Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare home health services billed on dates of service from January 1, 2020, through December 31, 2020. Below are the review results:

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 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

• Medical Necessity
  • Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.1, and 42 CFR 409.44(b). “Documentation submitted does not support skilled nursing services are reasonable and necessary.” To be covered as skilled nursing services, the services must require the skills of a registered nurse, or a licensed practical (vocational) nurse under the supervision of a registered nurse, must be reasonable and necessary to the treatment of the patient’s illness or injury and must be intermittent. Documentation submitted did not support the home health services provided were medically necessary as evidenced by a new medical diagnosis, exacerbation of a chronic condition, recent hospitalization, and/or documentation to support the beneficiary was at risk of exacerbation and/or hospitalization related to their chronic condition.
• Physician’s Certification of Eligibility
  • Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.1. A physician certification/recertification of patient eligibility for the Medicare home health benefit is a condition for Medicare payment per sections 1814(a) and 1835(a) of the Social Security Act (the “Act”). The regulations list the requirements for eligibility certification and recertification. The requirements differ for eligibility certification and recertification; however, if the requirements for certification are not met, then claims for subsequent episodes of care, which require a recertification, will be non-covered—even if the requirements for recertification are met. Documentation submitted did not include the initial plan of care, therefore services on the subsequent episode may not be allowed, and/or the documentation submitted did not include the initial valid certification of eligibility and/or valid face-to-face documentation.
• Requested Records Not Received
  • Refer to Internet-only Manual, Pub. 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6) and Social Security Act Title XVIII, Sections 1815(a), 1833(e), and 1862(a)(1)(A). “No medical record documentation was received.” The inpatient documentation was not submitted or not submitted timely, to support the claim as requested by the additional documentation request (ADR).

References

Social Security Act (SSA) Title XI

• § 1135. Authority to Waive Requirements During National Emergencies.

Social Security Act (SSA) Title XVIII

• § 1814 (a)(2)(C), (a)(7). Conditions of and Limitations on Payment for Services.
• § 1815(a). Providers Must Furnish Information.
• § 1833(e). Payment of Benefits.
• § 1835(a)(2)(A). Procedure for Payment of Claims of Providers of Services.
• § 1861(m). Definitions of Services, Institutions, etc.
• § 1862. Exclusion from Coverage and Medicare as a Secondary Payer.
• § 1879(a)(1). Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed.
• § 1895. Prospective Payment for Home Health Services.

Public Laws

• Balance Budget Act (BBA) 2018 (Pub. L. 115-123) Division E, Title X, § 51001, Home Health Payment Reform.
• 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 Covid-19 Emergency Declaration Blanket Waivers for Health Care Providers. Home Health Agencies: CMS Flexibilities to Fight COVID-19 .
• Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-136). Supporting America’s Health Care System in the Fight Against the Coronavirus.
• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments.

Code of Federal Regulations (CFR) Title 42

• § 409. Hospital Insurance Benefits.
• § 424. Conditions for Medicare Payment.
• § 424.516(f). Additional Provider and Supplier Requirements for Enrolling and Maintaining Active Enrollment Status in the Medicare Program.
• § 424.535. Revocation of Enrollment in the Medicare Program.
• §§ 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.

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 (LCD)

• 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 (LCA)

• 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
• 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. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model (cms.gov)

Last Updated Jan 16, 2024