Audits provide a valuable tool for validating billing and documentation compliance. The Department of Health and Human Services published the results of its audit in 2012 when it determined that there was a 39% increase in home healthcare agencies (HHAs) from 2002 to 2008, and an 84% increase in Medicare home healthcare spending in 2007.
A sample of 495 beneficiaries showed that: (a) 98% of the beneficiaries met the homebound eligibility requirement and needed skilled nursing or therapy services; and (b) beneficiaries were under the care of a physician. However, results also showed that HHAs received improper Medicare payments in the amount of $432 million because either wrong claim codes were used or specific services were not medically necessary. Further, the audit uncovered $462 million dollars worth of HHA claim upcoding and downcoding. As shared in the previous column, these findings flagged actual and possible fraud, contributing to the need to establish the Medicare Fraud Strike Force.
Billing
The Centers for Medicare and Medicaid Services (2015), explain that Medicare eligible home healthcare is paid under a prospective payment system (HH PPS) and revolves around 60-day episodes of care, and the assignment of beneficiaries into a case-mix index group called Home Health Resource Groups. The prospective payment system rate for each group includes all skilled nursing services, physical rehabilitative therapy, routine and nonroutine medical supplies, and home healthcare aide and medical social services. Durable medical equipment (DME) and osteoporosis drug injections are paid outside HH PPS. DME services are covered as a DME benefit and paid by a fee schedule. Osteoporosis drugs are included as a home healthcare benefit but paid in addition to the HH PPS payment using the reasonable cost of the drug.
Relationship Between Billing and Documentation
The Outcome and Assessment Information Set (OASIS) instrument is used in assigning a beneficiary to a case-mix group. OASIS data elements describe both the beneficiary's health condition and needs for care under clinical severity, functional severity, and service utilization for each 60-day episode of care. Numeric values are assigned to each data element, which are then totaled and linked to a case-mix group for payment for the expected services and supplies the beneficiary will require. Depending on the patient's condition and services prescribed, an outlier payment may be made in addition to the case-mix level payment to reflect the higher expenses incurred by a beneficiary in any or all home healthcare services disciplines.
Required Documentation for an HHA Beneficiary
An HH PPS payment requires that a Medicare-enrolled physician certify a beneficiary is eligible for Medicare home healthcare service, and a Plan of Care is signed and dated. The physician must evidence five things in the documentation:
1. Patient medical necessity to support the need for intermittent skilled nursing care, physical therapy, and/or speech-language pathology services.
2. Evidence that the patient is homebound because: (a) leaving the house is medically contraindicated, OR (b) the nature of the illness or injury requires the patient to have supportive devices (crutches, canes, wheelchairs, and walkers), or the use of special transportation, or the assistance of another person in order to leave their place of residence. The physician must also document the existence of a normal inability to leave home AND the tremendous exertion by the patient to leave home.
3. Evidence that a Plan Of Care (POC) has been established and signed by a physician with his or her periodic review. POC key elements are: pertinent diagnoses and mental status with prognosis and rehab potential; types of services, supplies, and equipment required; visit frequency; activities permitted with functional limitations, nutritional requirements, medications, and treatments; safety measures to protect against injury; discharge instructions and other information important to that beneficiary. When therapy services are necessary, measurable goals to be achieved, by each therapy method, over what length of time must be included.The POC is terminated when the beneficiary no longer meets home healthcare eligibility criteria by receiving at least one covered SN, PT, SLP service, or occupational therapy visit in a 60-day period.
4. Evidence that the beneficiary is under the care of a physician while services are furnished. This criterion goes hand-in-hand with the POC. It is expected that the physician who certifies the patient's eligibility for Medicare home healthcare services is the same physician who establishes and signs the POC.
5. Evidence that a face-to-face encounter was performed by a physician or allowed nonphysician practitioner (NPP), and related to the reason the beneficiary needed home healthcare. Allowed NPPs include nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse midwives. To qualify, the nurse practitioner and clinical nurse specialist must work in accordance with State law and in collaboration with the certifying physician or the acute/postacute care physician. A physician assistant and certified nurse midwife must work as authorized by State law and under the supervision of the certifying physician.
The encounter must occur no more than 90 days prior to the home healthcare start date or within 30 days of its start date. The physician must have cared for the beneficiary in the acute or postacute care facility from which he or she was directly admitted to home healthcare.
At the end of the 60-day episode, the physician or NPP must decide whether to recertify the beneficiary for a subsequent 60-day episode. Eligible beneficiaries would start the subsequent 60-day episode on day 61. Under HH PPS, the plan of care must be reviewed and signed by the physician every 60 days unless a beneficiary transfers to another HHA or is discharged from home healthcare. So long as the beneficiary meets the eligibility requirements, the number of continuous home-healthcare recertifications is limitless. Insufficient documentation to support eligibility, certification, and recertification for home healthcare with a POC will result in no Medicare payment.
Conclusion
Improper Medicare payments totaling millions of dollars have been made to HHAs due to noncompliant documentation, coding, and billing. Providers should routinely view the Centers for Medicare and Medicaid Services (CMS) Web site for written and webinar resources to remain compliant with home healthcare practices.
Resources
The CMS Web site offers an extensive resource center on Home Healthcare. Examples of publications are:
* Certifying Patients for the Medicare Home Healthcare Benefit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatte
* CMS Billinghttp://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HomeHealthPPS/index.
* CMS Coding and Billinghttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/codin
* OASIS Guidancehttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/OASIS
REFERENCES