Archive for 'Money Matters'

Remarks Field Helps You Hop Reimbursement Hurdles

Posted on 07. Oct, 2009 by .

Photo: Krysztof Mizera

Photo: Krysztof Mizera

If you submit claims with diagnosis code V15.88, you should add more details on the claim to avoid hold-ups.

When regional home health intermediary Cahaba GBA receives claims with a trauma diagnosis  code like V15.88 (Personal history of fall), it must research the claim to make sure another payor isn’t liable under auto, liability, or workers’ comp insurance, the intermediary explains in its August newsletter for providers.

Do this: “When submitting a claim with the V15.88 diagnosis code, include a note in the ‘Remarks’ field (FISS Page 04) acknowledging whether the services are related to a new injury and, if so, where the injury took place,” Cahaba instructs. Cahaba lists 10 place of occurrence diagnosis codes, ranging from E849.0 (Home) to E849.9 (Unspecified place), to identify where the injury took place.

If no other insurer is liable, include a note in the “Remarks” field to explain why, Cahaba suggests. For example, state that the patient fell on a certain date in the home and no other insurer was liable.

Tip: “Keep in mind that including information in the ‘Remarks’ field is always helpful in processing your Medicare claims,” the RHHI reminds providers. “In addition, Cahaba encourages providers to review the ‘Remarks’ page when claims are in RTP as there may be instructions from our staff to assist in the successful adjudication of your Medicare claims.” To see the article including the full list of place of occurrence diagnosis codes, go to here.

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What’s Causing Medicare Scooter Costs to Skyrocket?

Posted on 30. Sep, 2009 by .


The overhead required to serve Medicare benes, for one, industry insiders claim.

Recently, the OIG rolled out a report claiming Medicare and its beneficiaries paid up to four times more than the average amount paid by suppliers for wheelchairs, but some industry insiders are questioning the OIG’s math.

The report used “flawed methodology and incomplete data” to draw conclusions, claimed Eric Sokol, director of the Power Mobility Coalition (PMC), a nationwide association of manufacturers and suppliers of motorized wheelchairs and power operated vehicles.

These “inaccuracies” could affect more than just suppliers’ reputations.  “If readers incorrectly draw conclusions that low acquisition costs equates to high profit margins, then the PMC questions the completeness of the study and its usefulness to policymakers,” Sokol pointed out.

Mistakes: The OIG didn’t calculate costs of the services provided, as well as overhead expenses such as salaries, fuel, transportation, rents, beneficiary assistance in billing Medicare, and other defining factors. Also, “increased Medicare standards and documentation confusion” like the accreditation and surety process has “raised the cost to providers of partnering with the Medicare program,” Sokol said.

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Keep Your Focus On OASIS C Processes To Stay Profitable

Posted on 23. Sep, 2009 by .


Expect surveyor scrutiny of new assessments and interventions.

Major OASIS changes could soon hit you square in the wallet, as CMS looks for hard data to justify payment amounts. Home health agencies at long last have a final OASIS C form to examine, but they still need to hold off on training staff, advises consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. That’s because they’ll need the item-by-item guidance in the OASIS User’s Manual to complete the training. CMS plans to issue that guidance in September or October, it said in the most recent home health Open Door Forum.

Get ready: But if you haven’t done so already, now’s the time to jump into preparation for the process items in the new OASIS C form, Laff urges. Many agencies are focusing on the mechanics of filling out the new assessment form and may be missing the big picture on how all the process items will change the Medicare landscape in terms of quality improvement, surveys, and even reimbursement. (more…)

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Medicare Paid Nearly Four Times the Average Amount to Acquire Standard Power Wheelchairs

Posted on 16. Sep, 2009 by .




Look for fee schedule adjustments that lower reimbursement for scooters.

Medicare could be getting gouged on standard power wheelchair costs. “Medicare and its beneficiaries paid almost four times the average amount paid by suppliers to acquire standard power wheelchairs during the first half of 2007,” according to an August OIG report.

For example, suppliers purchased standard power wheelchairs for an average of $1,048 and performed an average of five services in conjunctionwith supplying. However, because Medicare allows an average of $4,018 for those wheelchairs, Medicare and its beneficiaries paid suppliers anaverage of $2,970 beyond the suppliers’ acquisition costs. That’s a difference of 383 percent, the OIG pointed out in “Power Wheelchairs in theMedicare Program: Supplier Acquisition Costs and Services.” Based on its report, the OIG advised CMS to determine whether Medicare’s power wheelchair fee schedule amounts should be adjusted.

CMS plans to use the information from the competitive bidding program and will consider new legislation to ensure fee schedule amounts respond to market changes.

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HHA Reimbursement: You Can Bill Auto Insurance For Patient Services

Posted on 09. Sep, 2009 by .


But take this step to avoid angry patients.

Scenario: Your home care patient is in an auto accident that leaves her in a wheelchair for an unspecified period of time. Her auto insurance — not her medical insurance — will foot the bill for her injuries. That leaves you out of the equation, right?

Wrong. “You can submit a claim to an auto insurance company,” assures M. Aaron Little, senior managing consultant with BKD in Springfield, Mo. But you shouldn’t submit the claim and hope the auto insurance company will pay it, he says.

Best bet: You should find out up front whether an auto or medical insurance company is handling a patient’s injuries, Little recommends.

That way, you can get a head start on the reimbursement process — and warn patients that they may wind up paying for some services out of pocket while waiting for the auto insurance to process their claim. (more…)

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HHA Reimbursement: Use These 4 Tips To Defend Long-Stay Claims

Posted on 02. Sep, 2009 by .


Intermediary cracks down on long-stay patients with new probe.

Get ready for a higher level of scrutiny for patients you’ve had on service for years. Regional home health intermediary Cahaba GBA is putting the medical review spotlight onclaims for patients with a length of stay greater than 999 days. A new widespread review edit will select these claims and review them for medical necessity, Cahaba says in its July provider newsletter.

Cahaba initiated the probe as a result of data analysis, it points out. The topic code for this review will be 5008W.

A length of stay of 999 days is almost three years, says consultant Betty Gordon with Simione Consultants in Westboro, Mass. “These patients should be few and far between,” not regulars on your roster, she adds.

Patients who need such long-term services include those with foley catheters, pernicious anemia that requires B12 injections, and sometimes blind diabetics who can’t self-inject if there is no one else to do so, Gordon observes. (more…)

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Checklist: Dx Code Sequencing That Boosts Your Bottom Line

Posted on 26. Aug, 2009 by .



1, 2, 3 ... all together now.

1, 2, 3 … all together now.

If you think ‘secondary’ means ‘second,’ think again.

Here’s one more good financial reason for clinicians and reimbursement personnel to collaborate closely.

Only the assessing clinician can determine the primary and secondary diagnoses and assign the severity, CMS says. And home health coders can’t assign the codes or change the sequencing without clinician agreement. But the two groups can confer together if the reimbursement pros think an alternate sequencing is more accurate — which may just improve your home health agency’s bottom line.

Ensure your diagnosis codes are sequenced correctly with this 4-step checklist from Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principle of Selman-Holman & Associates in Denton Texas.

New on CD: ICD-9 2010 update for home care reimbursement pros. With Judy Adams.

1. Choose the right principle diagnosis. This should be the chief reason for home care — the diagnosis most related to the current plan of treatment. It may be related to the patient’s most recent hospital stay, but that’s not always the case. It must always be related to the services your agency provides.

Make a choice: If two or more diagnoses meet this definition of the principle diagnosis, just choose one. But the principle diagnosis should be the one that represents the most acute condition and requires the most intensive services. (more…)

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K0823: Double-Check Your Wheelchair Coding To Avoid Losses

Posted on 20. Jul, 2009 by .


You could be losing $977 per K0823 claim if you’re not coding correctly, according to a new HHS Office of Inspector General report.

That’s how much suppliers who downcoded standard wheelchair claims lost on average, the OIG says in the study, “Miscoded Claims for Power Wheelchairs in the Medicare Program.”

In the first half of 2007, wheelchair suppliers miscoded 8 percent of power wheelchair claims overall, the OIG found. About 3 percent were upcoded, 4 percent were downcoded, and OIG reviewers couldn’t determine a coding level for 1 percent.

Three-fourths of power wheelchair claims under Medicare fall into the K0823 category, the OIG explains. In 2007, they had a fee schedule amount of $4,024. (more…)

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Therapy Cap Update for HHAs

Posted on 17. Jun, 2009 by .


GOOD NEWS! You don’t have to worry about therapy caps for patients who received outpatient Part B services in the first quarter of the year.

Due to delays in updating the claims system, “claims for outpatient therapy services provided during the January — March 2009 quarter, that were submitted and processed prior to April 6, 2009, were not applied to the 2009 calendar year (CY) therapy cap limitations,” regional home health intermediary Cahaba GBA explains in an e-mail to providers.

The free ride means some of your Part B outpatient therapy patients will get some extra room in their caps this year. (The caps do not apply to therapy furnished under a home health plan of care.)

CMS won’t go back and apply the amounts that have already been billed toward the cap.

But the therapy cap will apply any amounts billed after April 6 to the cap, Cahaba explains.

AUDIO TRAINING EVENT: Top reasons for HHA therapy denials, plus everything you need to know about MO826. With Cindy Krafft.

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One Denied Therapy Visit Can Cost Your HHA $600

Posted on 28. May, 2009 by .



Good care that is poorly documented can lead the feds to suspect fraud.

CMS is concerned that the prospective payment system includes financial incentives to provide more therapy than a patient needs, according to physical therapist Cindy Krafft, Peoria, Ill.-based consultant with Fazzi Associates.

To prevent that result, intermediaries focus intensely on the therapy documentation supporting the need for the visits provided.

Bottom Line: If you’ve provided six visits and the intermediary denies just one of them, your agency has lost $600, Krafft emphasizes. If the agency has already received the money for that episode, it must now return the overpayment. The most common reason for denial is that the visit was not medically necessary or did not require a therapist’s skills.

MO826 – how will it impact your therapy visits? Find out in this AUDIO TRAINING EVENT.

The Heat Is On Therapy Documentation

Unlike the 2008 work plan, the HHS Office of Inspector General’s 2009 work plan does not specifically include a heading for home health therapy. But therapy services scrutiny is continuing and even expanding, says attorney Lucien Bernard with Pearson & Bernard in Covington, Ky. (more…)

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