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CY 2011 Updates FAQ

Tuesday, December 28th, 2010

Over the past few weeks, many of our clients have called with questions regarding the CY2011 Final Rule. We have collected several of the most frequently asked questions for you to review.  Answer sources: November 17, 2010 Federal Register Final Rule, CMS: www.cms.gov/center/hha.asp,  NAHC: teleconferences and written medium, CMS12/20 Bulletin, and MLN Matters Articles at the following site: www.cms.gov/MLNMattersArticles/downloads/SE1038.pdf.

Question: “Does CY2011 Final Rule cover all Medicare and Medicaid beneficiaries?”

Answer: The Rule is effective for fee-for-service Medicare patients admitted/SOC on or after January 1, 2011. (SOC only).

Question: “If an agency provides care and the patient keeps promising to see a physician but does not can the patient be held liable for payment to the home health agency?”

Answer: No, states CMS. HHABNs are not appropriate when non-coverage is due to failure to complete the face-to-face encounter. Agencies must give the patient advance notice of their responsibility to have the physician face-to-face encounter. Home health agencies may NOT hold the Medicare beneficiary liable for payment due to non-compliance with the face-to-face encounter.

Question: ”Can the physician sign the POC before completing the face-to-face encounter.”

Answer: The POC may be signed prior to a face-to-face encounter as may occur if the patient sees the physician within 30 days of admission to care by a home health agency. However, both the POC and the face-to-face certification statement signatures MUST be present prior to submission of the final claim.

Question: “What if the physician does not complete all required items on the face-to-face encounter form?”

Answer: If the face-to-face encounter statements do not meet the requirements of CMS, as addressed in the CY 2011 Final Rule, agencies run the risk of having their claims denied. The agency must educate the physicians to the requirements.

Question: “Since the face-to-face encounter occurs at the SOC for home health, does it only occur at the recertification for a second, 90 day benefit period for Hospice?”

Answer: The face-to-face encounter requirement will track the benefit period status, no matter the number of days of hospice care delivered. For Hospice, the face-to-face encounter occurs at the start of the third benefit period, the 180th day recertification (the benefit period following the certification for the second 90 day benefit period). For Hospice the face-to-face encounter must occur at every subsequent recertification.

Question: “As to the new G-Codes, do therapy G-Codes go into effect January 1, 2011 or April 1, 2011?”

Answer: All G-Codes, per CMS, are effective January 1, 2011. (However, many advocacy organizations are requesting a delayed implementation date). A Transmittal from CMS is due out soon.

Question: “Which G-Code should be used for skilled nursing wound care, infusion, and catheter changes?”

Answer: G-Code “154 Direct skilled nursing services of a licensed nurse (LPN or RN) in the Home Health or Hospice setting, each 15 minutes.”

Question: “How does an agency calculate the reassessment 13th and 19th visits? Should each discipline count their own visits individually or should we count all therapy visits? When does this go into effect?”

Answer: Per CMS and NAHC “CMS goal is to ensure that the qualified therapist for EACH discipline providing services assess the patient before the TOTAL number of therapy visits reaches the 14th and 20th visit therapy threshold. Therefore, this is a combined therapy count.”

There has been speculation re “flexibility,” re reassessment visits and  days, but, agencies should read the soon to be released transmittal regarding this before finalizing policy.  CMS is to identify SPECIFICALLY how much flexibility will be given as to ranges of time for the qualified visit.

Before the episode completion, the qualified therapist must document progress toward goals established to justify continued therapy. The therapy requirements, other than therapy G-Codes, go into effect April 1, 2011.

Question: “Can a therapy assistant provide maintenance therapy visits?”

Answer: No. The PPS Update Notice stated, “Maintenance therapy will continue to be covered in the home health setting when the unique condition of the patient requires the complex services, which can only be provided effectively and safely by a qualified therapist. Furthermore, the maintenance therapy G-Codes are defined as provided by the qualified therapist.” (p.124)

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Part 3; RACs, MACs, Z-PICs

Tuesday, August 24th, 2010

Part 3 of 3 on RACs, MACs, Z-PICs:
The Home Health Industry and Insufficient Documentation for Medical Necessity and ICD-9 Coding.

Therapy and Home Health ICD-9 Coding and Supportive Services…
The therapy treatment plan must:

  • Relate to the exact diagnosis that has required therapy intervention
  • Identify visit frequency and duration
  • Identify the present and prior functional level
  • State specifically the procedures, treatments, and/or exercises to be performed
  • Clearly list the reasonable goals to be achieved
  • Specify the rehab potential
  • Specify the discharge plan in clear, easy to understand goals and plan.

In 2008, claims chosen with 10-11 therapy visits and discharge in episode two had a 74% rate of denial essentially due to poor or insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment.
NOTE: Do not use V57.1 Physical Therapy if SN is also involved with the care. (CMS OFFICIAL CODING GUIDELINES 2009).

  • If 781.2 Abnormality of Gait is used to justify PT care, PT needs specific documentation and objective testing to support gait and balance and strength e.g. TUG or Tinetti Test Tools.
  • Gait training should be specific with objective measurement progress.
  • The gait should be described specifically and graphically; ataxic, spastic, staggers with increase in ambulation of ___feet this day. Lack of complete documentation means payment denial risks will increase.
  • If 719.7- Difficulty in walking is coded, the therapist should be clear that this is due to e.g. degenerative and chronic joint disease.
  • Use for e.g. gait deficiencies due to lower extremity joint stiffness or effusion.
  • If muscle weakness 728.87 is coded, there should be manual muscle tests indicating weakness.
  • The therapeutic plan should have specific exercises and goals related to the weakness.

NOTE: Absence of a specific exercise plan can jeopardize visit payments.

  • The OT evaluation and documentation should reflect prior and present level with realistic goals.
  • If PT is also involved with care the OT should clearly delineate a plan that justifies the OT intervention.

NOTE: Have objective tests with clearly defined short and long term goals that are measureable and can be achieved within a realistic time point with direct relationship to the specified diagnoses.
Medical necessity must be evidenced EVERY visit. Document progress towards goals every visit is vital and must be stressed to therapists.
NOTE: There is a high incidence of visit denials when both PT and OT are providing care.
Of the ADRs selected, 1 SN and 4 OT visits have a denial rate of 71% essentially, because OT is not an initial qualifying skilled service.

The Plan and Supportive Services:

  • Medical Social Services can be added when skilled services are in place.
  • Covered services include:
  • Assessment of financial situation, community services available, personal/family social factors, and the potential for counseling
  • Patient risk areas must be clearly identified. Remember that assisting a patient to apply for Medicaid services is not an MSS skilled service.

NOTE: If a patient has a LUPA, 5 visits or less, and 1 visit is a MSW, the denial rate, as of 2008 data, was 67%.
Medical Social Services have non covered services that, if required, may be performed along with a covered service.
Non-covered services include:

  • Assistance with Living Wills and Advance Directives
  • Assistance with Medicaid Applications and Meals on Wheels
  • MSS is a service requiring a physician’s approval and the MSS may not be the only home health service being provided to a service. A qualifying service must also be providing care to the patient.

The Home Health Aide…
This service is provided by the least skilled individual and requires the most specific supervision as defined by CMS.
Home Health Aide Services are supportive and under the supervision of an RN, if multidiscipline case. If therapy only, the therapist may supervise the home health aide.
Supervision must be in the patient’s residence but the home health aide need not be present at the same time as the clinician performing the supervision.

Endpoint criteria to daily visits …

  • When skilled nursing visits are ordered daily, there must be a , “finite and predictable endpoint to daily skilled nursing visits.” It can be listed in days, weeks, months, or have a specific date.

The visit documentation must substantiate the skill and substantiate the endpoint. The Medicare Home Health Benefit was not established to provide daily skilled visits but rather, to provide intermittent skilled nursing services. CMS states that, “The one and only exception to this rule is a patient who requires and qualifies for skilled nursing services to perform daily insulin injections.” Remember, that because of the abuse of daily insulin injections they have a high likelihood of ADR review.

The Plan of Care:

  • The Plan of Care must be signed PRIOR to submission of the submission of the claim
  • A date stamp in Box #25 should be present when the Plan of Care is received
  • The POC must be supported by the clinician visits with a final claim.

There must be congruence between the OASIS 6 coding spaces: POC/485: 9 spaces+ E code on the UB-04 claim.

  • From the 6 lines of M1020 and M1022, CMS makes a payment decision.
  • Agencies should review progress notes and case management coordination to the POC.
  • Documentation should support the codes which are sequenced on the OASIS and POC.

NOTE: Clinicians should learn to establish an audit trail on the way toward expected patient outcomes.
ICD 9 Coding has become very important in home health. References include:

  • Official Coding Sources:
  • -The annually published CMS ICD-9-CM Coding Guidelines
  • -The Coding Clinic
  • Allowable Coding Sources:
  • -OASIS Chapter 3
  • -Appendix D to Chapter 3
  • -OASIS Q&As published quarterly by CMS
  • Promoting accurate coding selection in M1020, M1022, and M1024 requires:
  • Compliance with provisions of HIPAA, Title II.
  • Compliance with refinements to the PPS Grouper effective January, 2008.

Compliance with Section 1862 (a)(1)(A) of the Social Security Act to ensure payment is reasonable and necessary can be monitored with internal audits. Deal with an expert coding firm that places high regard on compliance for your peace of mind.

  • Diagnoses must comply with specific criteria to qualify as a primary or secondary diagnosis:
  • -Code by adhering to ICD-9-CM coding Guidelines
  • http://www.cdc.gov/nchs/icd.htm
  • -Code only relevant medical diagnoses
  • -Code only diagnoses supported by OASIS, POC, and clinician documentation

The 2011 changes in coding effective October 1, 2010 have become increasingly specific, preparing for the transition to ICD-10 Coding. It will be at that time when home health moves from 17,000 codes to more than 87,000 codes. It is only increasing in complexity and financial risk.

  • List diagnoses in the order that best reflects the seriousness of each condition and supports the disciplines and services provided.

SOURCE: Official CMS I-CD-9-CM Coding Guidelines

  • Assess the degree of symptom control in relation to identified signs and symptoms, medication profile review, frequency and duration, as well as care plan and treatments.
  • Clarify which diagnoses and symptoms have been controlled in the past.

The primary diagnosis should be the key reason for the POC and the most intensive service. CMS has noticed an increase in incongruence between primary diagnosis and actual plan of care and resulting visits. Do your agency visits support the patient POC? Are diagnoses truly reflective of patient condition at assessments?

The secondary diagnoses should coexist at the time the POC was established.
Agencies must be careful to use approved co-morbid diagnoses that could affect the plan of care even if that diagnosis is not a focus of care. Agencies should strive to have the diagnoses and codes describe the care to be provided in a specific episode. Approved co-morbidity diagnoses should be listed if the patient has one of the diagnoses, as it is believed that these approved co-morbidities will impact care.

There are diagnoses that can cause specific alerts.

  • These codes require VERY specific plans of care to substantiate need as they are case mix diagnoses. Once named case mix, these diagnoses were more frequently used by agencies and are now closely reviewed by CMS. They include:
  • -Low Vision
  • -GERD
  • -Depression
  • -HTN as a non SOC primary diagnosis
  • -Alzheimer’s (primary non SOC).

The wisdom of the home health clinician and the ability to use critically reflective thinking is essential.

  • Acute care coding is retrospective.
  • Home Health coding is prospective.
  • The diagnoses on the OASIS must match the POC/485 and the UB04

Clinicians must be certain the POC (primary/secondary diagnoses) and the discipline specific care plan are substantiated by each visit note and that each visit can withstand scrutiny on its own.

  • Documentation to substantiate coding and care have become critical to agency providers.
  • Documentation has become the key communication tool for care.
  • Documentation has become the first and last line of defense with the scrutiny of the industry auditors.
  • Documentation provides the demonstration of the skills of the clinician and justifies the retention of the agency payment received.

Truly, it is the critical thinking assessment and planning skills of the front line that will determine an agency’s bottom line. As we all know, it is easy to file a claim and be paid prospectively in home health. It is becoming more difficult to keep that payment, especially if fine skilled clinicians do not chart with the same fine skill.

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Part 2; RACs, MACs, Z-PICs

Monday, August 23rd, 2010

Part 2 of 3 on RACs, MACs, Z-PICs:
The Home Health Industry and Insufficient Documentation for Medical Necessity and ICD-9 Coding.

Home Health Eligibility Criteria Includes:

  • Homebound Status
  • Must be Under the Care of an MD, DO, or DPM
  • Medical Necessity and Skilled Need

Homebound Status per CMS
CMS expects that the patient’s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home.
NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1

Homebound status is…

  • Dependent on the limitations of the patient
  • Dependent on the patient’s illnesses
  • Can be acceptable for patient to attend partial hospitalization
  • Can be acceptable for the patient to attend medical appointments

NOTE: For a patient to be eligible to receive home health services, the regulation requires a physician to certify that the patient is confined to his/her home.

Homebound status requires…

  • Clear documentation that it is with considerable and taxing effort for the beneficiary to leave home. (74% of ADRs reviewed for lack of homebound status were denied).

NOTE: Documentation of “short of breath” does not justify homebound status. Acceptable documentation would include “short of breath after ambulating 10 feet and requiring rest period.” Agency documentation frequently stresses a problem with little justification.

Homebound status requires knowing the definition of a patient’s home. It is:

  • The patient’s residence is where the patient makes their home
  • Their personal dwelling
  • Residing with a family member or friend
  • In an assisted living facility

“The patient’s zip code is used for Home Health Compare to determine places where your agency provided service” Chapter 3, OASIS Guidance Manual, M0060.

CMS requires the beneficiary (patient) to be under the care of an MD, DO, or DPM.
Though there is active lobbying for orders to be signed by an NP or PA, that is presently not the law.

  • “A medical treatment plan of care or the optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments”
  • See 42 CFR Part484, Conditions of Participation, Subpart A General Provisions and 484.18 Plan of Care. Note the term, “attending physician”. CMS is frowning on a hospitalist signature with no patient follow through.

CMS accepts no stamped signatures and can disallow an entire episode with a stamped signature used by the physician.

“The physician’s signature on the Plan of Care must be obtained as soon as possible and must be obtained prior to billing Medicare for reimbursement” CMS Benefit Manual.

Skilled nursing visits must be intermittent.

The Medicare Benefits Manual, Chapter 7 states:

  • “To meet the requirement for “intermittent” skilled nursing care, a beneficiary must have a medically predictable recurring need for skilled nursing services…at least one every 60 days.” Therefore, a single nursing visit will usually trigger an alert if only one SN visit was scheduled. It will usually be denied, if selected for review.

Skilled nursing must be specific to justify medical necessity.

  • Skilled services are those services that are medically reasonable and necessary to the treatment of a patient’s illness or injury.

It must be clearly documented that the services provided required the skills of the professional clinician AND that the patient condition/illness/injury warranted those services:

  • Services can be performed by a Registered Nurse or RN supervised LVN/LPN
  • Physical Therapist, Speech/Language Pathologist (referred to in CMS home health operational and billing manuals as Speech Therapist)
  • Occupational Therapist (OT may not perform RFA1 OASIS assessment certification but may perform a recertification).

The Clinical Record…

  • The clinical record MUST have a specific order for EVERYTHING the clinician does
  • The clinician: MUST do EVERYTHING that has a physician order and MUST document EVERYTHING she/he does…thoroughly.

There are common documentation deficiency areas; one of which is a series of notes that reflect no real patient progress. Some other deficit areas include:

  • Repetitive clinical notes are frequently seen stating the same things over and over with no patient progress identified. How is it that the clinician is unable to teach a new med successfully within a visit or two?
  • Notes from different disciplines reflect lack of plan coordination
  • Visit notes do not substantiate orders and goals on Plan of Care/485
  • Clinical interventions without orders

Identifying the skilled need: Teaching…
There are three types of teaching that can rise to the skill level:

  • Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis.
  • Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching.
  • Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient has had prior instruction.

Teaching on new medications must include instruction or intervention on the related diagnosis. Do not confuse teaching the task of taking a medication with teaching about the medication and its impact on the disease or condition.
The clinician providing injections, such as insulin, requires specific documentation to support the need, specifically why the patient cannot self inject the med such as tremors, impaired cognitive functions, and/or no willing and capable caregiver. Without that documentation, the skilled need is not substantiated.

Skilled need and skilled nursing means:

  • The appropriate care must be coordinated with all clinicians and the patient and
  • each documented visit must be able to stand alone and clearly reflect homebound status on EACH and EVERY visit, clearly supporting skilled need, and identifying status of the patient progress with each note reflecting support of the physician’s ordered plan of care.
  • The CMS Benefits Policy Manual Chapter 7 states that a skilled nursing need requires the skill of an RN to oversee the nursing care. The manual also reminds us that skills performed by a skilled nurse do not necessarily skill the care.
  • Agencies should again be aware that one visit performed by the RN are being reviewed as to meeting the requirement for intermittent care.
  • If SN has 1 visit and therapy is the primary service, nursing requires an order for at least two visits (and a skilled need) and a well documented assessment unless SN is conducting the OASIS assessment only. (If the latter is the case, the therapist must skill the case first and the RN must visit AFTER therapy, on the same day or within the 5 day window to complete the OASIS C ). Note: Of ADRS selected in 2008, those with 1 SN and 4 therapy visits have a denial rate of 73%.
  • If a chronic diagnosis is the primary reason for ongoing care, the skilled nurse should be VERY VERY clear as to why (s)he is still making visits.
  • If visit notes do not EACH stand alone and justify care, the nurse’s visits are at risk.
  • The case-mix co-morbidities; such as CHF, CAD, COPD, DM, Parkinson’s disease should be included in the diagnoses list. If they are standing alone, the nurse should carefully justify the skilled need because of the chronic disease.
  • In justifying observation and assessment, the note must reflect that:
  • There is significant change in meds, treatments, or conditions
  • There is teaching and training needed
  • The condition or disease symptomatology has exacerbated or changed in another
  • way

NOTE: the SN care must tie to the POC and the discipline specific care plan as well as the ultimate outcomes.

Additional Development Requests (ADRs)

Per CMS, in 2008, the 5 main reasons for ADR denial included:
1. Downcoding due to inaccurate primary diagnosis
2. Therapy visits not medically necessary and were thus disallowed
3. None or poor documentation for medical necessity
4. Skilled observation was an initial identified need but then no progress was documented

Timeliness with ADR response has been a key reason to agency loss of the appeal process. (Agencies should check weekly for ADRs on the FISS system).
An increasing number of physicians are being interviewed re POCs and patient homebound status.

  • Denials for no physician orders, lack of homebound status, and untimely orders are on the rise.

NOTE: Recertifications require a verbal or signed written order prior to ongoing visits into that episode. Receiving a signed POC within 30 days (with no VO) of the episode, would disallow all visits within that 30 day period.

  • Treating a missing order as a late entry is not allowed. Backdating an order is illegal and considered a fraudulent practice.
  • If an agency has missing orders, they should discuss the issue with the physician and obtain the appropriate order but note the CORRECT date, it was obtained.

NOTE: Auditors are seeking trends. An oversite, properly corrected and documented reflects intent to correct an omission not perpetuate a fraud. Take action to instill processes so this issue does not reoccur.

Skilled nursing need including venipuncture, wound and psych care:

  • Effective February 5, 1998, “drawing blood for laboratory tests is not considered a qualifying skilled service under Medicare Part A home health benefit. If a patient qualifies for home health service based on another skilled service and requires venipuncture then the services may be considered for coverage. “(Balanced Budget Act of 1997)

NOTE: Having a primary documentation of long term anticoagulant therapy (V58.61) should reflect teaching and assessment on the disease process, as well as monitoring of other objective data such as lab results. Venipuncture alone would not skill the visits.

Wound Care

Wound Care coverage must have specific physician orders for one or all of the following:

  • Instruction/teaching on the wound care
  • Performance of the specific wound care
  • Assessment as to wound site progress/complications

NOTE: Documentation must include type of wound with size, depth, drainage, odor, color, skin condition, with specific interventions provided as ordered by the physician. Wound care is under significant scrutiny.

  • A stasis ulcer with a status of early/partial granulation adds two points to the Home Health Resource Group (HHRG). A “not healing” status adds 11 points. Auditors will look for the specific documentation to support each.
  • In addition, an early/partial granulation adds 25 supply points and not healing adds 36 points. (CMS –Regulation number 1560-F)

Note: Inadequate venous circulation to the affected area should be clearly documented. No such documentation leaves a visit suspect.

Psych Care

  • Homebound status can be applied in these cases if the patient refuses to leave the home because of manifestation of the disease or condition process or
  • If the patient is unsafe leaving the home because of behavior issues outside the home.

NOTE: Is OT involved with the psych care? While nursing tends to use words, the OT may assist to e.g. displace internalized anger through specific activities, which can also identify an objective sense of outcome achievement. An increasing number of agencies are finding this team; RN and OT, very dynamic.

What can the Psych Nurse do?

  • Evaluate the patient
  • Teach regarding the disease process
  • Discuss ways to cognitively restructure how the patient can approach ADL s
  • Psychotherapeutic interventions using techniques, such as cognitive restructuring therapy

Assisting the client to achieve optimal independence is a key goal.

  • For the disease combination Alzheimer’s and Parkinsons Disease, there is a 75% denial rate for SN.
  • Frequently, there are full denials because SN visits are not medically necessary.
  • The psych nurse visit must demonstrate skilled teach or intervention and/or assist with routine establishment and cueing education for the caregiver.

NOTE: If there are no changes in care, the SN visit is not considered medically necessary and visits are at risk.

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RACs, MACs, Z-Pics: The Home Health Industry and Insufficient Documentation for Medical Necessity and ICD-9 Coding

Friday, August 20th, 2010

Part 1 of 3 series on RACs, MACs, and Z-PICS:

CMS has now stated in the proposed PPS rule, “that after review of 2008 data that evidence continues to suggest that some Home Health Agencies may be providing unnecessary therapy.”

The RACs have also identified that insufficient documentation for medical necessity will be the first area of focus for their audits. But no agency should believe that only therapy documentation will be scrutinized. Skilled nursing with observation and assessment (O/A) continues to be high on the list for visit and episode denials. Link

In 2008, claims chosen with 10-11 therapy visits and discharges in episode two had a 74% rate of denial essentially due to poor or insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment.

The CY2011 proposed rule (dated July 23, 2010) requires objective evidence that the patient will improve. The rule also expects therapy patients to be assessed every thirty days and at the time of the 13th and 19th visit. It is expected that there will be more objective data inclusive of range of motion measurements, strength findings, and ADL dysfunctions with progress or regression noted. As previous; only the qualified therapist, not therapy assistant, will conduct the required assessment or reassessment.

Two new G-codes have been established to monitor therapy assistant visits. The current case-mix weight structure was designed based on data that home health patients received visits by qualified therapists 79% of the time with assistants visiting only 21% of the time. The new codes attached to both PTA and COTA will allow CMS to determine if that presumed fact is true.

CMS has Unleashed the Auditors

Annually, CMS receives 1.2 billion claims. That breaks down to 4.3 million claims per work day, 574,000 claims per hour, and 9,579 claims per minute. Fraud and abuse are on the rise and the pressure is on.
CMS has unleashed the age of the auditor with the advent of the RACs, MACs, CERTs, MICs, Z-PICs, and now, the HEAT.

RACs- The RACs are the contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, mostly due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, they are expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only .22 cents for every $1.00 recovered.

MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There will be 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for overpayment estimation of claims (current and prospective focus).

CERTS - To better calculate the performance of the FIs and MACs, as well as to look at the reasons for their errors, CMS decided to look at a number of additional rates. The additional rates include

  • provider compliance error (how well providers prepared claims for submission)
  • paid claims error rates (measures how accurately FIs and MACs make coverage, coding, and other claims payment decisions). CERTs randomly select a sample of about a 100,000 claims each reporting period.
  • CERTs review the claims for proper Medicare coverage, coding, and billing rules, and if not in compliance, they assign an overall error rate.

CERTs also identify if providers received overpayment letters or notices of adjustments to be made for claims that were overpaid and underpaid. CERTs are considered the Quality Improvement specialists who track and trend the performance of Fiscal Intermediaries and Medicare Administrative Contractors.

Z-PICs – Zone Program Integrity Contractors will perform Medicare Program integrity functions for CMS. They will interact with each MAC to handle fraud and abuse issues within their jurisdictions. Z-PICs are seen to consolidate the work of present CMS Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) and are divided into 7 zones.
Bill Dombi, Chief Legal Representative for NAHC stated (4/20/2010), “If an agency receives a RAC letter, they should just call their legal counsel” The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time. That power can cripple a financially devastate an agency.

HEAT –This auditing body are considered the more aggressive investigator of essentially DME and Home Health. There has been expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay.
This is the technologically oriented auditing body using state of the art technology to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector.

CMS states, “Providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and private sectors.”

Clearly, with all of the auditing bodies, CMS is making a bold statement; fraud and abuse will not be tolerated.. Unfortunately, in this kind of environment, innocent casualties can occur. Agencies need to take action now.

NOTE: Fiscal Intermediaries reviewing denials May 28, 2008- October 31, 2009 identified lack of medical necessity and homebound status unsupported in the medical record. In addition, ADRs were not received in a timely manner.

ADRs are on the rise. In 2007 47% of ADRs were denied by Fiscal Intermediaries

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Top 5 Questions asked regarding PECOS

Friday, July 9th, 2010

At Select Data, PECOS is a “hot” topic. Here are the 5 Top Questions asked of Select Data re PECOS….
Over the past three weeks, the home health industry has been focused on PECOS (Provider Enrollment, Chain, and Ownership System). The final interim rule was published in the Federal Register May 5, 2010, mandating physicians who certify DME and home health services be enrolled in PECOS by July 6, 2010. The situation heated up in June because many physicians thought they had until January 1, 2011. That mistaken information was stated in an April CMS transmittal and has caused confusion and angst within the industry. In addition many physicians, per our clients, thought that being a Medicare provider for years automatically meant they were enrolled in PECOS.

Question 1- An agency asked, can we hold off and see if CMS extends the deadline?
Answer 1- Agencies need to continue to verify that physicians are enrolled in PECOS. Physicians need to verify they are enrolled and active. Some physicians are finding that, though they have been enrolled in Medicare for many years, their information is not appearing in PECOS. If those physicians have not reported any changes to CMS within the past 5 years, they may not have any enrollment records in PECOS. They need to submit a PECOS application.
Question 2- Can a physician submit an application online?
Answer 2 -The PECOS enrollment process has progressed from paper (CMS-855) to an internet-based application process for physicians, non-physician practitioners, providers, and DME supplier organizations to not only enroll but, update their Medicare enrollment information and to verify status of the application process. For further information, go to: www.cms.gov/MedicareProviderSupEnroll/01_Overview.asp
Question 3 - How can a physician tell if (s)he has an enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS)?
Answer 3 – Per CMS: There are three ways to verify that you have an enrollment record in PECOS:
1. Check the Ordering Referring Report on the CMS website. If you are on that report, you have a current enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll, click on “Ordering Referring Report” on the left.
2. Use Internet-based PECOS to look for your PECOS enrollment record. If no record is displayed, you do not have an enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll , click on “Internet-based PECOS” on the left.
3. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll , click on “Medicare Fee-For-Service Contact Information” under “Downloads.”
Note: If you have submitted an enrollment application within the last 90 days, and your enrollment application has been accepted for processing by the carrier or A/B MAC, you need not take any additional actions based on this listserv message. Per CMS
Question 4 – Can I get some online help with enrollment?
Answer 4- Certainly. Tips on how to enroll in PECOS can be found at: www.cms.hhs.gov/MedicareProviderSupEnroll on the CMS website
Question 5 – How will the PECOS system work (once they get physicians enrolled)?
Answer 5 – Refer to the CMS MLN (Medicare Learning Network and reference article MM6856 and the CR 6856 Change Request which requires the NPI for the attending physician on the claim to be valid and enrolled in Medicare.
The FISS (Fiscal Intermediary Shared System will reconcile the physician claim data to the PECOS. To reconcile, the physician (an MD, DO, or DPM) must be enrolled in the Medicare system and be registered in the PECOS system (unless they have opt out status).
The FISS system, using the PECOS system will verify physician validity by matching the NPI number, the first letter of the first name, the first four letters of the last name to the claim information.
The FISS system requires physician enrollment for a valid claim and validity is tied to payment. CMS official instruction is available at www.cms.gov/Transmittals/downloads/R677OTN.pdf
Please be aware that on 6/30/2010 CMS posted the following:
“The Centers for Medicare and Medicaid Services (CMS) is working with providers to address concerns about enrollment in the Provider Enrollment, Chain, and Ownership System (PECOS) to ensure that Medicare beneficiaries continue to receive the health care services and items they need. PECOS is the electronic system used to enroll physicians and eligible professionals into the Medicare program.
As part of those efforts, CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals, made by providers that have not yet had their applications approved by July 6, 2010. While more than 800,000 physicians and other health professionals have enrolled and have approved applications in the PECOS System, some providers have encountered problems. CMS is continuing to update and streamline the process, and more providers have been enrolled in the past few days.”

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