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HOME HEALTH
BILLING TRAINING
(INTERMEDIATE)
PRESENTED BY
GLENDA SLOVAK – Tynet USA Billing Manager and Specialist.
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TOPICS
� HOME HEALTH BILLING OVERVIEW
� WORKING RTP CLAIMS AND CORRECTIONS
� MEDICARE ADVANTAGE BILLING AND STRATEGIES
� REGULATORY UPDATES
� MANAGING RISK FOR ADR, ZPIC and RAC AUDITS
� PROTECTING REIMBURSEMENTS
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MEDICARE BILLING
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Home Health Episode
� A home health episode is a period of up to 60 days in
which a home health agency provides care for a
Medicare beneficiary for whom a home health plan of
care has been established by the beneficiary’s
physician Episodes may be shorter than, but cannot
exceed 60 days in length
� If there is a continuing need for home health care, the
beneficiary may receive care for an unlimited number
of 60-day episodes
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HH PPS(Home Health Prospective Payment System (HH PPS)
� Pays HHAs a predetermined base payment for each
60-day episode of care for each Medicare beneficiary
Adjusted for health condition and care needs of the
beneficiary
� Adjusted for geographic difference in wages for HHAs across
the country Case-mix adjustment
� Outliers ensure payment for beneficiary’s with
expensive care needs and unusually high costs
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Consolidated Billing
�HHA must bill for all home health services which includes:
� Nursing and therapy services
� Routine and non-routine medical supplies
� Home health aide services
� Medical social services
� All home health services paid on a cost basis included in PPS rate
� Payment made to primary HHA regardless of whether or not items or services were furnished by the HHA
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Request for Anticipated Payment
(RAP )
� Requests initial split percentage payment for HH PPS episode Initial episode = 60% split (40% for final claim)
� Subsequent episode = 50% split (50% for final claim)
� •Submitted after receiving physician’s verbal orders and after delivering at least one service to the beneficiary � •Establishes agency as primary HHA Opens new
home health episode on CWF
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RAP
� RAP can be submitted when all of the
following conditions are met:
�OASIS Completion
�Physician’s Verbal Orders are in
�Face to face documentation for SOC (1st
Episode only for Home Health)
�Plan of Care Sent to Physician
�First Service Delivered
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Entering RAP on DDE
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Claims Entry – 26
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RAP Claim Page 1
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RAP Claim Page 1
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RAP Claim Page 1
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RAP Claim Page 1
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RAP Claim Page 2
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RAP Claim Page 2
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HIPPS
�HIPPS Coding Position 1: Episode Sequence
and Therapy Threshold
�Position 2-4: Clinical, Functional, and Service
Domains
�Position 5: Non-Routine Supply
� 1 A F K S
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RAP Episode Sequence
� Episode Sequencing Early: First or second episode in
a sequence of adjacent episodes*
� Later: Third or later episode in a sequence of
adjacent episodes*
� * “Adjacent Episodes” are defined as being
separated by no more than 60 days between
claims.
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RAP Claim Page 3
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RAP Claim Page 3
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RAP Claim Page 5
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RAP Claim Page 5
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EOE: Episode Claim
� Submitted at end of 60-day period, when a beneficiary is transferred or when beneficiary is discharged
� •Must be submitted after all services for the episode have been provided and physician has signed plan of care and all verbal orders
� •Episode claims may span calendar and fiscal years
� •RAP payment recouped when final episode claim is submitted and 100 percent payment is made once claim processes
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Claims Entry – 26
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HH Claim Page 1
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HH Claim Page 2
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HH Claim Page 3
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HH Claim Page 5
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MEDICARE ELIGIBILITY
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RUN ELIGIBILITY: CWF: HIQH
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CWF - HIQH
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Transfer Process
� Inform Beneficiary No further services from the initial
HHA
� No further payments received by initial HHA
� You are now primary HHA responsible for all services
outlined in the plan of care
� Document beneficiary was notified of transfer
process
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Transfer Process
� Receiving agency coordinates with initial HHA
Contact and coordinate transfer date
� Document communications between agencies
� Submits RAP indicating transfer
� Transferring agency submits discharge claim
showing transfer status – this claim will receive a
PEP adjustment due to the shortened episode
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Receiving Agency RAP
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Transferring Agency Claim
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Claim Timely Filing Limits
Services Rendered: Claim Filing Date:
08/22/15 and after 1 calendar year from date of service
One-year timely filing rule, based on date of service
Effective for all Medicare Part A and Part B fee-for-
service claims
Claims that require reporting line item date of service,
the line item date is used to determine the date of
service; other claims use the “From” date to determine
date of service
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CLAIMS CORRECTION
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Correcting Claims
� Enter the Claims Correction option (21, 23, or 25) that matches your provider type and press Enter. Claims that have been returned to you for correction (RTP) are located in status/location T B9997.
� The Claim Summary Inquiry screen (Map 1741) appears. The S/LOC field will default to the status/location T B9997. This is commonly referred to as your Return to Provider (RTP) file. Your cursor will be located at the HIC field.
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Type an U in the SEL field and press Enter. You can only select one claim at a time.
After you press Enter, Page 01 (Map 1711) of the claim appears. The reason
code(s) appears at the bottom left corner of the screen.
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Once you have reviewed the narrative, press F3 one time to return to the claim.
Make the correction and press F9. If the system automatically takes you back to the
Claim Summary Inquiry screen (Map 1741), the claim has been corrected.
You will also notice that the two-line summary for that claim no longer appears on
your list of claims to correct. Select the next claim to correct or press F3 to return to
the Claims Correction and Attachments Menu.
If you press F9 and are not returned to Map 1741 automatically, one or more errors
still exist. Press F1 again to see the narrative for the next reason code.
When you have finished reviewing the narrative, press F3 one time to return to the
claim.
Make your correction and press F9.
Repeat this process (F1, F3, F9) until the claim has been corrected, and you are
returned to Map 1741.
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Adjusting ClaimsAt times, you may need to adjust a claim after it has been processed
to make changes (e.g., add or remove services). Claim adjustments can be made to paid or rejected claims (i.e., status/ location P B9997 or R B9997). However, adjustments cannot be
made to:
� A line item that has been denied by Medical Review;
� Change Medicare from the primary payer to the secondary payer. (MSP: Condition, Occurrence, Value, and Patient Relationship, and Remarks Field Codes, http://www. cgsmedicare.com/parta/pubs/news/2013/0213/cope21194.html);
� Claims in status/location R B7501 or R B7516 (post-pay MSP review); and
� Claims in status/location R B9997 for the following reasons: Eligibility (entitlement date or date of death)
� HICN change
� Untimely claims (past timely filing deadline)
� Duplicates
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Adjustments are a four-step
process.
You must:
� a. Enter a Claim Change Reason Code on Page 01 of the claim;
� b. Enter an Adjustment Reason Code on Page 03 of the claim;
� c. Make your adjustment on the applicable page(s) and add remarks on Page 04 of the claim, if necessary; and Note: If you are adjusting a rejected claim, your charges have been moved to the noncoveredcharge field. As a result, you must also delete and re-enter each revenue code line so that the charges are in the covered charge column before pressing F9. Please see the “Deleting Revenue Code Lines” and “Adding Revenue Code Lines” instructions earlier in this chapter.
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Enter the Claim Change Reason
Code
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Press F9. If the system automatically takes you back to Map 1741, you have
successfully submitted the adjustment for processing. Select the next claim to adjust or
press F3 to return to the Claims Correction menu.
If you press F9 and are not returned to Map 1741, one or more errors exist. Press F1
to see the narrative for the reason code that displays in the lower left corner of the
screen. When you have finished reviewing the narrative, press F3 one time to return to
the claim. Make your correction and press F9.
If another reason code displays, repeat this process (F1, F3, F9) until you are returned
to Map 1741. More than one reason code may appear at the bottom of your screen.
Pressing F1 displays the narrative to the first reason code.
You should correct the reason codes one at a time. Sometimes, by correcting the first
code, other related codes will also be corrected.
Sometimes, new codes will appear. Continue to work through the reason codes until
you are returned to Map 1741.
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Cancellations are a three-step
process.
� a. Enter a Claim Change Reason Code on
Page 01 of the claim;
� b. Enter an Adjustment Reason Code on
Page 03 of the claim; and
� c. Press F9 to submit the cancellation.
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http://www.tynetusa.com
Phone: 1-877-558-9638
Fax: +1 817 795 1800
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HMO BILLING: THE BEGINNINGBefore Admission, Please verify Eligibility to know the
following and also get info from the patient’s card. DC from hospital paperwork normally contains most Insurance info.
You need to know the following before requesting for pre-authorization :
� What Contract do I have? Do I get paid per episode or not?
� Who is the primary payer?
� Review Contracts annually.
� Discuss rates.
� What codes are allowed. HCPCS? (ex: G0154, S9123, T1001) (Healthcare Common procedure Coding System (HCPCS)
� CMS 1500 or UB 04?
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AVOID LOSES
� Intake staff must know if Insurance is terminated
� Verify coverage and coverage dates
� Verify correct insurance ID most times not patient Socials.
� Correct spelling of name.
� Verify correct plan, example blue cross has many different plans.
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WHAT TO ASK DURING
AUTHORIZATION
Even when authorization is not required, call ALWAYS before intake.
� Verify Plan they have. HMO, PPO, Medicare Advantage Plan
� A fax of the authorization from the insurance company is ideal or print from the insurance website if available, ex CARECENTRIX.
� What are timely filling requirements? E.g Some Medicare Advantage is same as Medicare.
� Confirm Address to send if paper is sent, otherwise most will go through clearinghouses like Tynet USA.
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ELIGIBILITY
� ALWAYS CHECK HIQA/HIQH ELIGIBILITY before all services
� HMO and PPO plans would show the 1st of the month after 30 days.
� If they are Medicare advantage plans, you might not need pre authorization and can bill from effective date of care. But alwayscall to verify.
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MSP SITUATIONS
� MSP (Medicare Secondary Payer) billing
procedures apply to the following:
� Workers Compensation (WC)
� No-fault or Liability Insurance
� Group Health Plans(GHP)
� End stage Renal Disease (ESRD)
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Direct-Contracting Providers -
• A provider is a direct-contracting provider if the provider has a signed contract or agreement with a plan to deliver covered services to the plan’s members.
Deemed-Contracting Providers –
• Providers that do not have a signed contract with the plan is considered deemed to have a contract if the following conditions are met:
1. Provider is aware in advance of furnishing health care services that the individual receiving the services is enrolled in a plan;
2. Provider has reasonable access to the plan’s terms and conditions of payment in advance of furnishing services
3. Provider furnishes services that are covered by the plan.
Medicare Advantage Requirements
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Medicare Advantage
Requirements
MA Organizations offering plans must establish prompt payment requirements for deemed providers in their terms and conditions of payment.
At a minimum:
MA organization must pay 95 percent of the “clean claims” within 30 days of receipt, if they are submitted by or on behalf of a member of a plan; and
MA organization must pay interest on clean claims that are not paid within 30 days.
TIMELY FILING IS ONE AS WITH ORIGINAL
MEDICARE!
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Medicare Advantage/HMO
Collection Issues
1. Verification of Patient Start Date with Plan
2. No Authorization if HMO – Claims will deny if authorization is required
3. No OASIS Completed for PPS Payers
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Medicare Advantage/HMO
Collection Issues conthd.
4. Plans are numerous and differences are
subtle. Some require authorization, some
just notification, some want visit notes sent
with claims.
5. Often times credentialing with even the
PFFS plans can be a long and drawn out
process before payments can be received.
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Medicare Advantage/HMO
Collection Issues conthd.
� Anything over 120 days of your aging must
be shown and you need to ask why?
� Start checking early from 90 days old.
� Getting monthly reports help.
� Oasis HIPPS code needed for Medicare
Advantage and MSP.
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Medicare Advantage/HMO
Collection Issues conthd.
� Cases Include: Example: For Medicare
Advantage Plans, the claim should pay based on
HIPPS CODE not based on Charges. Most
would pay based on contract or allowable rate.
� If Moneys are incorrectly paid or taken back,
then you can Appeal. They have two levels of
appeals before you van contact the dispute
Resolution Dept.
� Print Appeal form from www.fcso.com
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KNOW THE APPEALS
PROCESS:� You have to know the appeals process for each
company you are dealing with.
� Get info from others on those who pay their bills and those who don’t before dealing with the Medicare Advantage plan.
� If Patient has only Medicare Part A or B, you can still bill. Hospice can only bill if they is Part A.
� Expect Payment errors with HMOs, so check your contract to see if medical records must be attached. Read the fine print of the authorization fax copy.
� Stop taking Patients from Insurance companies that don’t pay.
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Completing a CMS 1500
The Form CMS-1500 is the standard paper claim
form used by health care professionals and
suppliers to bill Medicare Carriers or Part A/B
and Durable Medical Equipment Medicare
Administrative Contractors (A/B MACs and DME
MACs).
The Form CMS-1500 is maintained by the National
Uniform Claim Committee (NUCC).
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Completing a CMS 1500
conthd.
� Note that some payers may give different
instructions on how to complete certain Item
Numbers on the claim form.
� Claims will be denied if they arrive after the
deadline date. When a claim is denied for having
been filed after the timely filing period, such a
denial does not constitute an “initial
determination.” As such, the determination that a
claim was not filed timely is not subject to
appeal.
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Tips for submitting error-free
paper claims
� TROUBLESHOOTING BASICS:•
� Use only an original red-ink-on-white-paper Form CMS-1500 claim form.
� Use dark ink.
� Do not print, hand-write, or stamp any extraneous data on the form.
� Do not staple, clip, or tape anything to the Form CMS-1500 claim form.
� Remove pin-fed edges at side perforations.
� Use only lift-off correction tape to make corrections.
� Place all necessary documentation in the envelope with the Form CMS-1500 claim form.
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Tips for submitting error-free
paper claims conthd.� Do not use italics or script.
� Do not use dollar signs, decimals, or punctuation.
� Use only upper-case (CAPITAL) letters.
� Use 10- or 12-pitch (pica) characters and standard dot matrix fonts.
� Do not include titles (e.g., Dr., Mr., Mrs., Rev., M.D.) as part of the beneficiary’s name.
� Enter all information on the same horizontal plane within the designated field.
� Follow the correct Health Insurance Claim Number (HICN) format. No hyphens or dashes should be used. The alpha prefix or suffix is part of the HICN and should not be omitted. Be especially careful with spouses who have a similar HICN with a different alpha prefix or suffix.
� Ensure data is in the appropriate field and does not overlap into other fields.
� Use an individual’s name in the provider signature field, not a facility or practice name.
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ACCURATE INFORMATION IS KEY:� Put the beneficiary’s name and Medicare number on each
piece of documentation submitted. Always use the beneficiary’s name exactly as it appears on the beneficiary’s Medicare card.
� Include all applicable NPIs on the claim, including the NPI for the referring provider.
� Indicate the correct address, including a valid ZIP code, where the service was rendered to the beneficiary. Any missing, incomplete, or invalid information in the Service Facility Location Information field will cause the claim to be unprocessable. Any claims received with the word “SAME”in fields indicating that the information is the same as in another field are unacceptable. A post office box address is unacceptable in the field for the location where the service was rendered.
� Ensure that the number of units/days and the date of service range are not contradictory.
� Ensure that the number of units/days and the quantity indicated in the procedure code’s description are not contradictory.
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CODING TIPS: � Use current valid diagnosis codes and code
them to the highest level of specificity (maximum number of digits) available. Also make sure that the diagnosis codes used are appropriate for the gender of the beneficiary.
� Use current valid procedure codes as described in the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) manuals.
� Use only Level II HCPCS codes, not local codes.
� Use current valid modifiers when necessary.
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More Troubleshooting Tips…
� Item 11: If Medicare is the primary payer, enter
the word “None” in Item 11. If Medicare is not
the primary payer, include the primary payer’s
information and a copy of the primary payer’s
Explanation of Benefits or Remittance Advice.
� Item 17: Enter the name of the referring or
ordering physician if the service or item was
ordered or referred by a physician.
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Remittance Advice
� After a claim has been received and
processed, the Medicare Contractor sends the
health care professional or supplier a notice of
payments and adjustments explaining the
reimbursement decisions including the reasons
for adjustments of processed claims. This
notice is called a Remittance Advice (RA). The
RA may serve as a companion to a claim
payment or as an explanation when there is no
payment. The explanation of the errors will be
provided in the form of a description or a code.
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Types of codes associated with
CMS-1500
Diagnosis codes -
� must always be at least one (can be more) ICD-
10 diagnosis code on a CMS-1500
� applies to that particular visit
� each HCPCS/CPT code must have a related
ICD-10 diagnosis code describes the patient’s
condition, not what was performed.
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BILLING THE CLAIM
� You can use either UB-04 or CMS-1500 to file claims:
� We are used to billing UB-04 for MEdicare, so we are not going to deal much on that, except to say the differences between your regular Medicare claims and HMO/Medicare Advantage claims for UB-04 are few:
� the Payer Address,
� use of S –codes, T codes, ICD-10- codes and G-codes, unlike Medicare that uses only G-codes
� Sometimes required items like Admission Diagnosis in the case of Blue cross of TX. These requirements are peculiar to different insurances but basically not many for UB-04s.
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FILLING OUT FORM CMS 1500
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NOTE: Enter the appropriate information in item
11c if insurance primary to Medicare is
indicated in item 11.
If there is no insurance primary to Medicare,
enter the word “NONE” and then proceed to
item 12.
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CMS 1500: Items 1-8
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CMS 1500: Items 9-23
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CMS 1500: Items 24- 33
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COMMON CODES FOR HOME
HEALTH
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REGULATORY UPDATES
� Prepayment Review
� Medical Review Additional
Development Request (ADR)
� Redeterminations (Appeals)
� Home Health Value-Based Purchasing
Model
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Prepayment Review and the
ADRs� Home Health Pre-Claim Review Demonstration
The Pre-Claim Review demonstration is a process for Medicare participating home health agencies (HHAs) when rendering home health services for Medicare beneficiaries. These providers will be required to submit medical documents in support of the final claim to their Medicare Administrative Contractor (MAC) These guidelines are in accordance with section 402(a)(1)(J) of the Social Security Act (the Act).
� The Home Health Pre-Claim Review demonstration for Illinois will begin no earlier than August 1, 2016 and then will be expanding to Florida no earlier than October 1, 2016, Texas no earlier than December 1, 2016 and then Michigan and Massachusetts no earlier than January 1, 2017. HHAs who are rendering home health services in those states for Medicare beneficiaries will be participants. Home Health Pre-Claim Review is a process through which a request for coverage is submitted for review before a final claim is submitted for payment. Requests for Anticipated Payment (RAPs) are not subject to Pre-Claim Review. Pre-Claim Review helps ensure that applicable coverage, payment and coding rules are met before the final claim is submitted for payment.
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� Home Health Agencies and beneficiaries are encouraged to utilize the Pre-Claim Review process for home health benefit periods with a from date no earlier than:
� August 1, 2016 for Illinois
� October 1, 2016 for Florida
� December 1, 2016 for Texas
� January 1, 2017 for Michigan and Massachusetts
� Final claims submitted without a Pre-Claim Review request during the first three months of the demonstration from the start date in that state will not be subject to a payment reduction
� The demonstration will continue for home health episodes for three years
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� Submitting a Pre-Claim Review request is voluntary
� Home Health Agencies or beneficiaries should place the unique tracking number (UTN) that was provided in the Pre-Claim Review decision letter on the final claim submitted for this benefit period
� If a Non-Affirmed Pre-Claim Review decision is on file, Medicare will deny payment for the described services if it receives a claim for those services. This denial will constitute an initial payment decision and the standard claims appeals process will apply.
� If a Home Health Agency in a demonstration state does not submit a Pre-Claim Review request, the final claim will be subject to pre-payment review
� If no Pre-Claim Review request was submitted and the claim is determined through pre-payment medical review to be payable, it will be paid with a 25 percent reduction of the full claim amount
� Final claims submitted without a Pre-Claim Review request during the first three months of the demonstration from the start date in that state will not be subject to a payment reduction
� The 25 percent payment reduction is non-transferable to the beneficiary
� The 25 percent payment reduction is not subject to appeal
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Recovery Audit Contractor (RAC)
appeal/redetermination process
� The RAC appeal/redetermination process is the same
as the regular appeal/redetermination process. All
providers have 120 days from the date of the remit to
file an appeal/redetermination. Please attach a copy of
the denial letter, if you received one from the RAC,
with your Request for Redetermination Form.
� Redetermination:1st Level Appeal letter included in
handout
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Home Health Value-Based
Purchasing Model � Effective January 1, 2016, The Centers for Medicare &
Medicaid Innovation (CMS Innovation Center) implemented the Home Health Value-Based Purchasing (HHVBP) Model. This new model is designed to support greater quality and efficiency of care among Medicare-certified Home Health Agencies (HHA) across the nation. The HHVBP Model supports the Department of Health and Human Services’ efforts to build a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people and communities.
� Provide incentives for better quality care with greater efficiency;
� study new potential quality and efficiency measures for appropriateness in the home health setting; and,
� enhance the current public reporting process.
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Initiative Details� Effective January 1, 2016, the Center for Medicare and Medicaid
Innovation (CMS Innovation Center) implemented the HHVBP Model among all home health agencies (HHAs) in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee will compete on value in the HHVBP model, where payment where payment is tied to quality performance.is tied to quality performance. HHAs in these nine states will have their payments adjusted in the following manner:
� a maximum payment adjustment of 3 percent (upward or downward) in 2018,
� a maximum payment adjustment of 5 percent (upward or downward) in 2019,
� a maximum payment adjustment of 6 percent (upward or downward) in 2020,
� a maximum payment adjustment of 7 percent (upward or downward) in 2021, and
� a maximum payment adjustment of 8 percent (upward or downward) in 2022.
� This model is designed so there is no selection bias, participants are representative of home health agencies nationally, and there is sufficient participation to generate meaningful results among all Medicare-certified HHAs nationally.
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MEDICARE BILLING
ACRONYMS
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ACRONYMS
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Web Resources� Electronic Billing & EDI Transactions – Professional Paper
Claim Form (CMS-1500) Web agehttp://www.cms.gov/ElectronicBillingEDITrans/16_1500.asp
� “National Uniform Claim Committee 1500 Health Insurance Claim Form Reference Instruction Manual”http://www.nucc.orgAdministrative Simplification Compliance Act http://www.cms.gov/HIPAAGenInfo/Downloads/ASCALaw.pdf
� HIPAA http://www.cms.gov/HIPAAGenInfo/
� ICD-10 http://www.cms.gov/icd10/
� National Provider Identifier (NPI) http://www.cms.gov/NationalProvIdentStand/
� NPI Registry
� https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
� CMS IOM Publication 100-04, Medicare Claims Processing Manual Chapter 1, Section 70 (Claim Processing Timeliness)
� Chapter 1, Section 80.2 (Clean Claim Submission)
� Chapter 10 (Home Health Billing)
� Chapter 25 (UB-04 Instructions)
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http://www.tynetusa.com
Phone: 1-877-558-9638
Fax: +1 817 795 1800
