Home Health & Hospice Week

This spring, hospices will have yet another piece of data to include on their Medicare claims. As of Jan. 1, hospices have had to report visits or phone calls for nearly all hospice days billed, the Centers  for Medicare  & Medicaid Services notes in Jan. 29 Transmittal No. 1897 (CR 6791).

The problem: "When a hospice patient has different levels of care within a given month, it is sometimes not clear from the claim which visits or calls are associated with each level of care reported on the claim," CMS explains in the transmittal. "This is because each level of care is only required to be reported once on the claim for the location it was provided and all days associated with that level of care are billed on one claim line, even when the days being billed on that line are not consecutive."

The solution: Starting April 29, "hospice claims ... should report separate line items for the level of care each time the level of care changes," CMS instructs in a related MLN Matters article."This includes revenue codes 0651 (Routine Home Care), 0655 (Inpatient Respite Care) and 0656 (General Inpatient Care)."

For example, if a patient starts the month in general home care, switches to general inpatient care, then goes back to general home care, there should be two different line items for the two general home care periods.

This strategy should ensure accurate data with "minimal administrative demands" on hospices, CMS says.

Watch out: If providers don't adhere to this policy, "CMS may consider implementing a line item date of service billing requirement for hospice level of care revenue codes," the transmittal warns. "This would require reporting a separate line for the level of care for each day billed on the hospice claim." That would be additional burden in reporting, CMS admits, "but would ensure that each level of care is reported with a line item date of service and therefore, each visit and call is appropriatelyassociated with the level of care during thetime of visit."

The transmittal is online at www.cms.hhs.gov/transmittals/downloads/R1897CP.pdf. The MLN Matters article is at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6791.pdf.

• At long last, CMS has posted the physician NPI file -- but it may not help suppliers much with their PECOS edit predicament.

A file with physicians' National Provider Identifier numbers and first and last names is now at www.cms.hhs.gov/MedicareProviderSupEnroll --click on "Ordering/Referring Report" on the left.

The file contains only docs who are eligible to refer in the Medicare program and have current PECOS records, CMS says.

Tip: The file doesn't contain duplicates,CMS notes. Many physicians share the same name, but they will have unique NPIs. Providers can look up docs' NPIs in the NPI registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.

The file, which is in alphabetical order by surname, also doesn't contain suffixes like "Jr." or physicians who are deceased, CMS adds.

CMS will refresh the file monthly, the agency's Pat Peyton said in last month's Open Door Forum for home care providers.

The file contains about 800,000 records, but there may still be as many as 200,000 physicians who aren't enrolled in PECOS, warns Wayne Stanfield with the National Association of Independent Medical Equipment Suppliers.

Providing this file to suppliers is good, but "the problem is not those [physicians] registered," Stanfield maintains. "It is those who are not registered that will stop payments for suppliers cold." Edits that check the referring physician field against PECOS on Part B claims, including those for durable medical equipment, start April 5 (see Eli's HCW, Vol. XIX, No. 5, p. 36).

"We are being punished for someone else's sins," Stanfield protests. "We have no control, nor any real responsibility for a physician's registration, but we must police this policy and will pay the price in rejected claims if the physician fails to comply."

Even if docs start enrollment today, the time lag will likely go past the April 5 start date for the edits, Stanfield points out. Medicare should "place the financial responsibility on the physician, not suppliers as a third party," says Stanfield, who is calling for a six-month delay on the requirement that CMS already pushed back from Jan. 1.

• Medicare has solved one claims problem relating to reason code U5391, but another one has cropped up.

From July to December, claims were returning to provider (RTPing) with reason code 38107 or U5391 because when a final claim rejected, an "X" got added to the document control number of the corresponding request for anticipated payment (RAP). Then the RAP and resubmitted final claim numbers didn't match, regional home health intermediary Cahaba GBA explains on its Web site.

The January claims system update fixed this problem, RHHI Palmetto GBA says on its Web site. But don't expect to see your claims immediately  cleared. For Palmetto, you have to manually report affected claims to the Provider Contact Center. Cahaba staff are manually correcting the claims, which takes up to 30 days, the intermediary says in an e-mail message to providers.

Now HHAs are again seeing a problem with final claims being rejected for not having matching RAPs, Cahaba says. However, it's a separate problem than the one that's been fixed, the intermediary explains. Investigation of the problem is underway.

• A recent legal victory for lawyers may mean less regulatory paperwork for you.

The American Bar Association has won a lawsuit against the Federal Trade Commission that will exclude ABA members from Red Flags Rule enforcement. Now health care provider trade groups are citing the ABA's victory in a bid to gain their own exclusion from the rule that will require providers to have identity theft protection programs in place by June 1.

The American Medical Association, American Dental Association, American Osteopathic Association, and American Veterinary Medical Association have asked FTC Chairman Jon Leibowitz for the FTC to leave health care professionals out of the regulation. If they succeed, the exclusion will most likely apply to all health care providers, including home care.

"The FTC's interpretation of the regulation imposes an unjustified, unfunded mandate on health professionals for detecting and responding to identity theft," the trade groups say in a release. The FTC has overstepped its authority with the oft-delayed rule.

"Congress did not intend the original red flags legislation to apply to small businesses, but rather it was intended to encourage large businesses like banks, credit firms and national retailers to implement best practices to protect customers from identity theft," ADA President Ronald Tankersley says in the release.

The bottom line: "Applying the rule to health professionals, but not to lawyers, would be unfair," says AMA President J. James Rohack.

• The feds are pressing full steam ahead on health care fraud-fighting, but they may target the wrong providers without valuable input from providers themselves.

That's one reason the American Association for Homecare is protesting that it wasn't included in the Department of Health and Human Services' and Department of Justice's recent "National Summit On Health Care Fraud."

"The Obama Administration has zero tolerance for health care fraud and abuse," HHS Secretary Kathleen Sebelius said in a release about the summit that took place Jan. 28.

The Health Care Fraud Prevention and Enforcement Action Team (HEAT) "has proven that better collaboration is the key to combating these crimes, recovering stolen resources, and protecting essential Medicare and Medicaid dollars," U.S. Attorney General Eric Holder says. "We welcome the private sector's participation in this work -- together, I'm confident we can make great strides in identifying, preventing and punishing health care fraud."

But home care providers have long said that their fraud and abuse complaints seem to fall on deaf ears when they try to go to the authorities, whether it's the HHS Office of Inspector General, state surveyors, the intermediaries, or other regulatory or enforcement officials.

And HHS and OIG didn't even allow AAHomecare reps to participate in their summit, the trade group protests. The summit occurred "without the benefits of the perspective and insight of the home medical equipment sector and we object to being left out of the discussions," AAHomecare'sTylerWilson says in a release.

Among other fraud-fighting suggestions for the industry, AAHomecare calls for "a dedicated office at the federal government level to combat Medicare fraud," Wilson notes.

• Is HIPAA 5010 a thorn in your side?

You might benefit from an upcoming CMS seminar.Confusion abounds regarding its HIPAA 5010 form, which takes effect on Jan. 1, 2012, and CMS aims to quell those issues with a series of educational events.

On Feb. 11, the agency will sponsor its fourth national conference call on the 5010 form, "CMS's Approach for New Error Handling Transactions: 999 and 277 CA." The call will consist of an educational session, followed by a Q&A.

To participate in the call, visit www2.eventsvc.com/palmettogba/02112010.

• Are you trying to justify hiring more wound care nurses? A forthcoming study may help you out.

The Wound, Ostomy and Continence Nurses Society (WOCN) has awarded a research grant to investigators at the University of Minnesota School of Nursing to evaluate the impact of WOC specialty nursing practice on the quality and cost of care, the Mt. Laurel, N.J.-based society says.

"By evaluating the effectiveness of WOC nurses to prevent and manage wounds, continence and UTI, findings of this study have the potential to validate the great value and need for WOC nurses," WOCN Society President Phyllis Bonham, of the Medical University of South Carolina, says in a release.

The study, which aims to determine whether care provided by WOC nurses improves patient outcomes, will compare OASIS data for different types of ulcers and wounds, incontinence, and UTIs.

• Just because you're not the mastermind behind a health care fraud scheme doesn't mean you won't do some serious jail time for it.

Detroit-area physical therapist Jessica Vigil pled guilty to health care fraud for her part in an HHA scheme that was busted by the HEAT Medicare Strike Force.

HHA All American Home Care Inc. employed Vigil and paid her $80 to $100 per form to create fictitious patient files showing that the patients received home care PT and occupational therapy services. In fact Vigil had never seen the patients or provided medically unnecessary therapy to them, according to a release from the DOJ.

All American paid Vigil more than $127,000 to sign the false forms, which the HHA used to bill Medicare for $2.375 million in home care claims, prosecutors say.

Vigil faces up to 10 years in prison and a $250,000 fine.

CMS and the OIG are "taking steps to increase accountability and decrease the presence of fraudulent providers," the release adds.