01-301 Home Health Findings of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for CMS, has conducted post-payment review of claims for Medicare Part A Home Health services billed on dates of service from January 1, 2020, through December 31, 2020. Below are the review results:
| Project ID | Project Title | Error Rate |
|---|---|---|
| 01-301 | Home Health | 62% |
Background
The Bipartisan Budget Act of 2018 (BBA of 2018) included several requirements for home health payment reform, effective January 1, 2020. The mandated home health payment reform resulted in the Patient-Driven Groupings Model, or PDGM. The PDGM is designed to emphasize clinical characteristics and other patient information to better align Medicare payments with patients’ care needs.
Under the PDGM, the national, standardized 30-day payment amount is adjusted to account for patient characteristics and other information; including the principal diagnosis, secondary diagnoses, and functional impairment level. The need for therapy services under PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines (OT/PT/SLP) provided or the frequency or duration of visits. Under the new PDGM, a possible drop in therapy utilization and/ or the manipulation of other combinations of care to maximize payments could create potential vulnerabilities.
Reason for Review
The SMRC was tasked with performing claim review on a sample of Home Health claims from January 1, 2020, through December 31, 2020. The SMRC conducted medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance. Applicable waivers and flexibilities established during the PHE were utilized during claim review activities.
Common Reasons for Denial
- No Response to the Documentation Request
- CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
- Face-to-Face Document was Missing.
- The face-to-face visit document was not submitted. The documentation submitted did not support the face-to-face visit was conducted using appropriate two-way audio-visual technology. Refer to CMS Internet-Only Manuals, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.5.1.1 and 30.5.1.2; 42 CFR 424.22(a) (1)(v), and COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.
- Skilled Nursing Services Not Reasonable and Necessary
- CMS Internet-Only Manuals, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1 indicates services must be reasonable and necessary. The documentation submitted did not support the skilled nursing services were reasonable and necessary.
References/Resources
Social Security Act (SSA) Title XVIII
- SSA §§ 1814 (a)(2)(C), (a)(7). Conditions of and Limitations on Payment for Services.
- SSA § 1815(a). Providers Must Furnish Information.
- SSA § 1833(e). Payment of Benefits.
- SSA § 1835(a)(2)(A). Procedure for Payment of Claims of Providers of Services.
- SSA § 1861(m). Definitions of Services, Institutions, etc.
- SSA § 1862. Exclusion from Coverage and Medicare as a Secondary Payer.
- SSA § 1879(a)(1). Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed.
- SSA § 1895. Prospective Payment for Home Health Services.
Code of Federal Regulations (CFR) Title 42
- CFR § 409. Hospital Insurance Benefits.
- CFR § 424. Conditions for Medicare Payment.
- CFR § 424.516(f). Additional Provider and Supplier Requirements for Enrolling and Maintaining Active Enrollment Status in the Medicare Program.
- CFR § 424.535. Revocation of Enrollment in the Medicare Program.
- CFR §§ 484. Home Health Services, Subpart A General Provisions, Subpart B. Patient Care, Subpart C. Organizational Environment, and Subpart E. Prospective Payment System for Home Health Agencies.
Public Law
- Balance Budget Act (BBA) 2018 (Pub. L. 115-123) Division E, Title X, § 51001.p
- Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-136). Supporting America’s Health Care System in the Fight Against the Coronavirus.
Internet-Only Manual (IOM) General Information, Eligibility and Entitlement Manual Publication 100-01
- Ch. 1, § 10.2. Home Health Services.
- Ch. 4, § 30. Certification and Recertification by Physicians and Allowed Practitioners for Home health Services.
- Ch. 4, § 80. Summary Table for Certifications/Recertifications.
IOM Medicare Benefit Policy Manual Publication 100-02
- Ch. 7. Home Health Services.
- Ch. 16, § 20. Services Not Reasonable and Necessary.
IOM, Medicare Claims Processing Manual, Publication 100-04
- Ch. 10. Home Health Agency Billing.
- Ch. 23, § 10. Reporting ICD Diagnosis and Procedure Codes.
- Ch. 30, § 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN).
IOM, Medicare Program Integrity Manual, Publication 100-08
- Ch. 3. Verifying Potential Errors and Taking Corrective Actions.
- Ch. 3, § 3.3.2.4. Signature Requirements.
- Ch. 6. Medicare Contractor Medical Review Guidelines for Specific Services.
CMS Coding Policies
- Outcome and Assessment Information Set (OASIS)-D1 Guidance Manual. Effective January 1, 2020-current
Local Coverage Determinations
- L33942. Physical Therapy – Home Health. Effective October 1, 2015
- L34560. Home Health Occupational Therapy. Effective October 1, 2015
- L34561. Home Health – Psychiatric Care. Effective October 1, 2015
- L34562. Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective October 1, 2015
- L34563. Home Health Speech-Language Pathology. Effective October 1, 2015
- L34564. Home Health Physical Therapy. Effective October 1, 2015
- L34565. Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective October 1, 2015
- L35132. Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus. Effective October 1, 2015
Local Coverage Articles
- A52845. Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances – Medical Policy Article. Effective October 1, 2015
- A53050. Case Scenario 1 Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015
- A53051. Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015
- A53052. Billing and Coding: Home Health Speech-Language Pathology. Effective October 1, 2015
- A53055. Home-Based Fall Evaluations and Interventions. Effective October 1, 2015
- A53057. Billing and Coding: Home Health Occupational Therapy. Effective October 1, 2015
- A53058. Billing and Coding: Home Health Physical Therapy. Effective October 1, 2015
- A56641. Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective July 4, 2019
- A56648. Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective July 4, 2019
- A56648. Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective July 4, 2019
- A56648. Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective July 4, 2019
- A56648. Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective July 4, 2019
- A56756. Billing and Coding: Home Health – Psychiatric Care. Effective August 1, 2019
- A57311. Billing and Coding: Physical Therapy – Home Health. Effective September 26, 2019
Other
- The Centers for Medicare & Medicaid Services (CMS). Home Health Patient-Driven Groupings Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.
- CMS. Medicare Learning Network ICN MLN20190214 February 2019. Overview of the Patient-Driven Groupings Model (PDGM). https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-02-12-PDGM-Presentation.pdf.
- CMS. Covid-19 Emergency Declaration Blanket Waivers for Health Care Providers. Home Health Agencies: CMS Flexibilities to Fight COVID-19.
- CMS. Additional Emergency and Disaster-Related Policies and Procedures That May be Implemented Only with a SS 1135 Waiver. Additional Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a § 1135 Waiver (cms.gov).
- CMS. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model (cms.gov)
Last Updated Sep 8, 2022