Industry Notes:
COPD CLAIMS UP FOR ADDITIONAL SCRUTINY
Published on Tue Apr 25, 2006
If you're not attempting to change the treatment, don't attempt to get paid.
Are your claims for COPD patients destined for trouble?
Regional home health intermediary Cahaba GBA denied more than 45 percent of claims it recently reviewed that had a primary diagnosis of Chronic Airway Obstruction (ICD-9-CM 496) and a length of stay greater than 120 days, it says in a posting on its Web site. In a widespread edit, the RHHI selected 169 recertification claims from January through March to review.
The problem: Of the denied claims, Cahaba shot down more than half due to lack of documentation to support ongoing skilled nursing in the home, the intermediary explains.
"Observation and assessment of the patient's condition are reasonable and necessary ... when the likelihood of change in a patient's condition requires a skilled nurse to identify and evaluate the patient's need for possible modification in the patient's plan of care until the patient's treatment regimen is essentially stabilized," Cahaba says.
The solution: "Indications such as abnormal/fluctuating vital signs, weight changes, edema and respiratory changes may justify further observation and assessment," the intermediary suggests. When such indications show a likelihood that skilled observation and assessment will result in changes to the patient's treatment, Medicare would cover the services.
On the other hand, observation and assessment aren't necessary when the patient's condition is longstanding and there is no attempt to change the treatment to resolve such indications, Cahaba concludes. • The Centers for Medicare & Medicaid Services could add more diagnosis codes to the categories that receive extra payment under the prospective payment system. After earlier discussion at PPS Technical Expert Panel (TEP) meetings, PPS contractor Abt Associates has been analyzing home health episodes to determine whether certain diagnoses correspond with higher or lower costs, reports the American Association for Homecare.
Abt is looking at diagnoses including gastrointestinal disorders, cancer, neurological disorders, stroke, hypertension, heart failure, diabetes, pulmonary diagnoses, wounds, Alzheimer's disease, psychiatric disorders, and blindness, AAH says.
CMS will propose any additions to the case-mix codes under its PPS refinement rule, slated for November (see Eli's HCW, Vol. XV, No. 18). • Suppliers of power mobility devices have gained ground in their battle against the PMD final rule, reports the Power Mobility Coalition. The House Government Reform Subcommittee on Regulatory Affairs released a May 19 letter calling on CMS to reevaluate the impact of the rule, which takes effect June 6.
The subcommittee is "greatly concerned" that CMS failed to "seriously evaluate the additional burden that the final rule imposes on suppliers of PMDs," Chair Candice Miller (R-MI) says in the letter. • If you want to enroll in Medicare or make changes to your enrollment information, you'd better obtain a National Provider Identification (NPI) number in a [...]
