Connolly, the Recovery Audit Contractor (RAC) for Region C, back in November received approval for three new home health issues, two of them automated review issues and one a semi-automated review of home health claims. On Dec. 28, an additional automated issue for core-based statistical areas was added.
Connolly will be conducting automated reviews using claims data to determine if agencies were paid incorrectly following situations in which a second episode of care was billed within the same 60-day period. Home health agencies are subject to a partial episode adjustment (PEP) whenever a patient transfers to another agency within such a period, or when the patient is discharged with goals met and is admitted for home health services by any other home health agency within 60 days. The PEP adjustment for the original 60-day episode should be prorated based on the actual number of days the patient received services from the home health agency. The actual number of days served is considered the first billable visit date up to and including the last billable visit date. This is different from the focus of the PEP issue that Connolly posted in January 2012; that issue was related to incorrect billing of partial episodes of home health. That review targeted claims that may have been adjusted incorrectly when they were not billed within 60 days of the initial claim date.
The second automated review targets home health services billed during an open hospice episode. Patients receiving hospice benefits waive all rights to Medicare Part A and B payments for services related to the terminal illness. However, other providers may bill Medicare Part A or Part B for services that are not related to the terminal illness by identifying the services using Condition Code 07 on the claim. One of the triggers for this review is the appropriateness of the diagnosis allowing for home care coverage. Due to incorrect coding practices, agencies may inadvertently submit a claim with the patient’s terminal illness listed as the primary diagnosis for home care even though the focus of the care was on another condition. For instance, a hospice patient with end-stage CHF may be admitted to home care for therapy following a fracture from a fall, with the services unrelated to the terminal diagnosis, but the home health coder may use the CHF as the primary diagnosis instead of the therapy and/or aftercare code. Although this alone would not be cause for a denial, it may appear to be incorrect billing during an automated claims review.
The third issue is a semi-automated review with a focus on timeliness of Outcome and Assessment Information Set (OASIS) assessments. The first part of this review will be automated, using claims data to identify aberrancy in the time frame in which the OASIS assessment is to be completed. The treatment authorization code found on the claim includes the start-of-care date (positions 1-2 and 3-4), the reason for assessment (position 9) and the date on which the assessment was completed (positions 5-6 and 7-8). The second part of this review involves a notification letter being sent to the provider explaining the potential billing error and requesting documentation to support the original claim.
Agencies that fail to complete the OASIS assessments within the specified time frames for each assessment period may be subject to payment-related issues. CMS reports that the expectation is that the home health orders be based on the results of the comprehensive assessment, and that the orders for patient care essentially expire at the end of day 60. CMS considers late assessments to be a potential legal issue, considering that an agency may not have orders for visits after the end of the 60-day period. CMS has replied to questions about OASIS assessments conducted outside of the specified time frames and consistently has provided instructions requiring each agency to make a home visit as soon as it becomes aware of the missed assessment (and to complete the assessment and provide documentation in the clinical record regarding the circumstances of the late completion).
Providers should review their OASIS assessment compliance using the comprehensive assessment update standards. If any agency finds a pattern of OASIS assessments being conducted outside the specified time frames, it should conduct an audit to determine the cause and take corrective action. The documentation found in the clinical records for noncompliant assessments should be reviewed to ensure that there is an explanation for the delay, and that the provider has physician orders for continuing care based on the patient’s needs.
The last approved issue is an automated review that will monitor for providers that are billing with core-based statistical area (CBSA) codes that are invalid or no longer in use. Agencies must watch for changes in CBSA codes, which are released each year with the update to home health PPS rates. If changes that impact a provider’s geographical service area occur, the provider should educate the clinicians responsible for completing OASIS assessments and ensure that the software used to build the OASIS assessments and claims are up-to-date.
The RACs in multiple regions have started examining home health claims. It is important to note that issues identified by one RAC frequently are adopted by the other RACs. Don’t become complacent just because issues are being discussed outside of your region. Be aware of all home health issues being reviewed and incorporate them into your quarterly records review processes.
About the Author
Bonny Kohr, RN, CHCE, HCS-D, is the manager of clinical services for FR &R Healthcare Consulting, Inc. She is a Registered Nurse, Certified Homecare Coding Specialist and a Certified Homecare and Hospice Executive. Bonny worked 23 years in home health care. She began her career in home care as a field staff nurse, then as a clinical director, and finally as the chief operating officer.
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