Intermediary denies HHA claims with ICD-9 code 332.x. Home health agencies can't seem to get it right when it comes to claims with a primary diagnosis of Parkinson's disease (332.x) -- and the mistakes can be costly. Regional home health intermediary Cahaba GBA is continuing edit 5THCD, which selects claims with Parkinson's disease as the primary diagnosis, a length of stay greater than 60 days, and no billed therapies, according to Cahaba's September newsletter for providers. Problem #1: Cahaba medical reviewers denied many of the claims caught up in the edit "because the documentation did not support the continued need for skilled nursing," the newsletter says. "To be covered as skilled nursing services, the services must require the skills of a nurse, and must be reasonable and necessary to the treatment of the patient's illness or injury." Providers must adhere to strict standards for observation and assessment to qualify for Medicare payment, Cahaba instructs. O&A "are reasonable and necessary skilled services 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 ... Plan of Care until the patient's treatment regimen is essentially stabilized." Don't count on fluctuating vital signs and other changes to meet that requirement. O&A "is not reasonable and necessary where these indications are part of a longstanding pattern of the patient's condition, and there is no attempt to change the treatment to resolve them," Cahaba says. Problem #2: Cahaba reviewers downcoded many claims because agencies inappropriately used Parkinson's as the primary diagnosis in M0230. "Parkinson's disease is a chronic disorder, and although it greatly affects a patient's health, it may not be the most specific skilled reason home health is currently seeing the patient," Cahaba cautions. Cahaba's September Newsline is online at
http://www.cahabagba.com/rhhi/news/newsletter/200809_rhhi.pdf. • A Texas home health agency owner has pled guilty in a Medicare scam centering on her false identity. Irene Anderson, owner of AG Total Care Home Health Services Inc. in Dallas, pled guilty to one count of mail fraud on Aug. 21, says U.S. Attorney Richard Roper of the Northern Dis-trict of Texas. Anderson owned a second HHA in Sulphur Springs, TX, called New Dimension Healthcare Services, but she did so under a fictitious identity she created, Iya Edwards. Anderson obtained a separate social security number and driver's license for the ID. Edwards and New Dimension were issued a Medicare provider number in March 2005 and billed Medicare fraudulently until April 2008, according to the release. Medicare paid them $1.2 million during that time. As part of the guilty plea, Anderson agreed to repay nearly $2.3 million and forfeit a 2006 Hummer, a 2002 Suzuki and $8,500 [...]
