Co-founder of Epiphany Medical Services LLC. Home Health Coding Presented by LeeAnn M. Logan Co-founder of Epiphany Medical Services LLC.

Agenda Background What is Home Health? Home health coding Medicare Fraud Frequently used forms

Objectives Increased knowledge Better comprehension of Medicare forms Identify possible red flags in Medicare

What is Home Health? Nursing Physical Therapy Occupational Therapy Medical Social Worker Dietitian

Home health services are covered under Parts A and B of Medicare. Part A covers home health services for individuals enrolled in Part A only, and Part B covers home health services for individuals enrolled in Part B only. Although there are copayments for most other Medicare services, there are generally no beneficiary copayments for home health services.

Requirements For Home Health be confined to the home (i.e., homebound); • be in need of intermittent skilled nursing care or physical, speech, or continuing occupational therapy; • be under the care of a physician; and • be under a plan of care established and periodically reviewed by a physician (every 30 days).

Home Health PPS Medicare makes payment under the Home Health Prospective Payment System (HH PPS) generally on the basis of a national standardized 60-day episode payment rate that includes the six home health disciplines (skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social

Home Health PPS G0151 – Services of physical therapist in home health setting, each 15 minutes; G0152 – Services of an occupational therapist in home health setting, each 15 minutes; G0153 – Services of a speech language pathologist in home health setting, each 15 minutes; and G0154 – Skilled services of a nurse in the home health setting, each 15 minutes to report the provision of skilled nursing services in the home.

Types of Bills RAP Final Claim LUPA PEP

RAPs Request for Anticipated Payment 60% of complete payment Type of bill 322 UB-92

Final Claims At the end of certification Final 40% of complete payment Type of bill 329 UB-92

LUPA Fewer than 5 visits Approximately $120.00 per visit Type of bill 329 UB-92

PEP Partial Episode Payment Patient goes to another agency within cert. period Type of bill 329 UB-92

Nursing HCPCS -G0154 Revenue Code – 055X

Nursing G0162 – Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting). G0163 – Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting). G0164 – Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.

Physical Therapy HCPCS G01541 Revenue Code – 042X

Physical Therapy G0159 – Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes; G0157 – Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes; and

Occupational Therapy HCPCS - G0151 Revenue Code – 043X

Medical Social Worker HCPCS - G0155 Revenue Code – 056X

Medical Social Worker G0158 – Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes. G0160 – Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes; and

Speech Therapy- Language Pathology HCPCS - G015 Revenue Code – 044X

Speech Therapy- Language Pathology G0161 – Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes.

Nutritional Therapy HCPCS -G0155 Revenue Code – 056X

New “Q Codes” On April 2, 2013 The Center for Medicare and Medicaid Services (CMS) issued Change Request which adds new data reporting requirement for Home Health Agencies must report new codes indicating the location of where services were provided. Effective for home health agencies (HHA), beginning on or after July 1, 2013, HHAs are to use the HCPCS codes Q5001, Q5002, or Q5009, which were revised effective April 1, 2013 as follows:

HCPCS Code Definition Q5001 Hospice or home health care provided in patient’s home/residence Q5002 Hospice or home health care provided in assisted living facility Q5009 Hospice or home health care provided in place not otherwise specified

Is there a list of 'Q' codes that identifies the place of service for hospice line item billing? Answer: A list of Q Codes, along with the definition of each code can be found in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (CMS),Publication 100-04; Medicare Claims Processing Manual; Chapter 11 - Processing Hospice Claims; Section 30.3. Scroll down to HCPCS/Accommodation Rates/HIPPS Rate Codes.

Medicare Fraud

Medicare Fraud – Home Health HHAs are considered to be particularly vulnerable to fraud, waste, and abuse. One in four home health agencies had questionable billing In 2010, Medicare paid $19.5 billion to 11,203 home health agencies (HHA) for home health services provided to 3.4 million beneficiaries.

Common Types of Fraud Stark Law Cycling patients Billing for patients that are not eligible for home health

States That Are High-Risk for Fraud Florida, Texas Louisiana California Illinois New York Michigan

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22 percent of claims in error because services were unnecessary or claims were coded inaccurately, resulting in $432 million in improper payments. That review assessed HHAs’ medical records for beneficiaries but did not determine whether those records accurately reflected beneficiaries’ medical conditions

Medicare’s Fight Against Fraud Additional Data Requested (36 months) Increased surveys Surveys to survey the last survey Radio announcements in different languages

ADRs Plan of Care and Certification Face to Face Encounter Documentation of Services Rendered Itemized supply list if billed

ABN ABN (Advanced Beneficiary Notice of Noncoverage) must be signed when: You believe Medicare may not pay for an item or service, Medicare usually covers the item or service, and Medicare may not consider it medically reasonable and necessary for this patient in this particular instance. If you do not issue a valid ABN to the beneficiary when Medicare requires, you cannot bill the beneficiary for the service and you may be financially liable.

Frequently Used Forms

Medicare Secondary Payer Form (MSP) The MSP provisions protect the Medicare Trust Fund by ensuring that Medicare does not pay for services and items that certain other health insurance or coverage is primarily responsible for paying. The MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage.

Medicare would be considered a secondary payer If a beneficiary is covered under any of the following insurance plans, : Group Health Insurance (employer has 20 or more employees) - This insurance is provided by an employer to a policyholder who is actively working. Laws affecting this type of insurance include TEFRA, DEFRA, OBRA, COBRA and ESRD. Automobile or Liability Insurance - This insurance is applicable in cases where an accident has occurred, whether it is a car accident, a fall or medical malpractice. Worker's Compensation - Worker's Compensation covers injuries on the job. The employer's Workmen's Compensation carrier is responsible for the claim first. ***

Federal Black Lung Program - This program covers Black Lung claims Federal Black Lung Program - This program covers Black Lung claims. Medicare cannot pay claims submitted with a Black Lung Diagnosis code unless a copy of the Explanation of Benefits from the Black Lung Program is submitted showing that no payment was made. Veterans Administration - Services rendered at a Veterans Administration facility are not covered under Medicare. If services are rendered at a non-VA facility, Medicare may consider payment for the covered part of the services that the VA didn't pay. End Stage Renal Disease (ESRD) - For beneficiaries covered through an employer sponsored health plan through their own or a family member's current or former employment, Medicare is secondary for 30 months for those beneficiaries entitled to Medicare based solely on ESRD from March 1, 1996.

Medicare Supplement/Medi-Gap The term "Medicare Secondary Payer" is sometimes confused with "Medicare Supplement." You may hear Medicare Supplement referred to as a "Medigap." Medigap is a private health insurance policy designed to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer.

Questions & Answers