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Home Health & Hospice Week

Prospective Payment System:

FIX FOR PPS SEQUENCING PROBLEM ON THE WAY

Published on Tue Jan 06, 2009

RHHI tells agencies how to ID their PPS adjustments.

A correction for a nagging PPS claims problem is coming, but not anytime soon -- leaving you vulnerable to incorrect payments in the meantime.

The Centers for Medicare & Medicaid Services will change the claims system to fix episode sequencing errors for episodes with 20 or more therapy visits, according to Jan. 30 CR 6305 (Transmittal No. 434).

Under current PPS Pricer software, an episode is assigned to Payment Grouping 5 if it has 20 or more therapy visits, so the five-digit HIPPS code would start with a 5. "The initial requirements for HH PPS case-mix refinements excluded HIPPS codes beginning with 5 from the edits that enforce correct episode sequence," CMS explains in the transmittal.

The problem: That's fine if the episode is expected to be in the 20-therapy-visit Group 5 category the whole time, CMS says. But if the claim must be recoded from a lower-therapy HHRG into the 20-therapy-visit Group 5 Category, the rest of the HIPPS code is then recoded based on the OASIS matching string an agency submits with its claim, instead of the Common Working File. The system then doesn't compare the HIPPS code against the CWF for accuracy because it starts with a 5.

The early/late episode information in an agency's OASIS matching string may be incorrect, points out reimbursement consultant M. Aaron Little with BKD in Springfield, Mo. That can be due to provider error or because the CWF may reflect different information that wasn't available at billing time, such as an earlier episode from another HHA.

The current PPS system will pay the claim based on the agency's erroneous early/late indicator in the matching string instead of the real information contained in the CWF, Little explains.

The error can cost an agency hundreds of dollars per claim, Little notes (see Eli's HCW, Vol.XVII, No. 34, p. 267 for an example).

"In these cases, which represent a small volume of claims nationally, the episode may be paid at the incorrect payment group," CMS says in the transmittal. "The requirements in this transmittal will prevent these payment errors."

Summer start date: Providers may be relieved that CMS has finally scheduled a fix for this problem, but the implementation date isn't until July 6. That means you'll have to be on your guard against such claims payment mistakes.

Corrections: Unlike the PPS adjustments intermediaries just made, it will be up to individual home health agencies to correct this problem, CMS directs in the transmittal. "Medicare contractors shall adjust HH PPS claims based on the incorrect ayment group when brought to their attention by the HHA," CMS says.

Little advises waiting until after the July 6 fix date to initiate those corrections. "Otherwise,both the assessment and the claim would need correcting to come up with the correct HIPPS code,which would then require a final claim correction,"he explains to Eli.

Bringing the claims to your intermediary's attention should be relatively simple if you're already tracking claims payment mistakes. "Hopefully the providers have been following the advice to reconcile their payments to find errors," Little notes.

More PPS Developments

In the transmittal, CMS also corrects some instructions to the regional home health intermediaries about counting episodes toward the early/later designation. "Fully denied episodes are not considered in determining whether an episode is early or later," CMS clarifies in the CR.

HHAs have also gotten a bit more information from one intermediary about the PPS adjustments that finally started last week (see Eli's HCW,Vol. XVIII, No. 5, p. 34).

"Once the adjustments have completed processing, they will display the type of bill 32I or 33I,"RHHI Cahaba GBA explains on its Web site. "In addition, the 'Remarks' field on Claim Page 04 will indicate which item the adjustment applies to in regard to CR 6250." The adjustments should have finished by Feb. 2, Cahaba said at the outset.

Neither Palmetto GBA nor National Government Services had posted any information on the adjustments by press time.

Lots at stake: Providers are eager to see their adjustments, especially for the M0110 early/later sequencing problems. Able Home Health in Rockford, Ill. is still waiting on adjustments of 23 such claims, says DJ Murdoch. It expects to receive an average of $278 per claim, or a total of nearly $6,400, from the M0110 adjustments.

"We have been waiting for the adjustments since April," Murdoch tells Eli.

Note: The transmittal about the Group 5 correction is at www.cms.hhs.gov/transmittals/downloads/R434OTN.pdf. The transmittal about the PPS adjustments referenced by Cahaba, CR 6250, is online at www.cms.hhs.gov/transmittals/downloads/R397OTN.pdf.

 

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