Prospective Payment System:
STAY WARY WHILE PPS KINKS ARE WORKED OUT
Published on Thu Feb 28, 2008
As CMS fixes old claims problems, new ones crop up, CMS admits in forum.
Major changes to a payment system are never smooth, and home health agencies are still experiencing a bumpy PPS ride into March.
The Centers for Medicare & Medicaid Services and its contractors have fixed the majority of the claims systems problems that arose in the transition to prospective payment system refinements Jan. 1, noted CMS' Wil Gehne in the Feb. 20 Open Door Forum for home care providers.
For example: A Feb. 4 claims system update fixed errors regarding upgrades for episodes with exactly 20 therapy visits, wage index adjustments for low utilization payment adjustment (LUPA) add-ons and supplies add-ons being applied to 2007 episodes, Gehne recounted. "We're whittling away at the number of problems," he told the 377 forum attendees.
But as a result of the fix, new problems cropped up. "We fixed one thing and actually then ... broke something else," Gehne said. "Sometimes it happens that way."
The first problem involved 2007 episodes with the first date of service in 2008 returning to provider (RTP'ing) in error. Regional home health intermediaries Cahaba GBA and Palmetto GBA reported the problem in February (see Eli's HCW, Vol. XVII, No. 7).
CMS expected RHHIs to implement the date-spanning fix "as soon as possible" after receiving the correction Feb. 21, Gehne said.
The second problem occurs with LUPA add-ons, Gehne explained. Instead of applying just one LUPA add-on for an appropriate claim, the system is applying the add-on to every service line item in the claim. CMS and its contractors were still testing a correction for that at the time of the forum, so there was no deadline for its fix to take effect. Reconciliation Confusion Plagues Providers One Michigan provider called into the forum and asked CMS to furnish more remittance advice codes to pinpoint the reasons for claims adjustments. CMS is considering the addition, Gehne said.
The problem: Agencies have difficulty, for example, distinguishing when the claim is up- or downcoded due to early/late episode sequence, the caller said.
The solution: The electronic RA should have the billed HIPPS code and the paid HIPPS code both on the advice, Gehne advised. Agencies can look at the first digit and see whether it changed from a 1 or 2 to a 3 or 4, or vice versa, to determine whether the adjustment is due to an early/late episode change. "A glance at those codes in combination will tell you if the adjustment is related to episode sequence," he explained.
Other adjustments, such as those for therapy, can confuse the matter, the caller said. More accurate RA codes would help agencies identify them, she urged.
Other issues addressed in the forum include: • HAVEN. CMS issued HAVEN 8.1 [...]
