Medicare Compliance & Reimbursement

HHAs: Head off costly appeals by monitoring RAPs.

Home health agencies have a moment to catch their breath now that looming PECOS edits have been delayed.

Latest update: "Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed," the Centers for Medicare & Medicaid Services says in an April 25 message to providers. "CMS will advise you of the new implementation date in the near future." The delay is "temporary," CMS says.

When CMS does finally turn on the edits, you can head off a costly appeal by paying attention to how your RAPs pay. If the attending physician National Provider Identifier (NPI) and name submitted on the Request for Anticipated Payment does not match the NPI and name in PECOS, the RAP will process with zero payment, stresses CGS in an article on its website.

"If this occurs, you may either: Cancel the RAP and resubmit a new RAP with the correct attending physician NPI and name to receive the RAP payment; OR Submit the final claim with the correct attending physician NPI and name to receive the full episode payment," CGS instructs.

On the other hand, if you submit a final claim with incorrect physician information, it will deny under the edits and you will have to submit an appeal — not an adjustment, reminds HHH MAC NHIC in a new message to providers.

Note: Specialty Code 01 for the physician was left out of the edits. CMS "has confirmed that the Specialty Code ‘01’ should be included in the edit logic and is taking steps to implement changes to correct this issue," CGS reports.