Survey website as soon as possible,” CMS urges.

Hospices are exempt if they have fewer than 50 survey-eligible decedents/caregivers in CY 2014, notes the National Association for Home Care & Hospice in a message to members. “CMS has previously advised that you make sure that your count is accurate (as opposed to estimating your count),” the trade group says.