CMS Plans to Have a Fifth RAC for Home Health, Hospice & DME

The Center for Medicare & Medicaid Services (CMS) is planning on making significant changes to the Recover Auditor Program (RAC) in 2014.  It plans to consolidate all Home Health, Hospice, and DME RAC duties to a new nationwide RAC.  Yes there will be a new RAC to review Home Health, Hospice and DME claims. 

CMS will also require the RAC auditors to support CMS in the administrative appeals process.  This will require the RAC auditors to defend their denials all the way to federal court if necessary.  They will be required to represent CMS at any hearings if requested by CMS.  These new requirements will hopefully make the RACs act in a more responsible manor, since the appeal process will require utilization of their resources.

Look for more information in a future Email Alerts.

CMS Announces Temporary Delay in PECOS Edit Implementation Temporary Delay in Implementing Ordering and Referring Denial Edits

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed. These edits would have checked the following claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If either of these were missing or incorrect, claims would deny.

• Medicare Part B claims from laboratories, imaging centers and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider; and  
• Part A Home Health Agency (HHA) claims that require an attending physician provider. 

CMS will advise you of the new implementation date in the near future. In the interim, informational messages will continue to be sent for those claims that would have been denied had the edits been in place.

MedPAC Recommends 3% to 5% Cut for Hospice SNF Residents

On April 4, 2013 Kim Neuman and Sara Sadownik MedPAC staff members spoke at a meeting in the Ronald Reagan Building concerning Medicare Hospice Policy Issues.   They reviewed MedPAC’s recommendations for hospice payment reform.  One of the recommendations was a 3% to 5% cut for Hospice patients who reside in Skilled Nursing Facilities.  They also discussed other issues such as the U-Shaped payment method which would pay hospice’s a higher rate at the beginning of care, lower rates during the middle of care, and a higher rate on the last seven days of the patients life. 

For more information please utilize the following link.

http://www.medpac.gov/transcripts/hospice_April_2013_presentation.pdf

CMS Issues Fact Sheet for Implementation Improvement Standard

On January 24, 2013 the U.S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo V. Sebelius.  The case involved skilled care being denied by contractors based on a rule-of thumb “Improvement Standard” – under which a claim would be summarily denied due to a beneficiary’s lack of restoration potential, even though the beneficiary did in fact require a covered level of skilled care in order to prevent or slow further deterioration in his or her clinical condition.

CMS agreed to the settlement agreement.  The language in the settlement agreement did not modify or expand existing eligibility requirements for receiving Medicare coverage. 

On April 4, 2013 CMS issued a fact sheet that describes their plans to conduct the following activities under the term of the settlement agreement.

1.     Clarifying Policy & Updating Program Manuals

2.     Develop an Education Campaign to inform stakeholders

3.     Preform a claims review to ensure beneficiaries are receiving care

CMS agrees to complete the manual revisions and educational campaign by January 23, 2014.

For more information please utilize the following link.

http://www.cms.gov/medicare/medicare-fee-for-service-payment/SNFPPS/downloads/jimmo-factsheet.pdf

CMS Rescinds Modifier on Medicare Claims

On April 2, 2013 CMS published Transmittal 2680 to remove the modifier to visits not ordered by the certifying physician for episodes starting July 1, 2013. 

The requirement to report where home health agencies and hospices services are provided remains the same.  Beginning on or after July 1, 2013, HHAs must report where home health services were provided.  The following codes are used for this reporting are listed below:

Q5001: Hospice or Home Health Care provided in patient’s home / residence

Q5002: Hospice or Home Health Care Provided in Assisted Living Facility

Q5009: Hospice or Home Health Care provided in a place not otherwise specified (NO)

If the location where services were provided changes during the episode, the new location should be reported with an additional line corresponding to the first visit provided in the new location.

For more information please utilize the following link.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2680CP.pdf

From the desk of: Theresa M. Forster Vice President for Hospice Policy & Programs National Association for Home Care & Hospice

From the desk of:
Theresa M. Forster
Vice President for Hospice Policy & Programs
National Association for Home Care & Hospice
Washington, D.C.
202-547-7424
tmf@nahc.org

Hi, everyone. This morning representatives from CMS, FISS, and the MACs met to discuss this issue and they decided to turn off the edit that caused hospice claims to be returned to provider (RTPed) with Reason Code 32061. CGS just sent the following notice to its listserv and we would expect that other MACs will soon be alerting their constituencies. Our contacts at CMS have indicated that this should result in the needed relief from this claims processing issue. Many thanks to those of you who wrote with your concerns. Take care, Theresa

_______
Home Health and Hospice News from CGS

Update to Reason Code 32061 System Issue — On April 2, 2013, CGS notified providers through a listserv message that a system problem had been identified which impacted hospice claims (types of bill 81X and 82X). CGS has also determined this is affecting type of bill 34X. These claims were being returned to the provider (RTPd) inappropriately with reason code 32061. The Centers for Medicare & Medicaid Services (CMS) has informed CGS that this edit will be turned off, and contractors can release these claims to continue processing. Providers with claims in status/location T B9997 with reason code 32061 do not need to take any action. CGS is in the process of releasing these claims, and anticipates all claims to be released within the week.

CMS Issues Claim Hold For Home Health Final Claims

The Centers for Medicare & Medicaid Services (CMS) has identified technical issues with certain parts of the April 2013 quarterly system release.  This is effective for claims with dates of service or “Through Dates” on or after April 1, 2013.  This applies to all home health final claims.  CMS has instructed the Medicare Administrative Contractors (MACs) to hold the claims until April 14, 2013, when system fixes are expected to be implemented.  The claims will be released into processing on April 15, 2013

For more information please utilize the following link.

http://www.cgsmedicare.com/articles/COPE21835.html