Part B Insider (Multispecialty) Coding Alert

Three Medicare carriers are pressuring physicians to choke off home care visits for patients who need them most.

Don't let the trio of miscreants muddy the waters when it comes to certifying home care patients, billing experts advise. Despite what these carriers are saying, there is no limit on the number of home health episodes a patient has.

These carriers seem especially confused about the meaning of "intermittent" and the extent of the home care benefit, industry experts contend.

Local medical review policies from a 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 threaten physicians with medical review for certifying or re-certifying a home health patient's plan of care more than three times in a year. The move is an attempt to restrict home care services, argues Heather Vasek with the Texas Association for Home Care. And they're doing so by trying to bully physicians, to the detriment of patients.

The policy 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, says John Beard, president of Birmingham, AL-based Alacare Home Health & Hospice.

As a Part B carrier, Trailblazer might not understand home care, Beard speculates. Physicians need to realize that 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 has raised the issue with the carrier and the feds and is trying to schedule a meeting to resolve it. 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 PBI.

In the meantime, physicians in doubt should consult 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 attorney Jim Pyles with Pyles Powers Sutter & Verville in Washington. Also, Section 203.3 rejects denial of service based on numerical utilization screens, he adds.

For about two years, physicians have been authorized to bill Medicare for their services in certifying and re-certifying patients for home health episodes and for care plan oversight, yet few take advantage of this.

Meanwhile, the Centers for Medicare & Medicaid Services 2003 physician fee schedule says it's up to the physician whether to review OASIS data when billing for certifications and re-certifications. CMS has removed mention of OASIS from codes G0179 and G0180.