Incorrect caps could cost you.
Warning: If you're a hospice whose Medicare reimbursement bumps up against the per beneficiary cap amount, you may have to give money back to Medicare for previous years.
The Centers for Medicare & Medicaid Services has finally settled on a cap amount for 2003 and 2004. Nearly two years ago, the agency announced it had incorrectly computed hospice caps in previous years (see Eli's HCW, Vol. XIV, No. 31).
The caps are $18,143.26 for the cap period ending Oct. 31, 2003 and $18,963.47 for the cap period ending Oct. 31, 2004, CMS says in April 20 Transmittal No. 1226 (CR 5596). That's down from the originally stated $18,661.29 and $19,635.67, respectively.
CMS will come knocking if you received too much reimbursement for those years as a result of the incorrect caps. Regional home health intermediaries and other contractors must recompute the 2004 aggregate cap for each hospice and issue resulting demand letters by July 31, the transmittal instructs.
For 2003, RHHIs can issue demand letters only if the hospice received a cap determination in time for the three-year reopening period to be valid now, CMS advises.
The transmittal is at
www.cms.hhs.gov/transmittals/downloads/R1226CP.pdf. • RHHI Cahaba GBA will eyeball more claims that have a primary diagnosis of 344.61 (Cauda equina syndrome with neurogenic bladder).
Cahaba's initiating a widespread review be-cause a probe that covered the last half of 2007 denied 41 percent of such claims.
The probe, which reviewed claims from 54 providers, denied about half of the claims due to incorrect diagnosis. HHAs receive an extra 20 case mix points for using 344.61 rather than 596.54 (Neurogenic bladder, NOS).
Cahaba denied another 20 percent of cauda equina claims as not medically necessary, the intermediary says in a post to its Web site at
www.cahabagba.com/part_a/whats_new/20070424_hhpps.htm. • It's official: Home health agencies in durable medical equipment competitive bidding areas will no longer be able to bill their own regional home health intermediary for DME once bidding begins.
So says CMS in April 20 Transmittal No. 1224 (CR 5551). "HHAs that furnish DME and are located in an area where DME items are subject to a competitive bidding program, must either be awarded a contract to furnish the items in this area or use a contract supplier in the community to furnish these items," CMS says in the transmittal.
However, HHAs that are not in a bidding area still can bill the RHHI for DME, CMS explains. Bidding starts in 10 metro areas next year and will spread to 70 areas in 2009.
If you submit a claim for a bid item, the claim will come right back to you. "Claims submitted to the RHHI for HCPCS codes subject to a competitive bidding program [...]
