Home Health and Hospice Coalition Questions and Answers: June 7, 2021
To: Home Health and Hospice Coalition
From: Palmetto GBA Provider Outreach and Education (POE)
Date: June 7, 2021
Location Sheraton Charlotte Airport Hotel, 3315 Scott Futrell Drive, Charlotte, NC 28208, and Zoom
Time: 9 a.m. ET
Attachments
- Home Health Appeals Report (PDF, 335 KB)
- Hospice Appeals Report (PDF, 335 KB)
- Hospice CAP update (PDF, 74 KB)
RCD Pre-Meeting
Question 1: What initiated the following changes to the FAQ? Why is it okay for an agency to forget to put a UTN on the claim and it is not okay for an agency to make a mistake in keying the UTN on the claim? Why isn’t the update applied the way that it reads?
For example, the update says if a valid UTN for a different period is entered on the wrong claim, this will result in an ADR. This is not what happens. If a first 30-day period is billed with a UTN for the second 30-day period, the claim pays. Does that mean that if the first 30-day period has a UTN on it for the second 30-day period in a later episode, it would still pay?
RCD Questions November 12, 2020
Q57: What will happen if I mis-key the UTN or accidently leave it off the final claim?
A: The claim will Return-to-Provider (RTP) for correction if the UTN is missing or mis-keyed.
Note: If there is no pre-claim review decision on file for a claim submitted by a provider who has chosen Choice 1: Pre-Claim review, the claim will be stopped for prepayment review.
RCD Questions March 4, 2021
Q58: What will happen if I mis-key the UTN or accidently leave it off the final claim?
A: The claim will Return-to-Provider (RTP) for correction if the UTN was created for the period but was omitted on the claim. The claim will RTP for correction if the UTN does not match a UTN, regardless of the period, for the beneficiary. If a valid UTN for a different period is entered on the wrong claim, this will result in an ADR. Providers should place the correct UTN on the corresponding 30-day billing period.
Note: If there is no pre-claim review decision on file for a claim submitted by a provider who has chosen Choice 1: Pre-Claim review, the claim will be stopped for prepayment review.
Answer: Some issues with CWF edits have been reported. CWF level edits are misfiring. The FAQ were updated based on how claims are processing due to the CWF misfiring.
If the claim ADR’d for a mis-key can the ADR be turned into an RTP? This will be investigated. There is no estimated time for the resolution.
Question 2: Stemming from the above scenario there was a 30-day period that was affirmed and then the UTN was incorrectly keyed on the claim and an ADR was triggered. The agency sent the chart in and it has now been denied under Medical Review for F2F content?
Answer: The goal for MR is to ensure that if mistakes are made, they will make every effort to ensure the corrections are made ASAP and ensure all nurses are educated across the board.
Question 3: Please provide the Medicare regulation that allows for the certifying physician to attest to a date of the face-to-face encounter that is not the actual date of the face-to-face encounter? If this is acceptable how does this meet the requirement? Our understanding is that this attestation is to provide evidence that the physician has reviewed and approves the face-to-face encounter. If he is attesting to the wrong encounter, how does this apply? How does the Palmetto GBA Medicare Review (MR) department handle this in an ADR situation?
Answer: While it is being affirmed in PCR, MR will apply regulation the same way for an ADR. MR does have the latitude to accept different dates for the F2F as long as the requirements are met. All other CMS contractors will need to follow the same guidelines that are set forth to include the UPICs, etc.
Question 4: What is the policy for accepting attestations for missing information? How does the PCR policy differ from the Palmetto GBA MR department policy for acceptance of attestations in ADR reviews?
The following excerpt is from the MPIM — Chapter 6. It specifically addresses Medicare Contractors in medical review of home health charts, regarding examples of sufficient documentation. In both examples below I have highlighted the reality that they are saying sufficient documentation includes that the physician has signed the plan of care (POC). I realize that in other Medicare guidance it reads “signed and dated.” That is understood. However, in a situation where an agency is submitting PCR review for a recertification episode during which the period’s POC has been fully signed and dated and it is timely. the agency also must submit the original F2F and the original plan of care in order to support the original certification.
The plan of care was signed by the physician, but he failed to date his signature. We agree that it should be dated. We got an attestation from the physician as to the date that he signed the original POC. The episode did not get affirmed because of an undated signature on a POC from 2019, and the attestation was refused. (Keep in mind that the date the agency was sent the signed document is printed on that document, and multiple other orders were signed the same day.)
Even if you wanted to deny the first claim that was directly associated with the POC, why would you not allow this for subsequent episodes, especially with an attestation? The Medical Review department and other Medicare Contractors do allow the attestation. Also, please know that one of the PCR reviewers did indeed affirm this for a different 30-day period.
Answer: The requirement of the certifying provider to document the date of, or to incorporate the actual clinical encounter note, is a required element of the certification which is expected to have been completed at the time of the claim submission. Since that was not in place initially, all subsequent billing periods do not meet the requirements per the regulation.The Medicare Program Integrity Manual requirement is referenced below. This is used to correct a signature error, not to back-date or correct documentation that was a requirement that was to be in place at the start of care.
3.3.2.4 — Signature Requirements (Rev. 751; Issued: 10-20-17; Effective: 11-20-17; Implementation: 11-20-17) C. Signature Attestation Statement
Note: The MACs and CERT shall not consider attestation statements where there is no associated medical record entry. Reviewers shall not consider attestation statements from someone other than the author of the medical record entry in question (even in cases where two individuals are in the same group, one should not sign for the other in medical record entries or attestation statements). Reviewers shall consider all attestations that meet the above requirements regardless of the date the attestation was created, except in those cases where the regulations or policy indicate that a signature must be in place prior to a given event or a given date. For example, if a policy states the physician must sign the plan of care before therapy begins, an attestation can be used to clarify the identity associated with an illegible signature. However, such attestation cannot be used to “backdate” the plan of care.
Other RCD Discussion
When a claim is denied for C5460, the appeals reviewer will look for an affirmed UTN (if the wrong UTN was billed). If there is an affirmed UTN, appeals will overturn the denial. If There is no affirmed UTN, it will be a full review and the claim can be denied for whatever reason the appeals reviewer discovers.
How do I find the RCD tools? Home Health Review Choice Demonstration (RCD)
Main Meeting
Claims Processing Issues Log
Open issues as of the June 7, 2021:
- Home Health: Reason Code 37257, Missing or Invalid Federal Information Processing Standards (FIPS) County Code: HH Pricer Issue, Certain CBSA Codes Change from Urban to Rural Designation
Answer: Ongoing, no updates. There is a workaround for this issue on the CPIL. Once fix, affected HHAs will have submit adjusts with the 2021 Core-Based Statistical Area (CBSA) codes.
- Home Health: Payment on Claims When the Requests for Anticipated Payment (RAP) Were Submitted More than 30 Days Late
Answer: Ongoing, no updates.
- Hospice Notice of Transfer (NOTR), Type of Bill (8XC)
Answer: Ongoing, no updates.
- Hospice Claims Editing for Reason Code U5181
Answer: Ongoing, no updates. There is a workaround for this issue on the CPIL.
Recently Resolved
- Home Health Reason Codes U524P/U524Q — Some Home Health Final Claims are Cycling in the System for the Timing of the Period/Episode
Answer: No action for HHAs, no claims are cycling with this issue.
- Recoding of Health Insurance Prospective Payment System (HIPPS) Codes from Late to Earlier Periods on Home Health Claims When There Is Separation Between the Periods of Less than 60 Days.
Answer: CPIL being updated/is updated that HHAs need to submit adjustments. If the HIPPS does not recode once the claim completes processing, the HHA may report it to the PCC
- Home Health: Medicare System Not Recoding the Health Insurance Prospective Payment System (HIPPS) Code on Some Claims
Answer: CPIL being updated/is updated that HHAs need to submit adjustments. If the HIPPS does not recode once the claim completes processing, the HHA may report it to the PCC.
- Hospice Payment Rates for Routine Home Care (RHC) on and after January 1, 2016
Answer: CPIL updated that hospices need to submit adjustments. If the tier RHC days do not recode correctly once the claim completes processing, the hospice may report it to the PCC.
Resolved (But pending mass adjustments by Palmetto GBA)
- RESOLVED: Home Health: Reason Code 37363 Editing on Low Utilization Payment Adjustment (LUPA) Claims
Answer: All adjustments were initiated May 7, 2021.
- RESOLVED: Home Health: Claims Spanning 2020–2021 Not Applying Correct 2021 Payment Rate
Answer: All adjustments initiated as of June 7, 2021.
- RESOLVED: Sequestration Reduction Applied Incorrectly on April 2021 Dates of Service
Answer: As of June 7, 2021, over 88,000 adjustments initiated. Not completed.
Additional Questions
Claims with KX modifier (to request override of late RAP penalty) are cycling in 7LRAP status. We have claims that have been in this status for over a month.
- Are the claims having to be looked at manually?
- Some have been returned for more information. We’ve sent info requested and claim back in 7LRAP again claims with KX modifier where the initial RAP had to be cancelled for one reason or another, and the new RAP is not billed within two days. This is virtually impossible. Not to mention, they are counting as calendar days, not workdays.
Answer: They suspend in 7LRAP for exception review. They shouldn’t cycle. They will be returned for more information if what was provided was insufficient. Yes, it is required “Claims with KX modifier where the initial RAP had to be cancelled for one reason or another and the new RAP has to be billed within 2 days.” Claims don’t approve on weekends on holidays, so this is obtainable.
Medical Review Questions
MACs Resume Medical Review on a Postpayment Basis. Is there any additional information Palmetto GBA can share, such as:
- “Later dates of service” is really vague. Is there anything more specific you can share about what service dates they might review?
Answer: Any date of service, to date, can be reviewed for postpayment.
- Will it be the same postpayment edits you currently have in place or will you look at other claim characteristics?
Answer: Yes, the same edits are applicable, to date.
- Is there any insight they can offer on how much later it might be before TPE is resumed?
Answer: The dates of service impacted can be any claims that are filed and processed to include 2021 dates of service. We do not have an expected date for TPE to return.