Wiki Wound care and home health, why are my E/Ms being re-couped

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mayra.zambrano

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I work at a wound care clinic where lot's of our patients are covered by Medicare. They come in at least 1 time a week for our provider to fill out orders for home health wound care. I have noticed that the claims are initially processed with no issues. E/M code and wound care are paid for. Months down the line, I receive letters recouping the amount paid on the E/M code. The message sent on the refund request letter states that the "patient was in a home health episode". Does anyone know why this is happening?
 
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Actually CPT codes 97597/97598 are on the HHA master list of consolidated billing codes as of the most recent list I find which is dated 4/1/19, which you can find here under 'Downloads: Home Health PPS > Coding and Billing Information. I had not realized this service was included in consolidated billing when performed by a physician or NPP, and in my opinion this doesn't make much sense, but apparently it is.

What this means, in the words of Medicare, is that for "individuals under a home health plan of care, payment for all services (nursing, therapy, home health aides and medical social services) and routine and non-routine medical supplies, with the exception of certain injectable osteoporosis drugs, DME, and furnishing negative pressure wound therapy (NPWT) using a disposable device is included in the HH PPS base payment rates. HHAs must provide the covered home health services (except DME) either directly or under arrangement, and must bill for such covered home health services." In other words, the payment for these debridement services is inclusive in the rates that Medicare has paid to the HH Agency. So if the patient is going to be sent out to a physician office for this particular level of wound care, it needs to be arranged and paid for by the agency, and then the agency can bill for having provided it to the patient. If Medicare has recouped these payments, then your recourse would be to try to seek reimbursement from the HH Agency directly.

The office visit code 99213 is not listed as a consolidated billing service so I'm not sure why they would recover that payment because a medically necessary E&M service by a physician or NPP is not normally within the scope of the HH staff.
 
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So this is only happening with Medicare, we bill the E/M because the provider has to set up the patient with home health, spends time on the phone calling referring doctor, and types up notes to be sent to the HH. As soon as the patient starts the HH episode we will get notices of refund requests.
 
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It sounds like the HHA is initiating the enrollment for the same day as your services. Have you verified that on any of these denials?
I'm more concerned that you're billing an E/M service but you didn't say the provider is having a face to face encounter with the patient. The activities you list are not sufficient to support billing an E/M for that day.
 
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trarut said:
It sounds like the HHA is initiating the enrollment for the same day as your services. Have you verified that on any of these denials?
I'm more concerned that you're billing an E/M service but you didn't say the provider is having a face to face encounter with the patient. The activities you list are not sufficient to support billing an E/M for that day.
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I should have clarified this, yes they are having a face to face encounter and from there new orders or updated ones are being sent to HHA.
 
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There really is no reason I know of that Medicare should deny a physician office service because of home health status. Unless something has changed recently or there is a regulation in place in your particular state, patients receiving home health are allowed to go out of their home to go to medically necessary physician office visits. There is no overlap in payment between the benefit for an office service and a home health service (one is paid under Part and the other Part B), and I've never seen a denial or recoup of a physician claim due to a patient being enrolled in home health.

Are you sure it's home health and not hospice service that the patient is receiving? If yes, I think you should start by getting in touch with someone at Medicare and get a little more information about why they are doing this.
 
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Hello everyone! I'm glad each one you has responded. Please see the images of the ERA, I'm in North Texas and our provider is a PA in case that does make a difference.
 

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Here is the info from CMS https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS . It appears that this patient was in the "30"day period for Home Health and it is probably the wound care codes that created the rejection. These denials for home health are not common, it's usually hospice or snf, hospice requires a modifier, and the 97597/8 are not covered when a patient is in a snf. I suspect this is the situation with HH as well. Here is the look up tool https://med.noridianmedicare.com/we...solidated-billing/consolidated-billing-lookup interestingly, these codes do not come up as an issue. I would make a call to Medicare and inquire about this claim if you are getting several of these.
Tonia
 
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Ok, I have looked at the Consolidated Billing Codes - something I had never heard of until yesterday. I have talked to the HHA about this. What we are having recouped are the 97597/97598. But 1104x codes are ok and not on the list???? Am I correct in how I am reading this??? And apparently we just get stiffed on the supplies unless patient brings them in from where HH provides them. Wound care I think is not a profitable business.
 
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Check the diagnoses you are using. That could make a difference too. I understand there are many changes to Home Health services
 
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Selective wound debridement is supposed to be provided by the home health agency. If your hospital/practice does that service, the HHA has already been paid for it under consolidated billing, and you need to recoup the money from them. The surgical debridement codes are outside the scope of the HHA, which is why they aren't recouping.
 
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dianakayf said:
Ok, I have looked at the Consolidated Billing Codes - something I had never heard of until yesterday. I have talked to the HHA about this. What we are having recouped are the 97597/97598. But 1104x codes are ok and not on the list???? Am I correct in how I am reading this??? And apparently we just get stiffed on the supplies unless patient brings them in from where HH provides them. Wound care I think is not a profitable business.
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The 97597/8 codes fall into the "physical therapy" category of codes and that is why it falls under consolidated billing. Your surgical 1104x codes will get paid even if a patient is in a SNF or under the care of a HHA.
 
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