Medicare Compliance & Reimbursement

Heed what CMS has to say about documentation needs on your HHPPS claim.

The Centers for Medicare & Medicaid Services (CMS) has a new directive for home health agencies in the MLN Matters Article MM8441. HHAs are reminded that they will need to list the names of both physicians — the one who certifies their patients and the one who signs the plan of care (POC).

Home health agencies “will begin reporting (on claims with dates of service on or after July 1, 2014) the National Provider Identifier (NPI) and the name of both the physician who certifies the patient’s eligibility for home health services and the physician who signs the home health plan of care (POC),” CMS explains in the article.

Background: “Medicare allows a physician (such as a hospitalist) who attends to hospitalized patients, but does not follow them into the community to: 1) Certify the need for home health care based on their face to face contact with patients in the hospital; 2) Initiate the orders and a plan of care for home health services, and 3) ‘Hand off’ the patients to their community-based physicians to review and sign the plan of care,” CMS tells home care providers.

Agencies already report the NPI and name of the physician who signs the POC. Now, “for claims with effective dates or dates of service on or after July 1, 2014, home health agencies (HHA) must report the [NPI] and name of the physician who certifies the patient’s eligibility for home health services,” CMS directs.

Don’t miss: “You should complete both the attending physician and the other physician fields even if the certifying physician is the same as the physician who signed the plan of care,” CMS instructs.

PECOS Edit Losses Lie Ahead

If PECOS edits are not in place by next July, this will just be one more piece of data for agencies to include during billing. “The current requirement is to code on the claim the attending physician,” notes billing expert M. Aaron Little with BKD in Springfield, Mo. Adding the certifying doc’s information is “an additional physician to code on the claim,” Little notes.

Beware: “This will be very important when the PECOS edits are finally put into place,” Little tells Eli. “Presumably, there will now be two physicians against which the edits will validate rather than just the one.” That means double the chance that the doc’s NPI will get your claim denied.

Deadline hazy: Much to providers’ relief, back in April CMS nixed the May 1 deadline it had set to turn on PECOS edits for ordering and referring physicians. CMS has yet to announce a new deadline for phase 2 of the edits, in which claims will be denied if doc information doesn’t match what’s in the PECOS system. CMS has pledged to give providers at least 60 days notice when it will turn on the edits.

Denials loom: In a test run earlier this year, HHH Medicare Administrative Contractor CGS found three-fourths of HHA claims failed PECOS edits. HHAs that neglect to make sure their physician info will pass the edits will face claims denials and costly appeals. 

Note: The MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8441.pdf.