OASIS Alert

Published on Wed Jul 31, 2013 PDF

Do your due diligence on whether patients have received a pneumococcal vaccination.

A home health provider in Maryland is on the hot seat for providing — and billing Medicare for — repeat pneumococcal vaccinations. And if you’re not careful, you could be next.

Background: “Current vaccination recommendations state that individuals without immunocompromising medical conditions should receive a single pneumococcal vaccination at the age of 65 years or older and that individuals with immunocompromising conditions should receive a second vaccination 5 years after their first,” the HHS Office of Inspector General says in a new report, “Potentially Improper Frequency of Pneumococcal Vaccinations for Medicare Beneficiaries” (OEI-07-13-00310).

“Medicare instructs providers to administer a pneumococcal vaccination if a beneficiary is uncertain of his or her vaccination history in the past 5 years.”

In a study of beneficiaries served from 2007 to 2011, an unnamed Columbia, Md., home health provider ranked number-one on the list of providers furnishing repeat vaccinations under HCPCS code 90732** (PPSV23), the OIG says. The HHA administered repeat vaccinations to 754 beneficiaries via locations with multiple NPIs.

Overall, 43 percent of providers gave patients the repeat vaccinations. The remaining benes received vaccinations from different providers. Medicare spent nearly $7 million on the repeat shots, the OIG says. Many of the unnecessary vaccinations “could be reduced through providers’ reviewing the medical history of established patients,” the OIG urges. “Tools, such as electronic medical records, may assist in this effort,” the agency says in the report at http://go.usa.gov/bssj.

Take Care with ADRs

If the blizzard of ADRs hitting the homecare industry is confusing you, you aren’t alone. Some Additional Development Requests include requests for the HHH Medicare Administrative Contractor “mixed in with ADRs for the Recovery Audit Contractor (RAC), the Zone Program Integrity Contractor (ZPIC), and/or the Comprehensive Error Rate Testing (CERT) contractor,” points out MAC Palmetto GBA on its website.

“Please review your … ADRs very closely. They can be confusing!” You don’t need to face additional payment delays or denials because of paperwork mix-ups. “Please make sure you esMD, fax or mail your records to the correct contractor,” Palmetto urges.

Reminder: “You cannot send ADR responses to the RAC, ZPIC or CERT via the electronic submission of Medical Documentation (esMD) process,” the MAC adds. “esMD only applies to requests that are solely responding to Palmetto GBA requests.”

Prepare for F2F Fight

Gear up for major battle over face-to-face physician encounter documentation — because your MAC is. HHH Medicare Administrative Contractor CGS has announced that July 8 is the date it began to require F2F documentation for all claims it reviews, even when they are not claims for initial episodes.

“The Centers for Medicare & Medicaid Services (CMS) clarified the ‘face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes,’” CGS says in its July newsletter for providers.

MACs CGS, Palmetto GBA, and NHIC all recently have announced a new focus on F2F requirements. CGS and National Government Services have posted new F2F educational resources on their websites.