OASIS Alert

Home health agencies may find themselves fielding physician’s questions on certification and re-certification reimbursement more frequently, now that local medical review policies are trying to limit these payments.

“Physicians are not well educated in billing their services related to home health care,” confirms John Beard, president of Birmingham, ALbased Alacare Home Health and Hospice.

For about two years, physicians have been authorized to bill Medicare for their services in certifying and re-certifying patients for home health episodes, yet few take  advantage of this. Agencies had hoped the ability to bill for these services would improve physicians’ cooperation with home care.

HHAs need to be aware of three areas of confusion for docs and carriers:

1. Doctors aren’t required to review OASIS data for cert/re-cert. Until the Centers for Medicare & Medicaid Services released the 2003 physician fee schedule, it was unclear  whether a physician was required to review OASIS data before certifying or re-certifying a home health plan of care. But the physician fee schedule says it’s up to the physician.

To make sure both HHAs and physicians realize doctors are under no obligation to review OASIS data when billing for certs or re-certs, CMS has removed all mention of  OASIS from codes G0179 and G0180.

LMRPs may not have caught up with this clarification, but CMS has specified that OASIS review is not required, notes Heather Vasek with the Austin-based Texas Association  for Home Care.

2. Medicare doesn’t restrict the number of home care episodes a patient may have. Three Medicare carriers seem confused about the meaning of “intermittent” and the extent  of the home care benefit, industry experts contend.

LMRPs from an upstate New York carrier in February 2002, a New Jersey carrier in July 2002 and TrailBlazer Health Enterprises — covering Texas, Delaware, Maryland,  Virginia and D.C. — in November 2002 attempt to restrict home care services by threatening medical review for certifying or re-certifying a plan of care more than three times in a year, says Vasek. This will affect chronic patients who need continuous home care to remain out of institutions — such as those with monthly catheter changes, daily  insulin injections or B-12 injections, she explains.

As a Part B carrier, Trailblazer may not understand home care, Beard speculates. Home care is not restricted to “complicated medical problems” and intermittent is a “term of  art” defining the amount of skilled nursing care the benefit covers, not the episodes themselves, he argues.

Vasek is working to resolve the issue with the carrier and the feds. At a recent medical review process meeting, CMS said it is aware of the problem and is reviewing it, Ann  Howard with the American Association for Homecare tells Eli.

In the meantime, agencies can point physicians to the Medicare HHA Manual Section 205.1.A.4 where CMS clarifies that a chronic need for skilled nursing can qualify a  patient for home care, counsels Jim Pyles with Pyles Powers Sytter & Verville in Washington. Also, Section 203.3 rejects denial of service based on numerical utilization  screens, he adds.

3. There’s a big difference between certification/re-certification and care plan oversight. Billing for CPO requires compliance with stringent regulations, extensive record- keeping and at least 30 minutes of physician service during the month being billed. Cert/re-cert doesn’t require a specific amount of time and pays for “creation and review of a plan of care for a patient and verification that the home health agency initially complies with the physician’s plan of care,” the HHS Office of Inspector General states.

Doctors can bill for care plan oversight in addition to certification and recertification, if the patient requires the more extensive services involved, the OIG agrees.