Home Health and Hospice Coalition Questions and Answers: June 12, 2023
The Review Choice Demonstration (RCD) meeting was held at 9 a.m. ET, followed by the main meeting at 10 a.m.
9–10 a.m. RCD Meeting
Question: Can we review common issues for non-affirmations and choice 4 and 5 with RCD?
Answer: Errors related to face-to-face is the most frequently occurring error for pre-claim review (PCR) and ADR options.
10 a.m. – 12 p.m. Main Meeting
EDI update: Several tools on the EDI web page have been updated. Providers are encouraged to include contact information and specific information when issues are mentioned in the Qualtrics surveys.
Claims Payment Issues Log Update
Status Changed to Resolved
Home Health: Incorrect Partial Period Payment Adjustments on Claims: CWF edit U538E is setting incorrectly causing some home health claims to receive incorrect partial period payment adjustments when the situations are not present. CPIL is being updated to resolved as CWF Problem 35937 was installed in production this past weekend, 6/17/23. Any new claims submitted on or after 6/19/2023 should not receive incorrect partial period payment adjustments when the situations are not present. The CPIL also states how to adjust claims affected by this issue.
Open
Home Health: Reason Code 31755: This CPIL is instruction at this time. MACs had still received timely claims for that span December 2021 and January 2022, January 2022 claims that used the artificial admit date and issues with MAC adjustments that fired 31755 but cannot be billed under the 31755 guidance. The CPIL provides information to the HHAs for the PCC to report these claims to Part A Claims to bypass 31755.
Hospice: Service Intensity Add-on (SIA) Payments Not Applying to Previous Month: When a patient is discharged deceased on a claim within the first six days of a month, CMS’ system is to perform a look back on the prior month’s claim to identify if there were SIA eligible services provided within the last seven days of life and if there are, a system-initiated adjustment would occur. The look back is currently not occurring. Workaround is providers may adjust the previous monthly claim to receive applicable SIA payment. No new update from CWF. On last Thursday’s CMS HHH Claims Call (6/5/23), CMS sounded like they agreed that FISS and CWF need to figure this out.
Medical Review
Question: Can you confirm that the reviewer’s comments should be available in the system for the organization to be able to review? We have had communications with hospices where we have determined that those within compliance roles can greatly benefit from reviewing the reviewer notes but, unfortunately, we think some of these individuals may not have access to “view” the notes. Is the “reviewer notes” section viewable by all? If not, can someone request access? How would they go about doing that within their organization?
Answer: Providers can see the review notes in DDE on page 4. DDE Training Modules explains how to use DDE. Direct Data Entry (DDE) IDs, Access and Security Measures, and Password Procedures explains how to get a DDE ID. Each user needs his or her own DDE ID. User IDs should never be shared.
Question: Letters regarding Targeted Probe and Educate (TPE) — We have a question regarding the letters that are sent on TPE denials. We have heard reports that TPE letters are being sent without information on how the agency can appeal. Is it correct that information on how to appeal is supposed to be a part of the TPE letter sent to organizations?
Answer: The appeals process is explained on the Appeals web page. Palmetto GBA will look at adding some appeal education in the TPE letters.
Question: Can a provider be on a UPIC review and TPE at the same time?
Answer: Palmetto GBA coordinates with the Unified Program Integrity Contractor (UPIC) to see who the UPIC is performing record reviews on. If a provider is on a UPIC review and TPE at the same time, they need to call the PCC.
Question: Letters regarding TPE and follow-up notifications — Can you detail out the process related to, not the number of claims selected, but more of the timeline expectation from review until notification to the hospice regarding status of the claims and what the timeline is to getting a follow up notification letter or call for education to discuss the findings?
Answer: The goals it to complete edit effectiveness and send the letter one to two months after the review sample is completed.
Question: If an agency thinks they should have gotten a letter in follow-up and have not heard from Palmetto GBA, what process should they take to follow up? Who should they call?
Answer: The goal is a week to ten days after the letter is sent to contact the provider. Sometime there is an issue contacting the provider due to poor or inaccurate contact information. The provider can call the PCC if they think they should have heard from Palmetto GBA by that time. The provider should look in DDE for the reason claims are denied and on claim page four for reviewer notes. The provider doesn’t need to wait for a letter to appeal. There is a Reason Code Help Tool to assist is understanding the denials.
Question: Have you had any updates from CMS on guidance for review of the reason for the face-to-face encounter compared to the primary diagnosis on the claim? Agencies must comply with ICD-10 coding conventions so they must list the diagnoses codes in a certain order which sometimes results in a diagnosis code that is not the primary reason for home health service being listed as the primary diagnosis. For example, hypothyroidism needs to be coded before dementia, and hypertension must be coded before congestive heart failure. It is our understanding that F2F encounter diagnosis with those on the plan of care, not those on the claim since the ICD-10 coding conventions apply only to the claim.
Answer: A workgroup will be formed consisting of NAHC, technology/vendors, providers, Palmetto GBA, state association members, CGS and NGS to discuss the need for ICD 10 code being on the plan of care. The diagnosis code (ICD code) was a requirement from the CMS form 485, which was made obsolete decades ago. The group will discuss the feasibility of removing the ICD 10 code from the plan of care.