CGS has identified two issues affecting claims processing. These issues are impacting all Medicare contractors. The Centers for Medicare & Medicaid Services (CMS) is aware of these issues, and is working to resolve them as quickly as possible.
Issue #1: Occurrence code 55, which was implemented with Change Request 7792, is required to be reported when the discharge status code reported on the claim is a 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown). However, claims submitted with the occurrence code 55 via the 5010 format are being rejected before entering the Fiscal Intermediary Standard System (FISS). This problem affects all provider types, and is being researched. Until the issue is resolved, providers may choose to submit these claims to CGS via Direct Data Entry (DDE).
Issue #2: Change Request 7755 requires hospice providers to report the certifying physician information (when different than the attending physician) on the claim in the referring physician 2310 F loop of the 5010 format. However, claims reporting physician information in the 2310 F loop are being rejected before entering FISS. This problem is currently only affecting hospice providers, and is being researched. Until the issue is resolved, providers may choose to submit these claims to CGS via Direct Data Entry (DDE).
Changes to M1024 Proposed in 2013
- Significant loss of payment expected
- If Agencies cannot report conditions resolved through surgery
- Presently case-mix points are garnered with use of these diagnoses
- CMS proposes that only fracture codes to be placed in M1024
What does this mean? This means a loss of case-mix and dollars so documentation must be stellar and every other code must be accurate.
CMS asked for comments on the proposed 2013 changes and they received them! Providers and others in the home health industry voiced their concern re the proposed changes.
Restricting M1024 to only permitting fracture (V- code) diagnoses codes while according to ICD-9 coding guidelines cannot be reported in a home health setting as a primary or secondary diagnosis. To further ensure compliance with coding guidelines, we propose to pair the fracture codes (V-code) with appropriate diagnosis codes and only when these pairings appear in the primary and payment diagnosis fields will the grouper award points, stated CMS in the proposed rule.
If providers cannot code medically identified conditions being treated in M1024, reimbursement will suffer. Agencies are providing the service but would not receive the payment for care delivered. The average lost per episode is estimated to be $200.00 per episode. Keep in mind non-routine medical supply points also.
Providers and organizations like the Visiting Nurse Associations of America are also actively speaking out.
Many neuro and skin conditions are treated surgically. These diagnoses must be replaced with V codes in the primary and secondary fields. The VNAA believes the proposed change would “place all homecare agencies at an unfair advantage.”
In addition, the proposed rule, per NAHC seems to indicate that case-mix points will no longer be available for fractures when a fracture is not a primary diagnosis. This too, can negatively impact on payment.
In early November, CMS expects to issue the 2013 home health PPS Final Rule.