Home Health & Hospice

Home health change requests take effect in 2015

Homecare Insider, January 12, 2015

On January 1, several of the change requests (CR) CMS issued during the last calendar year went into effect, heralding revised Medicare Administrative Contractor (MAC) guidelines on key home health policy and claims processing issues for the New Year.  

Salient updates include:
Edited diagnosis reporting guidelines on home health claims (CR8813). MACs will now implement edits to reject home health claims that list a manifestation code as a primary diagnosis, the result of a 2011 OASIS claim analysis that revealed some agencies were not complying with the existing coding guidelines surrounding certain primary diagnosis reporting practices (e.g., codes that require providers to sequence the underlying condition before the manifestation).
Consequently, under the new guidance outlined in CR 8813, the principal diagnosis reported on the home health claim must be the ICD-9-CM code that is most closely related to the plan of care—not a manifestation code. The change request instructs MACs to apply the "Manifestation code as principal diagnosis" edit to noncompliant claims and return them to providers.
To read CR 8813 in its entirety, click here.
Prevention of payment on RAPs for beneficiaries enrolled in MA plans (CR 8710)
Prior to the implementation of this guidance, CMS systems prevented the payment of Original Medicare claims for beneficiaries enrolled in Medicare Advantage (MA) plans. However, Requests for Anticipated Payment (RAP) for such episodes were still initially paid, then later rejected, creating unnecessary administrative burden for involved parties.
Under the guidance outlined in CR 8710, system edits will be put in place to ensure that RAPs with "From" dates falling within MA enrollment periods are processed, but are paid at 0%.
To read CR 8813 in its entirety, click here.
Additional measures to prevent duplicate payments when overlapping inpatient and home health claims are received out of sequence (CR 8699)
CMS has instructed MACs to implement edits that will prevent home health claims from processing with dates of service that overlap those of an inpatient stay. In response to a 2012 Office of Inspector General report that exposed claim vulnerabilities, CMS identified two gaps in existing Medicare edits:
  • The edit that rejects home health claims when they have dates overlapping an inpatient stay (other than the admission date, discharge date, or a date during an indicated leave of absence) does not consider inpatient stays in a swing bed
  • Medicare systems only identify overlaps with inpatient stays when the inpatient hospital or skilled nursing facility (SNF) claim was received before the home health claim
Under the new guidance promulgated by CR 8699, if a home health PPS claim is received, and the Common Working File identifies dates of service on the home health claim that fall within the dates of an inpatient, SNF, or swing bed claim, Medicare systems will reject the home health claim. The affected agency may then submit a new claim that excludes any dates of service within the inpatient stay that were billed in error. This policy change doesn’t apply to dates of admission, discharge, or indicated leaves of absence.
If the home health PPS claim is received before the inpatient hospital, SNF, or swing bed claim, but the latter claim contains dates of service that duplicate those within the home health PPS episode period, Medicare systems will adjust the previously-paid home health claim to non-cover the duplicated dates of service.
To read CR 8699 in its entirety, click here.