September 17, 2013

Drill Down: Home Health Consolidated Billing and Therapy Services

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RAC Region A contractor Performant posted an automated review on August 15, 2013, for Outpatient Hospital therapy claims for patients under Home Health plan of care. Therapy services (physical, occupational, and speech and language) are bundled into the Home Health Prospective Payment Systems, with reimbursement paid to the Home Health agency only, and no separate payment is made to outpatient hospital therapy provider.

Before a provider of therapy services initiates those services to the Medicare beneficiary, the provider would need to determine whether or not a Home Health episode of care exists for that beneficiary. This audit issue references the Centers for Medicare and Medicaid (CMS) Medicare Benefit Policy and Medicare Claims Processing Manuals.

A therapy provider should ask the beneficiary or their authorized representative if he/she is presently receiving Home Health services under a home health plan of care. Beneficiaries and their representatives should have the most complete information regarding Home Health care status. Therapy providers may document information from the beneficiary that states the beneficiary is not receiving Home Health care, but such documentation in itself does not shift liability to either the beneficiary or Medicare for any denied claims.

To determine if the Medicare beneficiary is under Home Health plan of care, contact the Medicare contractor’s toll-free number to request Home Health eligibility. Institutional providers (providers who bill using the institutional claim format) may access this information electronically through the Home Health Common Working File (CWF) inquiry process. Independent therapists or suppliers who bill using the professional claim format also have access to a similar electronic inquiry via the HIPAA standard eligibility transaction—the 270/271 transaction.

As an aid to suppliers and providers subject to Home Health consolidated billing, Medicare systems display, for each Medicare beneficiary, the code for certification (G0180) or recertification (G0179) and the date of service for either of the two codes.

RAC issues for the week of September 16 – September 20, 2013:

RAC Region A Performant

Independent Therapy Provider

  • Home Health Consolidated Billing and Therapy Services - JL - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (A) (Home Health Services Consolidated Billing), therapy services (physical, occupational, and speech-language pathology) are bundled into the Home Health Prospective Payment System (HH PPS) reimbursement made to the Home Health Agency (HHA), while the patient is under a home health plan of care. Medicare does not make separate payment made to the independent therapy provider.

Outpatient Hospital

  • Trastuzumab (Herceptin®), Multi-dose Vial Waste - Per its package label, Trastuzumab (Herceptin®) is supplied by the manufacturer in a 440 mg multi-dose vial. Per Medicare Claims Processing Manual (100-04) Chapter 17, §40: "When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. Note: Multi-use vials are not subject to payment for discarded amounts of drug or biological."

Physician/Non-Physician Practitioner

  • Trastuzumab (Herceptin®), Multi-dose Vial Waste - Per its package label, Trastuzumab (Herceptin®) is supplied by the manufacturer in a 440 mg multi-dose vial. Per Medicare Claims Processing Manual (100-04) Chapter 17, §40: "When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. Note: Multi-use vials are not subject to payment for discarded amounts of drug or biological."
  • Maximum Allowed Units for Part B Drugs and Biologicals - JL - Potential incorrect billing occurred for claims billed in excess of the maximum allowed units for Part B drugs and biologicals, when no additional supporting documentation is received from the provider for complex review within the 45-day response period.
  • Billing for Dead Beneficiaries - Jurisdiction K - Medicare does not pay for services provided after the beneficiary's date of death.
  • Billing for Dead Beneficiaries - Jurisdiction L - Medicare does not pay for services provided after the beneficiary's date of death.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

Contact the Author

Margaret.Klasa@context4.com

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Margaret Klasa, DC, APN, Bc

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