OASIS Alert

Published on Fri Oct 26, 2007 PDF

Once in the edit trap, the whole record is up for grabs.

Running afoul of edits means your agency will wind up wasting time and money providing the intermediary with medical records. And you can expect slower reimbursement to boot.

Regional home health intermediary Cahaba GBA promises continuing edits for non-start of care claims with a primary diagnosis of diabetes and a secondary diagnosis of congestive heart failure. Despite this edit's two-year history, the RHHI finds continuing errors, it reports.

Edit 5THBK will select claims that meet these parameters from across the provider community, Cahaba says. The intermediary will then review the claims for billing and coding errors as well as for local coverage determinations and compliance with all the Centers for Medicare & Medicaid Services guidelines.

Cahaba reports three main reasons for denials resulting from this edit: inadequate documentation to support skilled nursing visits, failure to respond to requests for medical records and inappropriate use of the diabetes primary diagnosis (see Eli's OASIS Alert, Vol. 6, No. 9, p. 86 for more about correct diabetes coding).

Cahaba will also initiate a widespread review (5006T) for claims without a qualifying skilled service billed, the intermediary announced in its Oct. 1 Medicare A Newsline. A probe review of 55 providers yielded an error rate of 63 percent, Cahaba reports.

The top three reasons for denials in the probe review were failure to respond to requests for medical records; physician's orders or plans of care not meeting Medicare coverage guidelines; and no qualifying skilled service provided for the billed dependent services, Cahaba says.

Cahaba offers suggestions about how to avoid denials in these two edits on pages 18 and 19 of its Oct. 1 Home Health & Hospice Medicare A Newsline at http://www.cahabagba.com/part_a/education_and_outreach/newsletter/200710_rhhi.pdf.