Medicare Billing Under PPS Reform! › wp-content › uploads › 201… · •Non‐routine Medical Supplies: 2.82% reduction offset by 2.5% Payment update •Recalibrated case mix

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Medicare Billing Under

PPS Reform!

Presented By:Melinda A. Gaboury, CEO

Healthcare Provider Solutions, Inc.

Medicare Billing Under PPS

Reform!

Session 1:

HHRG/HIPPS/Episode Exceptions

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• Paid by 60 day Episode not PER VISIT

• Episodic payment is based on standard PPS rate which is wage adjusted according to the CBSA corresponding to the address where the patient actually receives care•Exceptions - LUPA,PEP, OUTLIER &

THERAPY THRESHOLD

• Year 4 rebasing payment rates (4 year phase‐in)

• LUPA per visit rates: full increase (3.5%)

• Non‐routine Medical Supplies: 2.82% reduction offset by 2.5% Payment update

• Recalibrated case mix weights• Changes in all 153 case mix weights

• Case mix creep adjustment: 0.97% (2017 & 2018)

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• Outlier calculation extensive changes• 3% rural add‐on continues through 2017• 2% payment sequestration continues

• CY 2017 FINAL Base Episode Rate: $2,989.97• CY 2016 Base Episode Rate: $2,965.12

• Market basket Index (inflation factor): 2.5%• Budget neutrality factor: 0.5

Weight Weight FINAL FINAL FINAL FINAL2011 2012/2013 2014 2015 2016 2017

1AFKS 0.5827 0.8186 0.6080 0.5985 0.5908 0.5857

1AFLS 0.8507 0.9793 0.7273 0.7242 0.7197 0.7168

1AFMS 1.0599 1.1401 0.8468 0.8499 0.8485 0.8479

2BHLS 2.2074 2.2145 1.6448 1.6486 1.6434 1.5733

2BHMS 2.3445 2.4691 1.8339 1.8509 1.8307 1.7708

2CFKS 2.1524 2.0453 1.5191 1.4900 1.4569 1.4446

5CFKS 3.0835 2.7140 2.0157 2.1626 2.1567 2.1016

5CGKS 3.2730 2.8712 2.1325 2.2135 2.1784 2.1495

5CHKS 3.4872 3.0014 2.2292 2.2950 2.2475 2.2112

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• Case-mix refinement – Effective 01/01/08

–Expanded set of case-mix variables • 153 case mix groups

–Additional clinical conditions and co-morbidities

–Primary and secondary diagnoses

–Manifestation codes

–Four equation model (or is it five?)

• Early versus late episode

• Three therapy thresholds with smoothing

• Four equations–Early episodes (1st or 2nd) with fewer than 14 therapy visits–Early episodes (1st or 2nd) with 14 to 19 therapy visits –Late episodes (3rd or later) with fewer than 14 therapy visits–Late episodes (3rd or later) with 14 to 19 therapy visits

• Fifth Grouping Step–Early and late episodes with 20 or more therapy visits

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Clinical Domain–M1021 and M1023 and M1025–M1030 Therapies–M1200 Vision–M1242 Pain–M1311 & M1324 Pressure ulcer–M1334 Stasis ulcers–M1342 Surgical wounds–M1400 Dyspnea–M1620 Bowel incontinence–M1630 Ostomy–M2030 Injectable drugs

• M1810 – Dressing Upper Body

• M1820 – Dressing Lower Body

• M1830 – Bathing

• M1840 - Toileting

• M1850 - Transferring

• M1860 - Ambulation

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• 4 or fewer visits in a 60 day episode

• Paid on the National Standardized per Visit rate (wage adjusted for your CBSA)

• Doesn’t require a RAP

• Has less than $2.00 perEpisode built into rates for Non-Routine Supplies.

Final2014 2015 2016 2017

HHA $ 54.84 $ 57.89 $ 60.87 $64.23

MSS $194.12 $204.91 $215.47 $227.36

OT $133.30 $140.70 $147.95 $156.11

PT $132.40 $139.75 $146.95 $155.05

SN $121.10 $127.83 $134.42 $141.84

SLP $143.88 $151.88 $159.71 $168.52

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In the CY 2014 HH PPS Final Rule - changed the methodology for calculating the LUPA add-on amount by finalizing the use of three LUPA add-on factors:

1.8451 for SN 1.6700 for PT1.6266 for SLP

The per-visit payment amount for the first SN, PT, or SLP visit in LUPA episodes that occur as the only episode or an initial episode in a sequence of adjacent episodes by the appropriate factor to determine the LUPA add-on payment amount.

• HHRG = C1F2S2, HIPPS = 1AGLU (6 therapy) 1st Episode = 3rd NRS Level = $2,920.51

• Patient receives 1 SN & 2 HHA visits in episode• Payment =

• SN - $153.36 per visit = $153.36• HHA - $69.45 per visit x 2 visits = $138.90

• Payment before Add-on = $292.26

• If 5 visits had been provided the payment would have been the full amount.

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• HHRG = C1F2S2, HIPPS = 1AGLU (6 therapy) 1st

Episode = 3rd NRS Level = $2,920.51

• Patient receives 1 SN & 2 HHA visits in episode• Payment =

• SN - $153.36 per visit = $153.36 • DUE TO ADD-ON SN - $282.96

• HHA - $69.45 per visit x 2 visits = $138.90

• Payment before Add-on = $292.26with Add-on = $421.86

• If 5 visits had been provided the payment would have been the full amount.

• Due to 3 trigger events• Beneficiary elects transfer to another HHA

• Patient discharged & returns to HH care in same 60 day episode

• Patient becomes part of a Medicare Advantage Plan during 60 day episode

• If the patient expires or elects the Hospice Benefit the agency is paid for a full episode if 5 or more visits have been provided

• Payment based on Span of Days• 1st billable service date through last billable service date

• proportion of 60 days

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• Patient admitted 01/10/16 (episode would be 01/10/16 – 03/09/16) and is discharged with all goals met on 01/28/16. Last billable visit performed on 01/27/16.

• Patient readmitted on 03/01/16.

• The HHA will be paid for 18/60 under the first calculated HHRG & Readmission on 03/01/16 would start a new 60 day episode.

• Same situation if patient was admitted to another HHA on 03/01/16 rather than readmitted to yours.

• HHRG = C1F2S2, HIPPS = 1AGLU (6 therapy) 1st Episode = 3rd NRS Level = $2,920.51

• Discharged after 18 days of service

• Payment = $2,920.51/60 x 18 = $876.24

• Patient’s readmission begins a new 60 day episode for your agency or other admitting agency

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• In response to the commenter who requested further clarification regarding when occupational therapy must be followed by a skilled nursing, physician therapy, or speech therapy service, we clarify that the initial occupational therapy service must be followed by another qualifying service to be covered. Subsequent occupational therapy services, however, do not require another qualifying service to follow them. Specifically, we are clarifying that once a beneficiary’s eligibility for home health services has been established by virtue of a prior need for an intermittent skilled service (that is, skilled nursing care, physical therapy, or speech language pathology therapy), and the beneficiary also meets each of the criteria specified in §409.44(c), the first occupational therapy service provided to the patient is considered a dependent service.

• Three Major Therapy Thresholds

• 6, 14, 20 Visit

• Graduated payment increases

• Early & late episodes: 0-13 therapy

(6) - - (7-9) - - (10) - - (11-13)

• Early & late episodes: 14-19 therapy

(16-17) - - (18-19)

• Early & late episodes: 20 therapy

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THERAPY NEED• (M2200) Therapy Need: In the home health plan of

care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-language pathology visits combined)? (Enter zero [“000”] if no therapy visits indicated.)• (__ __ __) Number of therapy visits indicated (total of physical,

occupational and speech-language pathology combined).• NA - Not Applicable: No case mix group defined by this

assessment.

• Orders are obtained for 15 therapy visits at the SOC

• HIPPS = 2BGKS 2nd Episode = $4,685.64

• Patients actually receives only 9 visits

• HIPPS = 1BGMS 2nd Episode = $3,392.03

• Difference = $1,293.61

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EFFECTIVE DATE APRIL 1, 2011Requires that:

• Qualified therapist assess, establish goals and re-assess patient

• Measurable treatment goals be described :• Plan of care• Clinical record

• Methods used to assess a patient’s function include• Objective measurement• Successive comparison of measurements

• There must be objective measurement of progress toward goals and/or therapy effectiveness.

Documentation requirements

• Evaluation and goals

• Describe correlation between• Treatment for illness/injury to professional standards

• Measurable goal related to illness/injury

• Objective measures of function (e.g. swallow,

bathing, dressing, walking, stairs, use of devices)

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Professional (qualified) therapist assessment• Functional assessment for therapy provided by qualified

therapist from EACH discipline

• Documentation• Results of therapy

• Effectiveness of (or lack of) therapy

• Qualified therapist (vs. assistant) visits to functionally assess and treat • At least every 30 days by each discipline

Orders =PT 2w8

1

PT (1)

2 3 4

PTA (2)

5

6 7

PTA (3)

8 9 10

PTA (4)

11 12

13 14

PTA(5)

15 16 17

PTA(6)

18 19

20 21

PTA(7)

22 23 24

PTA(8)

25 26

27 28

PT (9)

29 30 31

PTA(10) Continue

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Orders =PT 2w8

1 2

3 4

PTA (11)

5 6 7

PTA (12)

8 9

10 11

PTA(13)

12 13 14

PTA(14)

15 16

17 18

PTA(15)

19 20 21

PT(16)

22 23

24 25 26 27 28 29 30

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Medicare Billing Under PPS Reform!

Session 2: Medicare Verifications/Billing Rap & Final Claims

• Adjacent episodes are best described as a series of episodes with one or more agencies that have less than a 60-day gap between the NATURAL END of one episode to the START of the next

• Example: Patient SOC: 12/15/16 – the NATURAL END of that 60-day episode would be 02/12/17

• The patient is recerted 02/13/17 with NATURAL END of 04/12/17

• Another agency admits the patient on 06/01/17 –would this be an early or late episode? Is this third in a series of adjacent episodes or is it the first?

ANSWER: LATE (third) episode – there is less than a 60 days from 04/13/17 to 06/01/17

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HETS HOME HEALTH PPS EPISODE PERIODS PAGE 03 OF 09

HH-REC CN 123456789A NM ANYONE IT S DB 06181919 SX M

START END INTER PROV DOEBA DOLBA PATIENT DATE DATE NUM NUM STAT IND

05/20/2016 07/18/2016 00011 123456 052016 071516 30 0

01/13/2016 03/13/2016 00011 123456 011316 031216 30 0

• (M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an “early” episode or a “later” episode in the patient’s current sequence of adjacent Medicare home health payment episodes? • 1 - Early

• 2 - Later

• UK - Unknown

• NA - Not Applicable: No Medicare case mix group to be defined by this assessment.

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• If another agency is listed as currently serving the patient the provider # will be listed & you can call FI to obtain name & phone #

• Your HHA can get paid under this scenario if your RAP is coded with the Condition Code 47

• Request for Anticipated Payment (RAP)

• not subject to 14 day floor

• not considered a claim

• 3 Things must happen before RAP filed

• First Billable Visit Performed

• OASIS form completed & input

• Verbal orders transferred to POC and sent to doctor for signature

• A RAP for a MSP claim will open a MSP file in the CWF and payment will be made with the final claim

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• FL4 - Bill Type - ALWAYS – 322• Effective October 1, 2013 “33x” bill types will

reject

• FL6 - Statement Covers Period• Initial RAP: SOC Date=From & Through

• This date is the same as the first billable visit

• Subsequent RAP: 1st Day of New Episode = From & Through• This date is 1st day regardless of first billable visit date

• FL12** - Admission Date• First billable visit/SOC date

• remains constant for subsequent episodes

• FL15** - Point of Origin Code• Post July 1, 2010 - - the PoO Code will always be “1”

for home health - - there is NO scenario that can be presented that “1” is not the appropriate response for a home health patient.

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• FL17** - Patient Status Code• ALWAYS 30 - Still Patient

• FL 18-28** - Condition Codes• Only used in canceling RAPs, hospice, and beneficiary

elected transfer post 07/01/10

• 47 – Condition Code for beneficiary elected transfer

• D5 - Cancel to correct HICN/Prov ID

• D6 - Cancel only to Repay a duplicate payment

• FL31-36** - Occurrence Codes & Dates

• These codes & dates are NOT required

• FL39-41 - Value Codes

• 61 & CBSA Code

• CBSA = address of service delivery, not necessarily patient residence

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• FL42 - Revenue Code• 0023 (used to report the HIPPS)

• FL44 – HCPCS/Rate/HIPPS Code• HIPPS Code

• FL45 - Service Date• First Billable Visit - on initial episode this must match

the SOC Date

• FL47 - Total Charges• ZERO - no charges can be reported on HIPPS code line

• FL56** - National Provider Identifier (NPI)

• NPI = 10-digit number used for all payers

• Prior to new form 6 digit Medicare Provider number is placed here

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Position Definition Actual Value Result

1-2 M0030 – Year 2007 07

3-4 M0030 – Julian Date Julian Date 245 JK

5-6 M0090 – Year 2008 08

7-8 M0090 – Julian Date Julian Date 001 AA

9 M0100 – Reason 04 4

10 M0110 – Timing 01 1

11 Clinical Pts – Equation 1 7 G

12 Functional Pts – Equation 1 2 B

13 Clinical Pts – Equation 2 13 M

14 Functional Pts – Equation 2 4 D

15 Clinical Pts – Equation 3 3 C

16 Functional Pts – Equation 3 4 D

17 Clinical Pts – Equation 4 12 L

18 Functional Pts – Equation 4 7 G

• FL63** - Treatment Authorization Code

• From previous screen:

• 18-Digit OASIS Matching Key would reflect the following:

07JK08AA41GBMDCDLG

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• FL67A-67Q** - Principal & Other Diagnosis• These must be reported at the number of digits

required using current ICD-10 Coding Manual

• Up to 18 codes will now fit on the claim

• Must match the 485/POC and OASIS – first 6 from OASIS now considered for payment

• FL71** - PPS Code• Do Not Use – Any data entered will be ignored

• FL76**- NPI for physician

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• Claim• end of episode• line item billing• must have all orders signed• subject to 14 day floor

• No-RAP LUPA• No RAP due to needed visits being 4 or less• Claim filed after discharge• Paid at National Per Visit Rates (wage

adjusted)

• Must be preceded by a RAP• If not submitted timely will cancel RAP payment

• If final is not received 60 days from the end of the episode or the RAP payment date, whichever is greater, the RAP will be canceled and funds recouped. The RAP must be refiled before filing final

• OASIS-C document (SOC or Followup – Recert) MUST be transmitted to the state before the Final Claim of any episode is sent in for payment

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MLN Matters® Number: MM9585 Related Change Request (CR) #: CR 9585Related CR Release Date: October 27, 2016 Effective Date: April 1, 2017Related CR Transmittal #: R3629CP Implementation Date: April 3, 2017

• Submission of an OASIS assessment is a condition of payment for HH episodes of care. OASIS reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary. In most cases, this 30-day period will have elapsed by the time a 60-day episode of HH services is completed and the HHA submits the final claim for that episode to Medicare. If the OASIS assessment is not found in the QIES upon receipt of a final claim for an HH episode and the receipt date of the claim is more than 30 days after the assessment completion date, Medicare systems will deny the HH claim. (While the regulation requires the assessment to be submitted within 30 days, the initial implementation of this edit will allow 40 days.)

• In denying the claim, Medicare will supply the following remittance messages:• Group Code of CO• Claim Adjustment Reason Code 272

NO OASIS – NO PAYMENT

• Must include line item billing with 15 minute increments

• Revenue code lines for Medical Supplies are separate:

• Medical Supplies - 0270

• Wound Care Supplies - 0623

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• Generates final episode payment

• adjusted for PEPs, LUPAs, Outliers & discrepancies in therapy threshold

• Remittance Advice will display reimbursement amount from the 0023 revenue code line

• Appears on RA as a debit/credit adjustment to the episode payment originally made for the RAP

• FL4 - Type of Bill ALWAYS – 329• Effective October 1, 2013 “33x” bill types will reject

• FL6 - Statement Covers Period• “From” date must match from date on RAP• “Through” date = discharge date or last day of episode if patient has

been recerted - this date must be 59 from the “From” date

• FL12 - Admission Date• Must match RAP

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• FL15** - Point of Origin• Enter same code as RAP - - - MUST be “1”

• FL17** - Patient Status• All codes are valid on Final

• 20 - “Through” date must be DOD - used only if patient died while in your care

• 06 - Make sure if this code is used that you have transferred the patient to another home health agency - It will PEP adjust your claim

• FL18-28** - Condition Codes• Use in beneficiary elected transfers/

adjustments/cancellations/hospice

• FL31-36** - Occurrence Codes & Dates• These codes & dates are not required except

when using Patient Status Code 20 – in this case the 55 Occurrence Code and Date of Death is required

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• FL39-41 - Value Code• 61 & CBSA Code - this should coincide with place

patient is receiving care

• FL42 - Revenue Codes• 0023 - HIPPS that matches RAP

• 0270 - Medical Supplies

• 0623 - Wound Care Supplies

• Revenue codes that correspond to each discipline billed in 15 minute increments

• FL44 – HCPCS/RATE/HIPPS Code• HIPPS Code• All HCPCS Codes corresponding to disciplines

billed

• FL45 - Service Date• First billable visit on HIPPS code line & should

match RAP• All other visit dates that correspond with

discipline billed

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EFFECTIVE DATE: July 1, 2013 (HH episodes beginning on or after this date.)

IMPLEMENTATION DATE: July 1, 2013

HHAs must report where home health services were provided on home health claims, using the Q codes

• Q5001 - Home

• Q5002 – Assisted Living Facility

• Q5009 – Other

• The location where services were provided must always be reported along with the first billable visit in an HH PPS episode.

• If the location where services were provided changes during the episode, the new location should be reported with an additional line corresponding to the first visit provided in the new location.

G0151: Qualified PT

G0152: Qualified OT

G0153: Qualified SLP

G0157: PTA

G0158: OTA

G0159: Maintenance therapy by qualified PT

G0160: Maintenance therapy by qualified OT

G0161: Maintenance therapy by qualified SLP

G0299: Registered Nurse – Hands On Care

G0300: Licensed Practical/Vocational Nurse – Hands On Care

G0162: Skilled services by Registered Nurse (RN) M&E of Care Plan

G0493: RN – Observation & Assessment

G0494: LPN – Observation & Assessment

G0495: RN - Training/Education patient or family

G0496: LPN/LVN - Training/Education patient or family

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• FL47 - Total Charges• Total Charges per revenue line - keep in mind no charges are

ever to be reported on HIPPS code line

• FL56** - National Provider Identifier (NPI)• NPI = 10-digit number used for all payers • Prior to new form 6 digit Medicare Provider number is placed

here

• FL63 - Treatment Authorization Code• OASIS matching key (18 digits)

• FL67A-67Q** - Principal & Other Diagnosis• Must match 485 & OASIS

FL76**- NPI for physician• Medicare allows a physician (such as a hospitalist)

who attends to hospitalized patients, but does not follow them into the community to: • 1) Certify the need for home health care based on

their face to face contact with patients in the hospital;

• 2) Initiate the orders and a plan of care for home health services, and

• 3) "hand off" the patients to their community-based physicians to review and sign the plan of care.

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• CR 8441, requires that, for claims with episodes that begin on or after July 1, 2014, home health agencies (HHA) must:

• Report the National Provider Identifier (NPI) and name of the physician who certifies/re-certifies the patient's eligibility for home health services, if this physician is different than the physician who signs the patient's plan of care ("attending physician"); and

• Continue to report the NPI and name of the physician who signs the patient's plan of care.

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Medicare Billing Under PPS

Reform!

Session 3:

Prebilling Audits

Audit 100% of ChartsCatch Compliance Issues

Catch Issues Associated w/PPS

Avoid unnecessary denials

Who should conduct these audits?Billing or Clerical Staff are

sufficient – it is not a clinical audit

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• When do we conduct these audits?

• End of episode – no need to audit prior

to end of episode or discharge

• What do you need for audit?

• Patient Chart

• Audit Tool

• Trial Bill (Pre-bill)

• Palmetto GBA A/B MAC will be performing pre-payment service-specific probe medical review on Home Health claims, utilizing the CH** HIPPS Codes, Early or Late Episodes, Clinical Severity Level 3 and Functional Severity Level 3.

• This probe is based on internal data analysis which included prioritization of the HIPPS Codes and will be focused on Oasis validation. Probe edits will be set in Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina and Tennessee and will select a sample of 100 claims for each edit.

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• Part-time or Intermittent Skilled Nursing Care & Aides

• Physical Therapy• Speech Language

Pathology• Occupational Therapy• Medical Social Services

• Routine & Non-Routine Medical Supplies – pdseparately post 1/1/08

• Medical Services provided by intern or resident-in-training of a hospital

• Some services at hospitals, skilled nursing facilities or rehabilitation centers

• Billing Medical Supplies• Revenue Code 0270 – Non-Routine Medical

Supplies – not related to wound care• Revenue Code 0623 – All Supplies related to wound

care • Bill supplies at CHARGES not COST• These charges should not include things like enteral

nutrition, etc. that can be billed by a medical supply company

• Supplies should be on list provided by CMS

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• Payment based on patient characteristics• Payment amount added to case-mix and wage

index adjusted rate–Episode rate reduction

• NRS Case-mix–OASIS: ostomies, catheters, stasis ulcers, therapies at

home–Diagnosis: wounds, burns, post-op complications–Ex. Urinary catheter=17 points, ostomy up to 35

• No supply payment for LUPAs

Non-Routine Medical Supplies

Severity Level Points2016 – FINAL

Urban2017 Final

Urban

1 0 $14.22 $14.16

2 1 – 14 $51.35 $51.15

3 15 – 27 $140.80 $140.24

4 28 – 48 $209.18 $208.35

5 49 – 98 $322.57 $321.29

6 99+ $554.79 $552.58

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HIPPS CodeHHRG

Conversion

C1 = A S1 = KC2 = B S2 = LC3 = C S3 = M

S4 = NF1 = F S5 = PF2 = GF3 = H

1st Digit = Equation

1= Early Episode 0-13 Therapy2= Early Episode 14-19 Therapy3= Late Episode 0-13 Therapy4= Late Episode 14-195= 20+ Therapy

Medical

Supplies

1 = S

2 = T

3 = U

4 = V

5 = W

6 = X

HIPPS Code

HHRG = C2F2S2 3rd

Episode, 6 therapy visits and Supply Category 2

HIPPS Code = 3BGLT

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Limit of 8 hours per day used in calculation of cost in the Outlier CalculationFixed Dollar Loss Ratio = 0.55 (2016 - 0.45)Loss Sharing Ratio = 80%

OUTLIER CALCULATIONS

OUTLIER CALCULATIONS

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Example:

HHRG = C2F2S4 (1st Episode & NRS Level 3) = HIPPS = 1BGNU

RALEIGH, NC CBSA (WAKE COUNTY) = 39580 – 0.9411

Wage Adjusted Episode Amount = $3,051.85 plus NRS add-on of $140.24 = $3,192.09

2016 Calculation FINAL 2017 CalculationFixed $ Loss Ratio – 0.45 Fixed $ Loss Ratio – 0.55Loss Sharing Ratio – 0.80 Loss Sharing Ratio – 0.80

Wage Adjusted Fixed Dollar Loss

Amount

Base PPS Amount x 0.45

$2,989.97 x 0.45 = $1,345.49

$1,345.49 x 0.78535 x 0.9411 =

$994.44

$1,345.49 x 0.21465 = $288.81

$994.44 + 288.81 = $1,283.25

Wage Adjusted Outlier Threshold

$1,283.25 + $3,192.09 = $4,475.34

FINAL 2017 Wage Adjusted Fixed

Dollar Loss Amount

Base PPS Amount x 0.55

$2,989.97 x 0.55 = $1,644.48

$1,644.48 x 0.78535 x 0.9411 =

$1,215.43

$1,644.48 x 0.21465 = $352.99

$1,215.43 + 352.99 = $1,568.42

Wage Adjusted Outlier Threshold

$1,568.42 + $3,192.09 = $4,760.51

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2016 Wage Adjusted Imputed Cost of the Episode

120 Skilled Nursing Visits

120 x $135.28 = $16,233.60

$16,233.60 – $4,475.34 = $11,758.26 x 0.80 = $9,406.61

FINAL 2017 Wage Adjusted Imputed Cost of the Episode

120 Skilled Nursing Visits = 15, 30 OR 45 minute visits

120 x 1 =120 units OR 120 x 2 = 240 units OR 120 x 3 = 360 units

120 X 47.49 = $5,698.80 OR 240 x 47.49 = $11,397.60 OR 360 x 47.49 = $17,096.50

$5,698.80 - $4,760.51 = $938.29 X 0.80 = $750.63

OR $11,397.60 – $4,760.51 = $6,637.09 x 0.80 = $5,309.67

OR $17,096.50 - $4,760.51 = $12,335.99 x 0.80 = $9,868.79

HIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 11IP-REC CN 753654123A NM LANE IT V DB 04171931 SX F IN 00380 PN 017149 APP REAS 1 DATETIME 072508 133610 REQ 1 DISP-CODE 25 MSG UNCONDITIONAL ACCEPT CORRECT 753654123A NM IT DB SX A-ENT 040196 A-TRM 000000 B-ENT 040196 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190

DAYS LEFT FULL-HOSP CO-HOSP FULL-SNF CO-SNF IP-DED BLOOD DOEBA DOLBA CURRENT 60 30 20 80 000 0 070907 071107 PRIOR PARTB YR 08 DED-TBM 00000 BLD 3 YR 07 DED-TBM 00000 BLD 3 DI 0000000000 FULL-NAME GABOURY.MELINDA.A PER 1 PLAN-TYP HMO CURR ID H0154 OPT C ENR 020108 TERM PRIOR PLAN-TYP PRIOR ID OPT ENR TERM

PART A YR BLD 3 PT TBM 1810.00 OT TBM 1810.00 CATASTROPHIC A: DED-TBM BLOOD CO-SNF FULL-SNF DOEBA DOLBA DED-APL YEAR 89 0056000 03 008 142 000000 000000 0000000

ESRD: CODE-1 EFF DATE CODE-2 EFF DATE

PF1=INQ SCREEN PF3/CLEAR=END PF8=NEXT

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HIQACOP CWF PART A INQUIRY REPLY PAGE 10 OF 16

IP-REC CN 404040404A NM CANMAR IT M DB 10011919 SX M

SUBSCRIBER NAME: POLICY NUM: EFF DTE: 03/14/2002 TRM DTE: PATIENT REL: 01 PATIENT MSP CODE: H = BLACK LUNG IS INSURED

INSURER INFORMATION: NAME : BLACK LUNG REMARKS CD: 1 2 3 ADDRESS 1 : PO BOX 828 ADDRESS 2 : CITY LANHAM-SEABROOK STATE MD ZIP CODE 207030000 GROUP NUM : TYPE : SPACES = UNKNOWN

EMPLOYER INFORMATION: NAME : ADDRESS 1 : ADDRESS 2 : CITY : STATE ZIP CODE EMPLOYEE : ID NUMBER INFO NONE PF1=INQ SCREEN PF3/CLEAR=END PF7=PREV PF8=NEXT

HIQACRO CWF PART A INQUIRY REPLY PAGE 10 OF 10

IP-REC CN 123344444A NM WEBB IT M DB 10011919 SX F

SUBSCRIBER NAME: POLICY NUM: 28373645 EFF DTE: 09/01/2001 TRM DTE: 02/29/2004 PATIENT REL: 01 PATIENT MSP CODE: B = ESRD IS INSURED

INSURER INFORMATION: NAME : ANTHEM BCBS REMARKS CD: 1 2 3 ADDRESS 1 : PO BOX 37180 ADDRESS 2 : CITY LOUISVILLE STATE KY ZIP CODE 402337180 GROUP NUM : TYPE : A = INSURANCE OR INDEMNITY


41

HIQACOP CWF PART A INQUIRY REPLY PAGE 10 OF 11

IP-REC CN 852369517A NM LANE IT V DB 04171931 SX F

SUBSCRIBER NAME: POLICY NUM: 852369517 EFF DTE: 06/01/2000 TRM DTE: PATIENT REL: 01 PATIENT MSP CODE: A = WORKING AGED IS INSURED

INSURER INFORMATION: NAME : BLUE CROSS AND BLUE SHIELD OF A REMARKS CD: 1 2 3 ADDRESS 1 : 450 RIVERCHASE PARKWAY EAST ADDRESS 2 : PO BOX 995 CITY BIRMINGHAM STATE AL ZIP CODE 352980001 GROUP NUM : TYPE : A = INSURANCE OR INDEMNITY


• Form Locator 39 - 41 • Use appropriate Value Code with the dollar amount paid by the primary

payer• VC 44 and amount: If applicable, report VC 44 and the amount you are

obligated/required to accept from the primary payer as payment in full due to a contractual arrangement/obligation under law (also known as expected amount or obligated to accept as payment in full, OTAF amount) when that amount is less than the claim’s Medicare covered charges but higher than the amount you received from the primary payer. An MSP payment may be due.

Example:• Medicare covered charges = $5,000, OTAF amount = $4,000, Primary payer paid

= $3,000 • Submit $5,000 MSP claim and report appropriate MSP VC = $3,000 and VC 44 =

$4,000

• Form Locator 50 - 51• Use Payer ID with the name of the Insurance Company & Provider #

• Form Locator 63B• Treatment Authorization Code is moved to second line to correspond

with the Medicare Entry

42

• Form Locator 58 - 62 • Required for MSP final claims• Insured’s Name• Patient’s Relationship to Insured• ID Number• Group Name• Insurance Group Number

• Form Locator 65• Employer Information

The amount of secondary benefits payable to you is the lowest of the following:• Total payable by Medicare minus the applicable Medicare

deductible and/or coinsurance amount.• Total payable by Medicare minus the amount paid by the

primary payer for Medicare covered charges.• Provider's charges (or an amount less than the charges that you

are obligated to accept as payment in full (OTAF) – also known as the VC 44 amount) minus the amount paid by the primary payer for Medicare covered charges.

• Provider's charges (or an amount less than the charges that you are obligated to accept in full (OTAF) – also known as the VC 44 amount) minus the applicable Medicare deductible and/or coinsurance amounts.

43

Patient receives 24 visits in a 60-day episode – Total charges equal $2,800 and the primary payer pays $2,360. The PPS amount equals $2,700.

Medicare will pay lower of the following:Gross PPS – Deductible: $2,700 - 0 = $2,700

Gross PPS – Primary Pymt: $2,700 - $2,360 = $340

HHA Charges – Primary Pymt: $2,800 - $2,360 = $440

HHA Charges – Deductible: $2,800 – 0 = $2,800

44

Session 4:Revenue Cycle Management

Documentation Updates

Medicare Billing Under PPS Reform!

• Billers – Collectors – Cash Posters –Managers/Supervisors• Do you have separate designations or does one

person wear all four hats?• Does each employee understand his/her

responsibilities?• Who is the leader/manager/supervisor?• Is there required reporting in place to monitor

progress?

45

BillersTransmits RAPs

Transmits Finals

Transmits/Processes NonMedicareClaims

Audits

Copies of Notes, etc (NonMedicare)

Collectors –•Works Medicare “T, D & R” status claims

•Tracks Medicare ADRs

•Works Accounts Receivable Reports

•Issues Patient Statements

46

• Cash Posters –• Posting payments to Patient Accounts• Transferring balances to secondary payors or

private pay• Medicare Patients – reconciling the type of

adjustment that was received and if you were paid correctly

• Reconciling amounts posted to amounts deposited into bank

• Managers/Supervisors –• Hold to your title

• Must be able to DELEGATE

• Require reports at specific time intervals

that monitor progress

• Never take a Verbal everything is fine in

place of concrete reports

47

• How many claims are over 120 days on my Accounts Receivable?• Require Billers/Collectors give you a detail explanation of each claim

that is 120+ days on the A/R as part of your month end close process

• What is my Average Days in A/R?• A/R Balance/(Total Revenues/Total Days)

• $333,000/($1,850,000/365) = 66 Days in A/R

Monitoring Reports on a weekly/bi-weekly basis such as: Management Summary

RAPs & Finals transmitted vs. averages

Cash Flow

Admissions & Recerts vs. RAPs filed -Review reports to ensure that all admitted and recertified

patients have had RAPs created and preferably actually billed by month end

# of days to transmit a RAP & FinalHow many days from date of admission before RAP is

transmittedHow many days from end of episode or discharge date

before Final is transmittedSome effect will be felt from clinical issues

48

• Develop measures to monitor staff performance• Review measures in team meetings

• Set reasonable expectations/goals

• Require staff to be accountable• Deal with low performance

• Set limits for time allowed to perform at these levels

• Reward high performance

• Allow staff to express concerns & act on issues in a timely manner

• Avoid typical billing problems•Inadequate time for collection

•Lack of adequate supervision/management

•Unorganized billing/collection tracking

•Incorrectly paid claims for lack of researching balances

49

• Avoid typical billing problems•Excessive RAP takebacks/takebacks not being rekeyed

•Inadequate cash posting reconciliation

•Inadequate or inefficient pre-billing audits

•Limited billing training

•Inadequate knowledge of software/tools

F2F FINAL RULE 2015 Update

Final Decision: We are finalizing our proposal to eliminate the face-to-face encounter narrative as part of the certification of patient eligibility for the Medicare home health benefit, effective for episodes beginning on or after January 1, 2015. The certifying physician will still be required to certify that a face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in §424.22(a)(1)(v)(A), and to document the date of the encounter as part of the certification of eligibility.

50

For instances where the physician is ordering skilled nursing visits for management and evaluation of the patient's care plan, the physician will still be required to include a brief narrative that describes the clinical justification of this need as part of the certification/re-certification of eligibility as outlined in §424.22(a)(1)(i) and §424.22(b)(2).

In determining whether the patient is or was eligible to receive services under the Medicare home health benefit at the start of care, we will require documentation in the certifying physician’s medical records and/or the acute /post-acute care facility’s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of home health eligibility. We will require the documentation to be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described at §424.22(a)(1) and §424.22(b).


HHAs should obtain as much documentation from the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria have been met and must be able to provide it to CMS and its review entities upon request. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.Therefore, in order to determine when documentation of a patient’s face-to-face encounter is required under sections1814(a)(2)(C) and 1835 (a)(2)(A) of the Act, we proposed to clarify that the face-to-face encounter requirement is applicable for certifications (not recertifications), rather than initial episodes. A certification (versus recertification) is considered to be any time that a new SOC OASIS is completed to initiate care.


51

• The certifying physician must also document the date of the face to face encounter as part of the certification.• Certifying physician is NOT required to sign a discharge summary, etc.

from a facility encounter, but must certify that the F2F encounter occurred and the date.

• WISE to also include the physician’s name that provided F2F visit.

• I certify that this patient had a face to face encounter with Dr. John Smith on 09/01/16.• Supporting documentation such as the discharge summary should include

the visit information for when the patient was seen by John Smith on 09/01/16.

• This statement is being accepted when included on the 485/POC.

• Recertification includes that the physician must include in his/her recertification statement of the patient, an estimated amount of time that services will continue to be required! This can be as simple as: “I certify, that in my estimation, continued services will be required for _______.” • There must be documented evidence that the estimation of time originated

from the physician.

• A statement for the estimation of services is required for every recertification 60-day period

• Common mistake….estimation is 60 days and we write POC frequency and goals for 30 days…..

52

Does the patient have a normal inability to leave home? AND Does leaving the

home require a considerable and taxing effort?

Structural Impairment

Is there a structural impairment?

• Structures of the nervous system

• Eye, ear and related structures

• Structures involved in voice and speech

• Structures of the cardiovascular system

• Structures of the immunological system

• Structures of the respiratory system

• Structures related to the digestive system

• Structures related to the metabolic and endocrine systems

• Structures related to the genitourinary system

• Structures related to movement

• Skin and related structures

Does the patient have a normal inability to leave home? AND Does leaving thehome require a considerable and taxing effort?

Functional ImpairmentsIs there a functional impairment? • Mental functions• Sensory functions and pain• Voice and speech functions• Functions of the cardiovascular system• Functions of the hematological and immunological systems• Functions of the respiratory system• Functions of the digestive system• Functions of the metabolic and endocrine systems• Genitourinary functions• Neuromusculoskeletal and movement-related functions• Functions of the skin and related structures

53

Does the patient have a normal inability to leave home? AND Doesleaving the home require a considerable and taxing effort?

Activity Limitations

Are there activity limitations?

• Communication

• Mobility

• Self-care

• Domestic life

• Interpersonal interactions and relationships

Why does this patient need home health?

Outline what the clinicians will be providing to help correct/heal the issues used to support homebound/clinical need:

How do the skills of a nurse or therapist address the specific functional and structural impairments and the activity limitations?

• The skills of a nurse are needed to monitor the healing process of the surgical wound and educate the patient or caregiver on the dressing changes and monitoring signs and symptoms of infection.

• Physical and Occupational therapy is necessary to evaluate the patient’s functional status, capacity for improved mobility and self care or to implement a personalized patient centered plan of care to address activity limitations.

54

Melinda A. Gaboury, COS-CChief Executive OfficerHealthcare Provider Solutions, Inc.810 Royal Parkway, Suite 200Nashville, TN 37214615.399.7499615.399.7790healthcareprovidersolutions.com

CMS-1648-F 23

an episode’s clinical score. The points for the functional variables are added together to

determine an episode’s functional score.

TABLE 3: Case-Mix Adjustment Variables and Scores

Case-Mix Adjustment Variables and Scores

Episode number within sequence of adjacent episodes 1 or 2 1 or 2 3+ 3+

Therapy visits 0-13 14+ 0-13 14+

EQUATION: 1 2 3 4

CLINICAL DIMENSION

1 Primary or Other Diagnosis = Blindness/Low Vision . . . .

2 Primary or Other Diagnosis = Blood disorders . 2 . .

3 Primary or Other Diagnosis = Cancer, selected benign neoplasms . 5 . 5

4 Primary Diagnosis = Diabetes . 4 . 2

5 Other Diagnosis = Diabetes 1 . . .

6

Primary or Other Diagnosis = Dysphagia

AND Primary or Other Diagnosis = Neuro 3 – Stroke

2 18 2 12

7

Primary or Other Diagnosis = Dysphagia

AND M1030 (Therapy at home) = 3 (Enteral)

2 6 . 6

8 Primary or Other Diagnosis = Gastrointestinal disorders . . . .

9

Primary or Other Diagnosis = Gastrointestinal disorders

AND M1630 (ostomy)= 1 or 2

. 7 . .

10

Primary or Other Diagnosis = Gastrointestinal disorders

AND Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis,

OR Neuro 2 - Peripheral neurological disorders, OR Neuro 3 - Stroke,

OR Neuro 4 - Multiple Sclerosis

. . . .

11 Primary or Other Diagnosis = Heart Disease OR Hypertension 1 2 . 2

12 Primary Diagnosis = Neuro 1 - Brain disorders and paralysis 2 12 7 12

13

Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis

AND

M1840 (Toilet transfer) = 2 or more

. 3 . 3

14

Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis

OR Neuro 2 - Peripheral neurological disorders

AND M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

2 3 1 3

15 Primary or Other Diagnosis = Neuro 3 - Stroke 3 12 2 5

16

Primary or Other Diagnosis = Neuro 3 - Stroke

AND

M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

. . . .

17

Primary or Other Diagnosis = Neuro 3 - Stroke

AND

M1860 (Ambulation) = 4 or more

. . . .

18

Primary or Other Diagnosis = Neuro 4 - Multiple Sclerosis AND AT

LEAST ONE OF THE FOLLOWING:

M1830 (Bathing) = 2 or more

OR

M1840 (Toilet transfer) = 2 or more

OR

3 7 6 11

1

CMS-1648-F 24


M1850 (Transferring) = 2 or more

OR

M1860 (Ambulation) = 4 or more

19

Primary or Other Diagnosis = Ortho 1 - Leg Disorders or Gait

Disorders

AND M1324 (most problematic pressure ulcer stage)= 1, 2, 3 or 4

8 1 7 .

20

Primary or Other Diagnosis = Ortho 1 - Leg OR Ortho 2 - Other

orthopedic disorders

AND M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

3 . 3 4

21 Primary or Other Diagnosis = Psych 1 – Affective and other

psychoses, depression . . . .

22 Primary or Other Diagnosis = Psych 2 - Degenerative and other

organic psychiatric disorders . . . .

23 Primary or Other Diagnosis = Pulmonary disorders . . . 1

24 Primary or Other Diagnosis = Pulmonary disorders AND

M1860 (Ambulation) = 1 or more . 1 . .

25 Primary Diagnosis = Skin 1 -Traumatic wounds, burns, and post-

operative complications 4 20 7 18

26 Other Diagnosis = Skin 1 - Traumatic wounds, burns, post-operative

complications 7 15 8 15

27

Primary or Other Diagnosis = Skin 1 -Traumatic wounds, burns, and

post-operative complications OR Skin 2 – Ulcers and other skin

conditions

AND

M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

3 . . .

28 Primary or Other Diagnosis = Skin 2 - Ulcers and other skin conditions 2 17 8 17

29 Primary or Other Diagnosis = Tracheostomy 4 17 4 17

30 Primary or Other Diagnosis = Urostomy/Cystostomy . 18 . 13

31 M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) . 17 6 17

32 M1030 (Therapy at home) = 3 (Enteral) . 16 . 9

33 M1200 (Vision) = 1 or more . . . .

34 M1242 (Pain)= 3 or 4 3 . 2 .

35 M1311 = Two or more pressure ulcers at stage 3 or 41 5 10 5 10

36 M1324 (Most problematic pressure ulcer stage)= 1 or 2 4 19 7 16

37 M1324 (Most problematic pressure ulcer stage)= 3 or 4 9 32 11 26

38 M1334 (Stasis ulcer status)= 2 4 15 8 15

39 M1334 (Stasis ulcer status)= 3 7 17 10 17

40 M1342 (Surgical wound status)= 2 2 7 5 11

41 M1342 (Surgical wound status)= 3 . 6 4 9

42 M1400 (Dyspnea) = 2, 3, or 4 . . . .

43 M1620 (Bowel Incontinence) = 2 to 5 . 4 . 3

44 M1630 (Ostomy)= 1 or 2 4 12 2 8

45 M2030 (Injectable Drug Use) = 0, 1, 2, or 3 . . . .

FUNCTIONAL DIMENSION

46 M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3 1 . 1 .

47 M1830 (Bathing) = 2 or more 6 5 5 2

48 M1840 (Toilet transferring) = 2 or more 1 2 . .

1M1308 ‘Current Number of Unhealed Pressure Ulcers at Each Stage or Unstageable’ will be changed to M1311 ‘Current

Number of Unhealed Pressure Ulcers at Each Stage’ under the new OASIS C2 format, effective January 1, 2017.

2

CMS-1648-F 25


49 M1850 (Transferring) = 2 or more 3 1 2 .

50 M1860 (Ambulation) = 1, 2 or 3 7 . 4 .

51 M1860 (Ambulation) = 4 or more 8 9 6 8

Source: CY 2015 Medicare claims data for episodes ending on or before December 31, 2015 (as of June 30, 2016) for which we

had a linked OASIS assessment. LUPA episodes, outlier episodes, and episodes with SCIC or PEP adjustments were excluded.

Note(s): Points are additive; however, points may not be given for the same line item in the table more than once.

In updating the four-equation model for CY 2017, using complete 2015 data as of June 30, 2016

(the last update to the four-equation model for CY 2016 used 2014 data), there were few changes

to the point values for the variables in the four-equation model. These relatively minor changes

reflect the change in the relationship between the grouper variables and resource use between

2014 and 2015. The CY 2017 four-equation model resulted in 119 point-giving variables being

used in the model (as compared to the 124 point-giving variables for the 2016 recalibration). Of

those 119 variables, the CY 2017 four-equation model had 113 variables that were also present

in the CY 2016 four-equation model. Of those 113 variables, the points for 33 variables

increased in the CY 2017 four-equation model compared to CY 2016 and the points for 33

variables decreased in the CY 2017 4-equation model compared to CY 2016. There were 47

variables with the same point values between CY 2016 and CY 2017. There were 6 variables

that were added to the model in CY 2017 that weren’t in the model in CY 2016. Also, 11

variables were in the model in CY 2016 but dropped in CY 2017 due to the absence of additional

resources associated with these variables. In other words, these variables are not associated with

additional resources beyond what is captured by the other case-mix adjustment variables in the

regression model.

Step 2: Re-define the clinical and functional thresholds so they are reflective of the new

points associated with the CY 2017 four-equation model. After estimating the points for each of

the variables and summing the clinical and functional points for each episode, we look at the

distribution of the clinical score and functional score, breaking the episodes into different steps.

3

CMS-1648-F 26

The categorizations for the steps are as follows:

● Step 1: First and second episodes, 0-13 therapy visits.

● Step 2.1: First and second episodes, 14-19 therapy visits.

● Step 2.2: Third episodes and beyond, 14-19 therapy visits.

● Step 3: Third episodes and beyond, 0-13 therapy visits.

● Step 4: Episodes with 20+ therapy visits

We then divide the distribution of the clinical score for episodes within a step such that a

third of episodes are classified as low clinical score, a third of episodes are classified as medium

clinical score, and a third of episodes are classified as high clinical score. The same approach is

then done looking at the functional score. It was not always possible to evenly divide the

episodes within each step into thirds due to many episodes being clustered around one particular

score.2 Also, we looked at the average resource use associated with each clinical and functional

score and used that to guide where we placed our thresholds. We tried to group scores with

similar average resource use within the same level (even if it meant that more or less than a third

of episodes were placed within a level). The new thresholds, based off of the CY 2017

four-equation model points are shown in Table 4.

TABLE 4: CY 2017 Clinical and Functional Thresholds

1st and 2nd Episodes 3rd+ Episodes All Episodes

0 to 13

therapy

visits

14 to 19

therapy

visits

0 to 13

therapy

visits

14 to 19

therapy

visits

20+ therapy

visits

Grouping Step: 1 2.1 3 2.2 4

Equation(s) used to

calculate points:

(see Table 3) 1 2 3 4 (2&4)

2 For Step 1, 49.2 percent of episodes were in the medium functional level (All with score 14). For Step 2.1, 70.7 percent of episodes were in the low functional level (Most with score 5 and 6).

For Step 2.2, 78.7 percent of episodes were in the medium functional level (Most with score 2).

For Step 3, 51.0 percent of episodes were in the medium functional level (Most with score 10). For Step 4, 51.2 percent of episodes were in the medium functional level (Most with score 5 and 6).

4

CMS-1648-F 27

Dimension

Severity

Level

Clinical C1 0 to 1 0 to 1 0 to 1 0 to 1 0 to 3

C2 2 to 3 2 to 7 2 2 to 9 4 to 16

C3 4+ 8+ 3+ 10+ 17+

Functional F1 0 to 13 0 to 6 0 to 6 0 to 1 0 to 2

F2 14 7 to 13 7 to 10 2 to 9 3 to 6

F3 15+ 14+ 11+ 10+ 7+

Step 3: Once the clinical and functional thresholds are determined and each episode is

assigned a clinical and functional level, the payment regression is estimated with an episode’s

wage-weighted minutes of care as the dependent variable. Independent variables in the model

are indicators for the step of the episode as well as the clinical and functional levels within each

step of the episode. Like the four-equation model, the payment regression model is also

estimated with robust standard errors that are clustered at the beneficiary level. Table 5 shows

the regression coefficients for the variables in the payment regression model updated with CY

2015 data. The R-squared value for the payment regression model is 0.4929 (an increase from

0.4822 for the CY 2016 recalibration).

5

60 Day Episodes - January - June 2016

End of End of End ofSOC Date Episode SOC Date Episode SOC Date Episode01/01/16 thru 02/29/16 02/01/16 thru 03/31/16 03/01/16 thru 04/29/1601/02/16 thru 03/01/16 02/02/16 thru 04/01/16 03/02/16 thru 04/30/1601/03/16 thru 03/02/16 02/03/16 thru 04/02/16 03/03/16 thru 05/01/1601/04/16 thru 03/03/16 02/04/16 thru 04/03/16 03/04/16 thru 05/02/1601/05/16 thru 03/04/16 02/05/16 thru 04/04/16 03/05/16 thru 05/03/1601/06/16 thru 03/05/16 02/06/16 thru 04/05/16 03/06/16 thru 05/04/1601/07/16 thru 03/06/16 02/07/16 thru 04/06/16 03/07/16 thru 05/05/1601/08/16 thru 03/07/16 02/08/16 thru 04/07/16 03/08/16 thru 05/06/1601/09/16 thru 03/08/16 02/09/16 thru 04/08/16 03/09/16 thru 05/07/1601/10/16 thru 03/09/16 02/10/16 thru 04/09/16 03/10/16 thru 05/08/1601/11/16 thru 03/10/16 02/11/16 thru 04/10/16 03/11/16 thru 05/09/1601/12/16 thru 03/11/16 02/12/16 thru 04/11/16 03/12/16 thru 05/10/1601/13/16 thru 03/12/16 02/13/16 thru 04/12/16 03/13/16 thru 05/11/1601/14/16 thru 03/13/16 02/14/16 thru 04/13/16 03/14/16 thru 05/12/1601/15/16 thru 03/14/16 02/15/16 thru 04/14/16 03/15/16 thru 05/13/1601/16/16 thru 03/15/16 02/16/16 thru 04/15/16 03/16/16 thru 05/14/1601/17/16 thru 03/16/16 02/17/16 thru 04/16/16 03/17/16 thru 05/15/1601/18/16 thru 03/17/16 02/18/16 thru 04/17/16 03/18/16 thru 05/16/1601/19/16 thru 03/18/16 02/19/16 thru 04/18/16 03/19/16 thru 05/17/1601/20/16 thru 03/19/16 02/20/16 thru 04/19/16 03/20/16 thru 05/18/1601/21/16 thru 03/20/16 02/21/16 thru 04/20/16 03/21/16 thru 05/19/1601/22/16 thru 03/21/16 02/22/16 thru 04/21/16 03/22/16 thru 05/20/1601/23/16 thru 03/22/16 02/23/16 thru 04/22/16 03/23/16 thru 05/21/1601/24/16 thru 03/23/16 02/24/16 thru 04/23/16 03/24/16 thru 05/22/1601/25/16 thru 03/24/16 02/25/16 thru 04/24/16 03/25/16 thru 05/23/1601/26/16 thru 03/25/16 02/26/16 thru 04/25/16 03/26/16 thru 05/24/1601/27/16 thru 03/26/16 02/27/16 thru 04/26/16 03/27/16 thru 05/25/1601/28/16 thru 03/27/16 02/28/16 thru 04/27/16 03/28/16 thru 05/26/1601/29/16 thru 03/28/16 02/29/16 thru 04/28/16 03/29/16 thru 05/27/1601/30/16 thru 03/29/16 03/30/16 thru 05/28/1601/31/16 thru 03/30/16 03/31/16 thru 05/29/16

End of End of End ofSOC Date Episode SOC Date Episode SOC Date Episode04/01/16 thru 05/30/16 05/01/16 thru 06/29/16 06/01/16 thru 07/30/1604/02/16 thru 05/31/16 05/02/16 thru 06/30/16 06/02/16 thru 07/31/1604/03/16 thru 06/01/16 05/03/16 thru 07/01/16 06/03/16 thru 08/01/1604/04/16 thru 06/02/16 05/04/16 thru 07/02/16 06/04/16 thru 08/02/1604/05/16 thru 06/03/16 05/05/16 thru 07/03/16 06/05/16 thru 08/03/1604/06/16 thru 06/04/16 05/06/16 thru 07/04/16 06/06/16 thru 08/04/1604/07/16 thru 06/05/16 05/07/16 thru 07/05/16 06/07/16 thru 08/05/1604/08/16 thru 06/06/16 05/08/16 thru 07/06/16 06/08/16 thru 08/06/1604/09/16 thru 06/07/16 05/09/16 thru 07/07/16 06/09/16 thru 08/07/1604/10/16 thru 06/08/16 05/10/16 thru 07/08/16 06/10/16 thru 08/08/1604/11/16 thru 06/09/16 05/11/16 thru 07/09/16 06/11/16 thru 08/09/1604/12/16 thru 06/10/16 05/12/16 thru 07/10/16 06/12/16 thru 08/10/1604/13/16 thru 06/11/16 05/13/16 thru 07/11/16 06/13/16 thru 08/11/1604/14/16 thru 06/12/16 05/14/16 thru 07/12/16 06/14/16 thru 08/12/1604/15/16 thru 06/13/16 05/15/16 thru 07/13/16 06/15/16 thru 08/13/1604/16/16 thru 06/14/16 05/16/16 thru 07/14/16 06/16/16 thru 08/14/1604/17/16 thru 06/15/16 05/17/16 thru 07/15/16 06/17/16 thru 08/15/1604/18/16 thru 06/16/16 05/18/16 thru 07/16/16 06/18/16 thru 08/16/1604/19/16 thru 06/17/16 05/19/16 thru 07/17/16 06/19/16 thru 08/17/1604/20/16 thru 06/18/16 05/20/16 thru 07/18/16 06/20/16 thru 08/18/1604/21/16 thru 06/19/16 05/21/16 thru 07/19/16 06/21/16 thru 08/19/1604/22/16 thru 06/20/16 05/22/16 thru 07/20/16 06/22/16 thru 08/20/1604/23/16 thru 06/21/16 05/23/16 thru 07/21/16 06/23/16 thru 08/21/1604/24/16 thru 06/22/16 05/24/16 thru 07/22/16 06/24/16 thru 08/22/1604/25/16 thru 06/23/16 05/25/16 thru 07/23/16 06/25/16 thru 08/23/1604/26/16 thru 06/24/16 05/26/16 thru 07/24/16 06/26/16 thru 08/24/1604/27/16 thru 06/25/16 05/27/16 thru 07/25/16 06/27/16 thru 08/25/1604/28/16 thru 06/26/16 05/28/16 thru 07/26/16 06/28/16 thru 08/26/1604/29/16 thru 06/27/16 05/29/16 thru 07/27/16 06/29/16 thru 08/27/1604/30/16 thru 06/28/16 05/30/16 thru 07/28/16 06/30/16 thru 08/28/16

05/31/16 thru 07/29/16

Prepared By: Healthcare Provider Solutions, Inc.

6

60 Day Episodes - July - December 2016

End of End of End ofSOC Date Episode SOC Date Episode SOC Date Episode07/01/16 thru 08/29/16 08/01/16 thru 09/29/16 09/01/16 thru 10/30/1607/02/16 thru 08/30/16 08/02/16 thru 09/30/16 09/02/16 thru 10/31/1607/03/16 thru 08/31/16 08/03/16 thru 10/01/16 09/03/16 thru 11/01/1607/04/16 thru 09/01/16 08/04/16 thru 10/02/16 09/04/16 thru 11/02/1607/05/16 thru 09/02/16 08/05/16 thru 10/03/16 09/05/16 thru 11/03/1607/06/16 thru 09/03/16 08/06/16 thru 10/04/16 09/06/16 thru 11/04/1607/07/16 thru 09/04/16 08/07/16 thru 10/05/16 09/07/16 thru 11/05/1607/08/16 thru 09/05/16 08/08/16 thru 10/06/16 09/08/16 thru 11/06/1607/09/16 thru 09/06/16 08/09/16 thru 10/07/16 09/09/16 thru 11/07/1607/10/16 thru 09/07/16 08/10/16 thru 10/08/16 09/10/16 thru 11/08/1607/11/16 thru 09/08/16 08/11/16 thru 10/09/16 09/11/16 thru 11/09/1607/12/16 thru 09/09/16 08/12/16 thru 10/10/16 09/12/16 thru 11/10/1607/13/16 thru 09/10/16 08/13/16 thru 10/11/16 09/13/16 thru 11/11/1607/14/16 thru 09/11/16 08/14/16 thru 10/12/16 09/14/16 thru 11/12/1607/15/16 thru 09/12/16 08/15/16 thru 10/13/16 09/15/16 thru 11/13/1607/16/16 thru 09/13/16 08/16/16 thru 10/14/16 09/16/16 thru 11/14/1607/17/16 thru 09/14/16 08/17/16 thru 10/15/16 09/17/16 thru 11/15/1607/18/16 thru 09/15/16 08/18/16 thru 10/16/16 09/18/16 thru 11/16/1607/19/16 thru 09/16/16 08/19/16 thru 10/17/16 09/19/16 thru 11/17/1607/20/16 thru 09/17/16 08/20/16 thru 10/18/16 09/20/16 thru 11/18/1607/21/16 thru 09/18/16 08/21/16 thru 10/19/16 09/21/16 thru 11/19/1607/22/16 thru 09/19/16 08/22/16 thru 10/20/16 09/22/16 thru 11/20/1607/23/16 thru 09/20/16 08/23/16 thru 10/21/16 09/23/16 thru 11/21/1607/24/16 thru 09/21/16 08/24/16 thru 10/22/16 09/24/16 thru 11/22/1607/25/16 thru 09/22/16 08/25/16 thru 10/23/16 09/25/16 thru 11/23/1607/26/16 thru 09/23/16 08/26/16 thru 10/24/16 09/26/16 thru 11/24/1607/27/16 thru 09/24/16 08/27/16 thru 10/25/16 09/27/16 thru 11/25/1607/28/16 thru 09/25/16 08/28/16 thru 10/26/16 09/28/16 thru 11/26/1607/29/16 thru 09/26/16 08/29/16 thru 10/27/16 09/29/16 thru 11/27/1607/30/16 thru 09/27/16 08/30/16 thru 10/28/16 09/30/16 thru 11/28/1607/31/16 thru 09/28/16 08/31/16 thru 10/29/16


Prepared By: Healthcare Provider Solutions, Inc.

7

60 Day Episodes - January - June 2017End of End of End of

SOC Date Episode SOC Date Episode SOC Date Episode01/01/17 thru 03/01/17 02/01/17 thru 04/01/17 03/01/17 thru 04/29/1701/02/17 thru 03/02/17 02/02/17 thru 04/02/17 03/02/17 thru 04/30/1701/03/17 thru 03/03/17 02/03/17 thru 04/03/17 03/03/17 thru 05/01/1701/04/17 thru 03/04/17 02/04/17 thru 04/04/17 03/04/17 thru 05/02/1701/05/17 thru 03/05/17 02/05/17 thru 04/05/17 03/05/17 thru 05/03/1701/06/17 thru 03/06/17 02/06/17 thru 04/06/17 03/06/17 thru 05/04/1701/07/17 thru 03/07/17 02/07/17 thru 04/07/17 03/07/17 thru 05/05/1701/08/17 thru 03/08/17 02/08/17 thru 04/08/17 03/08/17 thru 05/06/1701/09/17 thru 03/09/17 02/09/17 thru 04/09/17 03/09/17 thru 05/07/1701/10/17 thru 03/10/17 02/10/17 thru 04/10/17 03/10/17 thru 05/08/1701/11/17 thru 03/11/17 02/11/17 thru 04/11/17 03/11/17 thru 05/09/1701/12/17 thru 03/12/17 02/12/17 thru 04/12/17 03/12/17 thru 05/10/1701/13/17 thru 03/13/17 02/13/17 thru 04/13/17 03/13/17 thru 05/11/1701/14/17 thru 03/14/17 02/14/17 thru 04/14/17 03/14/17 thru 05/12/1701/15/17 thru 03/15/17 02/15/17 thru 04/15/17 03/15/17 thru 05/13/1701/16/17 thru 03/16/17 02/16/17 thru 04/16/17 03/16/17 thru 05/14/1701/17/17 thru 03/17/17 02/17/17 thru 04/17/17 03/17/17 thru 05/15/1701/18/17 thru 03/18/17 02/18/17 thru 04/18/17 03/18/17 thru 05/16/1701/19/17 thru 03/19/17 02/19/17 thru 04/19/17 03/19/17 thru 05/17/1701/20/17 thru 03/20/17 02/20/17 thru 04/20/17 03/20/17 thru 05/18/1701/21/17 thru 03/21/17 02/21/17 thru 04/21/17 03/21/17 thru 05/19/1701/22/17 thru 03/22/17 02/22/17 thru 04/22/17 03/22/17 thru 05/20/1701/23/17 thru 03/23/17 02/23/17 thru 04/23/17 03/23/17 thru 05/21/1701/24/17 thru 03/24/17 02/24/17 thru 04/24/17 03/24/17 thru 05/22/1701/25/17 thru 03/25/17 02/25/17 thru 04/25/17 03/25/17 thru 05/23/1701/26/17 thru 03/26/17 02/26/17 thru 04/26/17 03/26/17 thru 05/24/1701/27/17 thru 03/27/17 02/27/17 thru 04/27/17 03/27/17 thru 05/25/1701/28/17 thru 03/28/17 02/28/17 thru 04/28/17 03/28/17 thru 05/26/1701/29/17 thru 03/29/17 03/29/17 thru 05/27/1701/30/17 thru 03/30/17 03/30/17 thru 05/28/1701/31/17 thru 03/31/17 03/31/17 thru 05/29/17

End of End of End ofSOC Date Episode SOC Date Episode SOC Date Episode04/01/17 thru 05/30/17 05/01/17 thru 06/29/17 06/01/17 thru 07/30/1704/02/17 thru 05/31/17 05/02/17 thru 06/30/17 06/02/17 thru 07/31/1704/03/17 thru 06/01/17 05/03/17 thru 07/01/17 06/03/17 thru 08/01/1704/04/17 thru 06/02/17 05/04/17 thru 07/02/17 06/04/17 thru 08/02/1704/05/17 thru 06/03/17 05/05/17 thru 07/03/17 06/05/17 thru 08/03/1704/06/17 thru 06/04/17 05/06/17 thru 07/04/17 06/06/17 thru 08/04/1704/07/17 thru 06/05/17 05/07/17 thru 07/05/17 06/07/17 thru 08/05/1704/08/17 thru 06/06/17 05/08/17 thru 07/06/17 06/08/17 thru 08/06/1704/09/17 thru 06/07/17 05/09/17 thru 07/07/17 06/09/17 thru 08/07/1704/10/17 thru 06/08/17 05/10/17 thru 07/08/17 06/10/17 thru 08/08/1704/11/17 thru 06/09/17 05/11/17 thru 07/09/17 06/11/17 thru 08/09/1704/12/17 thru 06/10/17 05/12/17 thru 07/10/17 06/12/17 thru 08/10/1704/13/17 thru 06/11/17 05/13/17 thru 07/11/17 06/13/17 thru 08/11/1704/14/17 thru 06/12/17 05/14/17 thru 07/12/17 06/14/17 thru 08/12/1704/15/17 thru 06/13/17 05/15/17 thru 07/13/17 06/15/17 thru 08/13/1704/16/17 thru 06/14/17 05/16/17 thru 07/14/17 06/16/17 thru 08/14/1704/17/17 thru 06/15/17 05/17/17 thru 07/15/17 06/17/17 thru 08/15/1704/18/17 thru 06/16/17 05/18/17 thru 07/16/17 06/18/17 thru 08/16/1704/19/17 thru 06/17/17 05/19/17 thru 07/17/17 06/19/17 thru 08/17/1704/20/17 thru 06/18/17 05/20/17 thru 07/18/17 06/20/17 thru 08/18/1704/21/17 thru 06/19/17 05/21/17 thru 07/19/17 06/21/17 thru 08/19/1704/22/17 thru 06/20/17 05/22/17 thru 07/20/17 06/22/17 thru 08/20/1704/23/17 thru 06/21/17 05/23/17 thru 07/21/17 06/23/17 thru 08/21/1704/24/17 thru 06/22/17 05/24/17 thru 07/22/17 06/24/17 thru 08/22/1704/25/17 thru 06/23/17 05/25/17 thru 07/23/17 06/25/17 thru 08/23/1704/26/17 thru 06/24/17 05/26/17 thru 07/24/17 06/26/17 thru 08/24/1704/27/17 thru 06/25/17 05/27/17 thru 07/25/17 06/27/17 thru 08/25/1704/28/17 thru 06/26/17 05/28/17 thru 07/26/17 06/28/17 thru 08/26/1704/29/17 thru 06/27/17 05/29/17 thru 07/27/17 06/29/17 thru 08/27/1704/30/17 thru 06/28/17 05/30/17 thru 07/28/17 06/30/17 thru 08/28/17

05/31/17 thru 07/29/17

8

60 Day Episodes - July - December 2017End of End of End of

SOC Date Episode SOC Date Episode SOC Date Episode07/01/17 thru 08/29/17 08/01/17 thru 09/29/17 09/01/17 thru 10/30/1707/02/17 thru 08/30/17 08/02/17 thru 09/30/17 09/02/17 thru 10/31/1707/03/17 thru 08/31/17 08/03/17 thru 10/01/17 09/03/17 thru 11/01/1707/04/17 thru 09/01/17 08/04/17 thru 10/02/17 09/04/17 thru 11/02/1707/05/17 thru 09/02/17 08/05/17 thru 10/03/17 09/05/17 thru 11/03/1707/06/17 thru 09/03/17 08/06/17 thru 10/04/17 09/06/17 thru 11/04/1707/07/17 thru 09/04/17 08/07/17 thru 10/05/17 09/07/17 thru 11/05/1707/08/17 thru 09/05/17 08/08/17 thru 10/06/17 09/08/17 thru 11/06/1707/09/17 thru 09/06/17 08/09/17 thru 10/07/17 09/09/17 thru 11/07/1707/10/17 thru 09/07/17 08/10/17 thru 10/08/17 09/10/17 thru 11/08/1707/11/17 thru 09/08/17 08/11/17 thru 10/09/17 09/11/17 thru 11/09/1707/12/17 thru 09/09/17 08/12/17 thru 10/10/17 09/12/17 thru 11/10/1707/13/17 thru 09/10/17 08/13/17 thru 10/11/17 09/13/17 thru 11/11/1707/14/17 thru 09/11/17 08/14/17 thru 10/12/17 09/14/17 thru 11/12/1707/15/17 thru 09/12/17 08/15/17 thru 10/13/17 09/15/17 thru 11/13/1707/16/17 thru 09/13/17 08/16/17 thru 10/14/17 09/16/17 thru 11/14/1707/17/17 thru 09/14/17 08/17/17 thru 10/15/17 09/17/17 thru 11/15/1707/18/17 thru 09/15/17 08/18/17 thru 10/16/17 09/18/17 thru 11/16/1707/19/17 thru 09/16/17 08/19/17 thru 10/17/17 09/19/17 thru 11/17/1707/20/17 thru 09/17/17 08/20/17 thru 10/18/17 09/20/17 thru 11/18/1707/21/17 thru 09/18/17 08/21/17 thru 10/19/17 09/21/17 thru 11/19/1707/22/17 thru 09/19/17 08/22/17 thru 10/20/17 09/22/17 thru 11/20/1707/23/17 thru 09/20/17 08/23/17 thru 10/21/17 09/23/17 thru 11/21/1707/24/17 thru 09/21/17 08/24/17 thru 10/22/17 09/24/17 thru 11/22/1707/25/17 thru 09/22/17 08/25/17 thru 10/23/17 09/25/17 thru 11/23/1707/26/17 thru 09/23/17 08/26/17 thru 10/24/17 09/26/17 thru 11/24/1707/27/17 thru 09/24/17 08/27/17 thru 10/25/17 09/27/17 thru 11/25/1707/28/17 thru 09/25/17 08/28/17 thru 10/26/17 09/28/17 thru 11/26/1707/29/17 thru 09/26/17 08/29/17 thru 10/27/17 09/29/17 thru 11/27/1707/30/17 thru 09/27/17 08/30/17 thru 10/28/17 09/30/17 thru 11/28/1707/31/17 thru 09/28/17 08/31/17 thru 10/29/17


9

Agency Name: Reviewed By:

Patient Name: SOC Date:

Episode: Discharge Date:

1. Are the first 6 Diagnosis codes on the 485 on the OASIS and in the same order?Yes No

2. Has the SOC or recert OASIS associated with this episode been transmitted to the state?Yes No

3. Is the 485 signed and dated by the clinician in box 23?Yes No

4. Is the 485 signed and dated by the physician ?Yes No

Yes No N/A

6. Were there physicians orders to cover all non-routine supplies dispensed during this episode?Yes No N/A

7. Is this a SOC episode for this patient?Yes No

8. Is the F2F document back signed from the physician?

Yes No N/A

9. Were any of the visits in this episode provided in an Assisted Living Facility?Yes No

From To

11. Please list below any visits to be billed as non-covered or any visits that need to be changedDate

Fax this audit and a list of all visits and supplies to be billed to HPS

Medicare and Other PPS Billing Audit Tool

5. Are all supplemental orders signed and dated by the physician?

Required for Medicare. N/A for Other PPS payers

If no, you can skip the next question

Checking N/A on this question tells usthe episodes is to be billed without supplies.

10. If the answer to question 9 is yes, you must indicate below the date spans for care provided in an ALF

Visit Correction Needed

10

Home Health PPS Billing Audit Tool

Agency: Patient Name:

Audited By: Episode Dates:

Review Date: Discharge Date:

ADR ReviewYES NO

YES NO

Patient Status ReviewYES NO

OASIS Compliance ReviewYES NO

HCPCS Code ReviewYES NO N/A

Visit and Supply ReviewYES NO N/A

F2F Compliance ReviewYES NO N/A

Q Code ComplianceYES NO N/A

Q5001=Care Provided at Home, Q5002=Care Provided in an ALF, Q5009=Hold the claim

YES NO N/A

PT

OT

ST

List the Dx Code on the claim that supports medical necessity for each discipline

SN PT OT ST

Comments

Is there at least one other registered therapy visit for this discipline within 30 days of the Eval or last reassess visit?

Therapy Re-Assess Compliance

If yes, confirm that the patient was discharged and readmitted to this or any other agency within this episode

If "No" place claim on hold.

Q Code Verification

Does claim have a 06 Patient Status Code?

Does the Q Code on the claim match the audit tool and does the revenue onthe Q Code line match the revenue code of the first visit in the episode? If "No" place claim on hold.

Identify the first therapy visit for each therapy discipline on the claim. These visits will have a code of G0151,G0152, G0153 and/or be identified as an Eval or Assessment visit on the visit desciption line. Within thirty days of the first Eval visit for each discipline of therapy there must be at least one other registered therapy visit (G0151, G0152, and G0153).

Do the supplies on the claim match the audit? If "No" place claim on hold.

Audit tool must indicate compliance with F2F for SOC episodes only. F2F not applicable for other pps payers.

If audit indicates supplies used and there are no supplies on claim, place claim on hold.

Status Verification

Is this a Palmetto client? If "Yes" answer questions. If "No" skip section.

If you answered yes to any of these questions hold the claim and see your supervisor.

Is there at least one other registered therapy visit for this discipline within 30 days of the Eval or last reassess visit?Is there at least one other registered therapy visit for this discipline within 30 days of the Eval or last reassess visit?

F2F Compliance Verification

Is the HIPPS code 2BGL*, 2CGL*, or 2CHL* with fewer than 16 or greater than 17 therapy visits?is the HIPPS code 1BGP* with fewer than 11 or greater than 13 therapy visits?

Any nursing visits have the G code G0162?

If "Yes", answer all three questionsbelow

Does the audit tool indicate compliance with F2F?

Therapy Reassess Compliance

Does the audit indicate compliance with OASIS requirements? If "No" place claim on hold unless softwarevalidates for this.

OASIS Verification

If "Yes" place claim on hold.If "Yes" place claim on hold.

Medicare requires a functional reassessment at least once evey thirty days for each discipline of therapy. You must verify compliance for each discipline of therapy individually.

Do the vists on the claim match the audit?

Is the HIPPS code 5AFK*, 5AGK*, 5AHK*, 5BFK*, 5BGK*, 5BHK*, 5CGK*, 5CHK*with fewer than 20 therapy visits?

Any therapy visits have the G codes G0159, G0160, G0161?

Is there therapy on this claim? (G0151,G0152,G0153,G0157,G0158)

HCPCS Code Verification

Visit and Supply Verification

11

Home Health Consolidated Billing List as of Tr. 3618

HCPCS Code Descriptor

Effective Date Code Type

A4212 Non coring needle or stylet 1/1/2017 Non-routine SupplyA4213 Syringe, Sterile, 20 cc or greater 1/1/2017 Non-routine SupplyA4215 Needle, sterile, any size, each 1/1/2017 Non-routine SupplyA4216 Sterile water/saline up to 10ml 1/1/2017 Non-routine SupplyA4217 Sterile water/saline 500ml 1/1/2017 Non-routine SupplyA4244 Alcohol or peroxide, per pint 1/1/2017 Non-routine SupplyA4245 Alcohol wipes, per box 1/1/2017 Non-routine SupplyA4246 Betadine or phisohex solution, per pint 1/1/2017 Non-routine SupplyA4247 Betadine or iodine swabs/wipes, per box 1/1/2017 Non-routine SupplyA4248 Chlorhexidine, containing anticeptic, 1ml 1/1/2017 Non-routine SupplyA4310 Insert tray w/o bag/cath 1/1/2017 Non-routine SupplyA4311 Catheter w/o bag 2-way latex 1/1/2017 Non-routine SupplyA4312 Cath w/o bag 2-way silicone 1/1/2017 Non-routine SupplyA4313 Catheter w/bag 3-way 1/1/2017 Non-routine SupplyA4314 Cath w/drainage 2-way latex 1/1/2017 Non-routine SupplyA4315 Cath w/drainage 2-way silcne 1/1/2017 Non-routine SupplyA4316 Cath w/drainage 3-way 1/1/2017 Non-routine SupplyA4320 Irrigation tray 1/1/2017 Non-routine SupplyA4321 Cath therapeutic irrig agent 1/1/2017 Non-routine SupplyA4322 Irrigation syringe 1/1/2017 Non-routine SupplyA4326 Male external catheter 1/1/2017 Non-routine SupplyA4327 Fem urinary collect dev cup 1/1/2017 Non-routine SupplyA4328 Fem urinary collect pouch 1/1/2017 Non-routine SupplyA4330 Stool collection pouch 1/1/2017 Non-routine SupplyA4331 Extension drainage tubing 1/1/2017 Non-routine SupplyA4332 Lubricant for cath insertion 1/1/2017 Non-routine SupplyA4333 Urinary cath anchor device 1/1/2017 Non-routine SupplyA4334 Urinary cath leg strap 1/1/2017 Non-routine SupplyA4335 Incontinence supply 1/1/2017 Non-routine SupplyA4338 Indwelling catheter latex 1/1/2017 Non-routine SupplyA4340 Indwelling catheter special 1/1/2017 Non-routine SupplyA4344 Cath indw foley 2 way silicn 1/1/2017 Non-routine SupplyA4346 Cath indw foley 3 way 1/1/2017 Non-routine Supply

A4349 Male ext catheter, with or without adhesive, disposable, each 1/1/2017 Non-routine SupplyA4351 Straight tip urine catheter 1/1/2017 Non-routine SupplyA4352 Coude tip urinary catheter 1/1/2017 Non-routine SupplyA4353 Intermittent urinary cath 1/1/2017 Non-routine SupplyA4354 Cath insertion tray w/bag 1/1/2017 Non-routine SupplyA4355 Bladder irrigation tubing 1/1/2017 Non-routine SupplyA4356 Ext ureth clmp or compr dvc 1/1/2017 Non-routine SupplyA4357 Bedside drainage bag 1/1/2017 Non-routine SupplyA4358 Urinary leg bag 1/1/2017 Non-routine Supply

A4360disposable external urethral clamp or compression device with pad and/or pouch 1/1/2017 Non-routine Supply

A4361 Ostomy face plate 1/1/2017 Non-routine SupplyA4362 Solid skin barrier 1/1/2017 Non-routine SupplyA4363 Ostomy clamp, any type, replacement only, each 1/1/2017 Non-routine SupplyA4364 Liq adhes for facial prosth 1/1/2017 Non-routine SupplyA4366 Ostomy vent, any type, each 1/1/2017 Non-routine SupplyA4367 Ostomy belt 1/1/2017 Non-routine SupplyA4368 Ostomy filter 1/1/2017 Non-routine SupplyA4368 Ostomy pouch filter 1/1/2017 Non-routine Supply

Division of Institutional Claims Processing 1 1/1/201712


A4369 Skin barrier liquid per oz 1/1/2017 Non-routine SupplyA4371 Skin barrier powder per oz 1/1/2017 Non-routine SupplyA4372 Skin barrier solid 4x4 equiv 1/1/2017 Non-routine SupplyA4373 Skin barrier with flange 1/1/2017 Non-routine SupplyA4375 Drainable plastic pch w fcpl 1/1/2017 Non-routine SupplyA4376 Drainable rubber pch w fcplt 1/1/2017 Non-routine SupplyA4377 Drainable plstic pch w/o fp 1/1/2017 Non-routine SupplyA4378 Drainable rubber pch w/o fp 1/1/2017 Non-routine SupplyA4379 Urinary plastic pouch w fcpl 1/1/2017 Non-routine SupplyA4380 Urinary rubber pouch w fcplt 1/1/2017 Non-routine SupplyA4381 Urinary plastic pouch w/o fp 1/1/2017 Non-routine SupplyA4382 Urinary hvy plstc pch w/o fp 1/1/2017 Non-routine SupplyA4383 Urinary rubber pouch w/o fp 1/1/2017 Non-routine SupplyA4384 Ostomy faceplt/silicone ring 1/1/2017 Non-routine SupplyA4385 Ost skn barrier sld ext wear 1/1/2017 Non-routine SupplyA4387 Ost clsd pouch w att st barr 1/1/2017 Non-routine SupplyA4388 Drainable pch w ex wear barr 1/1/2017 Non-routine SupplyA4389 Drainable pch w st wear barr 1/1/2017 Non-routine SupplyA4390 Drainable pch ex wear convex 1/1/2017 Non-routine SupplyA4391 Urinary pouch w ex wear barr 1/1/2017 Non-routine SupplyA4392 Urinary pouch w st wear barr 1/1/2017 Non-routine SupplyA4393 Urine pch w ex wear bar conv 1/1/2017 Non-routine SupplyA4394 Ostomy pouch liq deodorant 1/1/2017 Non-routine SupplyA4395 Ostomy pouch solid deodorant 1/1/2017 Non-routine SupplyA4396 Peristomal hernia supprt blt 1/1/2017 Non-routine SupplyA4397 Irrigation supply sleeve 1/1/2017 Non-routine SupplyA4398 Ostomy irrigation bag 1/1/2017 Non-routine SupplyA4399 Ostomy irrig cone/cath w brs 1/1/2017 Non-routine SupplyA4400 Ostomy irrigation set 1/1/2017 Non-routine SupplyA4402 Lubricant per ounce 1/1/2017 Non-routine SupplyA4404 Ostomy ring each 1/1/2017 Non-routine SupplyA4405 Nonpectin based ostomy paste 1/1/2017 Non-routine SupplyA4406 Pectin based ostomy paste 1/1/2017 Non-routine SupplyA4407 Ext wear ost skn barr <=4sq” 1/1/2017 Non-routine SupplyA4408 Ext wear ost skn barr >4sq” 1/1/2017 Non-routine SupplyA4409 Ost skn barr w flng <=4 sq” 1/1/2017 Non-routine SupplyA4410 Ost skn barr w flng >4sq” 1/1/2017 Non-routine Supply

A4411Ostomy skin barrier, solid 4x4 or equiv., extended wear, w/ built-in convexity, each 1/1/2017 Non-routine Supply

A4412Ostomy pouch, drainable, high output, for use on a barrier w/ flange (2 piece system) without filter, each 1/1/2017 Non-routine Supply

A4413 2 pc drainable ost pouch w/ filter 1/1/2017 Non-routine SupplyA4414 Ostomy skn barr w/ flng < 4sq" 1/1/2017 Non-routine SupplyA4415 Ostomy skn barr w/ flng > 4sq" 1/1/2017 Non-routine SupplyA4416 Ost pch clsd w barrier/filtr 1/1/2017 Non-routine SupplyA4417 Ost pch w bar/bltinconv/fltr 1/1/2017 Non-routine SupplyA4418 Ost pch clsd w/o bar w filtr 1/1/2017 Non-routine SupplyA4419 Ost pch for bar w flange/flt 1/1/2017 Non-routine SupplyA4420 Ost pch clsd for bar w lk fl 1/1/2017 Non-routine SupplyA4421 (6) Ostomy supply misc 1/1/2017 Non-routine SupplyA4422 Ost pouch absorbent material 1/1/2017 Non-routine SupplyA4423 Ost pch for bar w lk fl/fltr 1/1/2017 Non-routine SupplyA4424 Ost pch drain w bar & filter 1/1/2017 Non-routine SupplyA4425 Ost pch drain for barrier fl 1/1/2017 Non-routine SupplyA4426 Ost pch drain 2 piece system 1/1/2017 Non-routine Supply



A4427 Ost pch drain/barr lk flng/f 1/1/2017 Non-routine SupplyA4428 Urine ost pouch w faucet/tap 1/1/2017 Non-routine SupplyA4429 Urine ost pouch w bltinconv 1/1/2017 Non-routine SupplyA4430 Ost urine pch w b/bltin conv 1/1/2017 Non-routine SupplyA4431 Ost pch urine w barrier/tapv 1/1/2017 Non-routine SupplyA4432 Os pch urine w bar/fange/tap 1/1/2017 Non-routine SupplyA4433 Urine ost pch bar w lock fln 1/1/2017 Non-routine SupplyA4434 Ost pch urine w lock flng/ft 1/1/2017 Non-routine Supply

A4435Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each. 1/1/2017 Non-routine Supply

A4455 Adhesive remover per ounce 1/1/2017 Non-routine SupplyA4456 Adhesive remover, wipes, any type 1/1/2017 Non-routine SupplyA4458 Reusable enema bag 1/1/2017 Non-routine Supply

A4459Manual Pump Enema System, Includes Balloon, Catheter And All Accessories, Reusable, Any Type 1/1/2017 Non-routine Supply

A4460 Elastic compression bandage 1/1/2017 Non-routine SupplyA4461 Surgical dressing holder, non-reusable, each 1/1/2017 Non-routine SupplyA4463 Surgical dressing holder, reusable, each 1/1/2017 Non-routine SupplyA4481 Tracheostoma filter 1/1/2017 Non-routine SupplyA4623 Tracheostomy inner cannula 1/1/2017 Non-routine SupplyA4625 Trach care kit for new trach 1/1/2017 Non-routine SupplyA4626 Tracheostomy cleaning brush 1/1/2017 Non-routine SupplyA4649 Surgical supplies 1/1/2017 Non-routine SupplyA4657 Syringe, with or without needle, each 1/1/2017 Non-routine SupplyA4930 Sterile, gloves per pair 1/1/2017 Non-routine SupplyA4932 Rectal thermometer, reusable, any type, each 1/1/2017 Non-routine SupplyA5051 Pouch clsd w barr attached 1/1/2017 Non-routine SupplyA5052 Clsd ostomy pouch w/o barr 1/1/2017 Non-routine SupplyA5053 Clsd ostomy pouch faceplate 1/1/2017 Non-routine SupplyA5054 Clsd ostomy pouch w/flange 1/1/2017 Non-routine SupplyA5055 Stoma cap 1/1/2017 Non-routine Supply

A5056Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each 1/1/2017 Non-routine Supply

A5057 Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each 1/1/2017 Non-routine Supply

A5061 Pouch drainable w barrier at 1/1/2017 Non-routine SupplyA5062 Drnble ostomy pouch w/o barr 1/1/2017 Non-routine SupplyA5063 Drain ostomy pouch w/flange 1/1/2017 Non-routine SupplyA5071 Urinary pouch w/barrier 1/1/2017 Non-routine SupplyA5072 Urinary pouch w/o barrier 1/1/2017 Non-routine SupplyA5073 Urinary pouch on barr w/flng 1/1/2017 Non-routine SupplyA5081 Continent stoma plug 1/1/2017 Non-routine SupplyA5082 Continent stoma catheter 1/1/2017 Non-routine Supply

A5083Continent Device, Stoma Absorptive Cover for Continent Stoma 1/1/2017 Non-routine Supply

A5093 Ostomy accessory convex inse 1/1/2017 Non-routine SupplyA5102 Bedside drain btl w/wo tube 1/1/2017 Non-routine SupplyA5105 Urinary Suspensory With Leg Bag or Without Tube, Each 1/1/2017 Non-routine SupplyA5112 Urinary leg bag 1/1/2017 Non-routine SupplyA5113 Latex leg strap 1/1/2017 Non-routine SupplyA5114 Foam/fabric leg strap 1/1/2017 Non-routine SupplyA5120 Skin barrier, wipes or swabs, each 1/1/2017 Non-routine SupplyA5121 Solid skin barrier 6x6 1/1/2017 Non-routine SupplyA5122 Solid skin barrier 8x8 1/1/2017 Non-routine SupplyA5126 Disk/foam pad +or- adhesive 1/1/2017 Non-routine Supply



A5131 Appliance cleaner 1/1/2017 Non-routine Supply

A6010Collagen based wound filler, dry form, sterile, per gram of collagen 1/1/2017 Non-routine Supply

A6011Collagen based wound filler, gel/paste, sterile, per gram of collagen 1/1/2017 Non-routine Supply

A6020 Collage wound dressing 1/1/2017 Non-routine SupplyA6021 Collagen dressing, sterile, 16 sq. in. or less, each 1/1/2017 Non-routine Supply

A6022Collagen dressing, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each 1/1/2017 Non-routine Supply

A6023 Collagen dressing, sterile, more than 48 sq. in., each 1/1/2017 Non-routine SupplyA6024 Collagen dressing wound filler, sterile, per 6 inches 1/1/2017 Non-routine SupplyA6154 Wound pouch each 1/1/2017 Non-routine Supply

A6196Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing 1/1/2017 Non-routine Supply

A6197

Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6198Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6199Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches 1/1/2017 Non-routine Supply

A6203Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6204

Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6205Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6206 Contact layer, sterile, 16 sq. in. or less, each dressing 1/1/2017 Non-routine Supply

A6207Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6208 Contact layer, sterile, more than 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6209Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6210

Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6211Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6212Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6213

Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6214Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6215 Foam dressing, wound filler, sterile, per gram 1/1/2017 Non-routine Supply

A6219Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6220

Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6221Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply



A6222

Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6223

Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6224

Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6228Gauze, impregnated water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border each dressing 1/1/2017 Non-routine Supply

A6229

Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6230Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6231Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing 1/1/2017 Non-routine Supply

A6232

Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in. but less than or equal to 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6233Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6234Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6235

Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6236Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6237Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6238

Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6239Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6240 Hydrocolloid dressing, wound filler, paste, sterile, per ounce 1/1/2017 Non-routine Supply

A6241 Hydrocolloid dressing, wound filler, dry form, sterile, per gram 1/1/2017 Non-routine Supply

A6242Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6243

Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6244Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6245Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1/1/2017 Non-routine Supply



A6246

Hydrogel dressing, wound cover, sterile, pad size, more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6247Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6248 Hydrogel dressing, wound filler, gel, sterile, per fluid ounce 1/1/2017 Non-routine Supply

A6251Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6252

Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6253Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1/1/2017 Non-routine Supply

A6254

Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6255

Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6256

Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing 1/1/2017 Non-routine Supply

A6257 Transparent film, sterile, 16 sq. in. or less, each dressing 1/1/2017 Non-routine Supply

A6258Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6259 Transparent film, sterile, more than 48 sq. in., each dressing 1/1/2017 Non-routine Supply

A6261Wound filler, gel/paste sterile, per fluid ounce, not otherwise specified 1/1/2017 Non-routine Supply

A6262Wound filler, dry form, sterile, per gram, not otherwise specified 1/1/2017 Non-routine Supply

A6266Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard 1/1/2017 Non-routine Supply

A6402 Sterile gauze <= 16 sq in 1/1/2017 Non-routine SupplyA6403 Sterile gauze>16 <= 48 sq in 1/1/2017 Non-routine SupplyA6404 Sterile gauze > 48 sq in 1/1/2017 Non-routine SupplyA6405 Sterile elastic gauze /yd 1/1/2017 Non-routine SupplyA6406 Sterile non-elastic gauze/yd 1/1/2017 Non-routine Supply

A6407Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard 1/1/2017 Non-routine Supply

A6410 Sterile eye pad 1/1/2017 Non-routine SupplyA6412 Eye patch, occlusive, each 1/1/2017 Non-routine SupplyA6440 Zinc Paste >=3"<5" w/roll 1/1/2017 Non-routine Supply

A6441Padding bandage, non-elastic, non-woven/non-knitted, width > or = 3" and < 5", per yard 1/1/2017 Non-routine Supply

A6442Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard 1/1/2017 Non-routine Supply

A6443

Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard 1/1/2017 Non-routine Supply

A6444Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 inches, per yard 1/1/2017 Non-routine Supply



A6445Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard 1/1/2017 Non-routine Supply

A6446

Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard 1/1/2017 Non-routine Supply

A6447Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard 1/1/2017 Non-routine Supply

A6448Light compression bandage, elastic, knitted/woven, width less than three inches, per yard 1/1/2017 Non-routine Supply

A6449

Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard 1/1/2017 Non-routine Supply

A6450Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard 1/1/2017 Non-routine Supply

A6451

Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard 1/1/2017 Non-routine Supply

A6452

High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard 1/1/2017 Non-routine Supply

A6453Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard 1/1/2017 Non-routine Supply

A6454

Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard 1/1/2017 Non-routine Supply

A6455Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to five inches, per yard 1/1/2017 Non-routine Supply

A6456

Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard 1/1/2017 Non-routine Supply

A6457Tubular dressing with or without elastic, any width, per linear yard 1/1/2017 Non-routine Supply

A6531Gradient Compression Stocking, Below Knee, 30-40 MMHG, Each 1/1/2017 Non-routine Supply

A6532Gradient Compression Stocking, Below Knee, 40-50 MMHG, Each 1/1/2017 Non-routine Supply

A6545Gradient Compression Wrap, non-elastic, below knee, 30-50 mmHg, each 1/1/2017 Non-routine Supply

A7040 One way chest drain valve 1/1/2017 Non-routine Supply

A7041Water seal drainage container and tubing for use with implanted chest tube 1/1/2017 Non-routine Supply

A7045Exhalation port with or without swivel used with accessories for postive airway devices, replacement only 1/1/2017 Non-routine Supply

A7047 Oral Interface Used With Respiratory Suction Pump, each 1/1/2017 Non-routine Supply

A7048

Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each 1/1/2017 Non-routine Supply

A7501 Tracheostoma valve w diaphra 1/1/2017 Non-routine SupplyA7502 Replacement diaphragm/fplate 1/1/2017 Non-routine SupplyA7503 HMES filter holder or cap 1/1/2017 Non-routine SupplyA7504 Tracheostoma HMES filter 1/1/2017 Non-routine SupplyA7505 HMES or trach valve housing 1/1/2017 Non-routine SupplyA7506 HMES/trachvalve adhesivedisk 1/1/2017 Non-routine Supply



A7507 Integrated filter & holder 1/1/2017 Non-routine SupplyA7508 Housing & Integrated Adhesiv 1/1/2017 Non-routine SupplyA7509 Heat & moisture exchange sys 1/1/2017 Non-routine SupplyA7520 Tracheostomy/larynectomy tube, non-cuffed 1/1/2017 Non-routine SupplyA7521 Tracheostomy/larynectomy tube, cuffed 1/1/2017 Non-routine SupplyA7522 Tracheostomy/larynectomy tube, stainless steel 1/1/2017 Non-routine SupplyA7523 Tracheostomy shower protector, each 1/1/2017 Non-routine SupplyA7524 Tracheostomy stent/stud/button, each 1/1/2017 Non-routine SupplyA7527 Tracheostomy/laryngectomy tube plug/stop, each 1/1/2017 Non-routine SupplyK0614 chem/antiseptic solution, 8oz. 1/1/2017 Non-routine SupplyK0620 tubular elastic dressing 1/1/2017 TherapyG0193 Endoscopic study swallow functn 1/1/2017 TherapyG0194 Sensory testing endoscopic study 1/1/2017 TherapyG0195 Clinical eval swallowing funct 1/1/2017 TherapyG0196 Eval of swallowing with radioopa 1/1/2017 TherapyG0197 Eval of pt for prescip speech devi 1/1/2017 TherapyG0198 Patient adapation & train for spe 1/1/2017 TherapyG0199 Reevaluation of patient use spec 1/1/2017 TherapyG0200 Eval of patient prescip of voice p 1/1/2017 TherapyG0201 Modi for training in use voice pro 1/1/2017 TherapyG0281 Elec stim unattend for press 1/1/2017 TherapyG0282 Elect stim wound care not pd 1/1/2017 TherapyG0283 Elec stim other than wound 1/1/2017 TherapyG0329 Electromagntic tx for ulcers 1/1/2017 Therapy0019T Extracorp shock wave tx, ms 1/1/2017 Therapy0020T Extracorp shock wave tx, ft 1/1/2017 Therapy64550 Apply neurostimulator 1/1/2017 Therapy90901 Biofeedback train, any meth 1/1/2017 Therapy90911 Biofeedback peri/uro/rectal 1/1/2017 Therapy92507 Speech/hearing therapy 1/1/2017 Therapy92508 Speech/hearing therapy 1/1/2017 Therapy92510 Rehab for ear implant 1/1/2017 Therapy92521 Evaluation of speech fluency (eg, stuttering, cluttering) 1/1/2017 Therapy

92522Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) 1/1/2017 Therapy

92523with evaluation of language comprehension and expression (eg, receptive and expressive language) 1/1/2017 Therapy

92524 Behavioral and qualitative analysis of voice and resonance 1/1/2017 Therapy92526 Oral function therapy 1/1/2017 Therapy92601 Cochlear implt f/up exam < 7 1/1/2017 Therapy92602 Reprogram cochlear implt < 7 1/1/2017 Therapy92603 Cochlear implt f/up exam 7 > 1/1/2017 Therapy92604 Reprogram cochlear implt 7 > 1/1/2017 Therapy92605 Eval for nonspeech device rx 1/1/2017 Therapy92606 Non-speech device service 1/1/2017 Therapy92607 Ex for speech device rx, 1hr 1/1/2017 Therapy92608 Ex for speech device rx addl 1/1/2017 Therapy92609 Use of speech device service 1/1/2017 Therapy92610 Evaluate swallowing function 1/1/2017 Therapy92611 Motion fluoroscopy/swallow 1/1/2017 Therapy92612 Endoscopy swallow tst (fees) 1/1/2017 Therapy92614 Laryngoscopic sensory test 1/1/2017 Therapy92616 Fees w/laryngeal sense test 1/1/2017 Therapy95831 Limb muscle testing, manual 1/1/2017 Therapy95832 Hand muscle testing, manual 1/1/2017 Therapy



95833 Body muscle testing, manual 1/1/2017 Therapy95834 Body muscle testing, manual 1/1/2017 Therapy95851 Range of motion measurements 1/1/2017 Therapy95852 Range of motion measurements 1/1/2017 Therapy96000 Motion analysis, video/3d 1/1/2017 Therapy96001 Motion test w/ft press meas 1/1/2017 Therapy96002 Dynamic surface emg 1/1/2017 Therapy96003 Dynamic fine wire emg 1/1/2017 Therapy96105 Assessment of aphasia 1/1/2017 Therapy96125 Standardized Cognitive Performance Testing Per Hour 1/1/2017 Therapy97012 Mechanical traction therapy 1/1/2017 Therapy97016 Vasopneumatic device therapy 1/1/2017 Therapy97018 Paraffin bath therapy 1/1/2017 Therapy97022 Whirlpool therapy 1/1/2017 Therapy97024 Diathermy treatment 1/1/2017 Therapy97026 Infrared therapy 1/1/2017 Therapy97028 Ultraviolet therapy 1/1/2017 Therapy97032 Electrical stimulation 1/1/2017 Therapy97033 Electric current therapy 1/1/2017 Therapy97034 Contrast bath therapy 1/1/2017 Therapy97035 Ultrasound therapy 1/1/2017 Therapy97036 Hydrotherapy 1/1/2017 Therapy97039 Physical therapy treatment 1/1/2017 Therapy97110 Therapeutic exercises 1/1/2017 Therapy97112 Neuromuscular reeducation 1/1/2017 Therapy97113 Aquatic therapy/exercises 1/1/2017 Therapy97116 Gait training therapy 1/1/2017 Therapy97124 Massage therapy 1/1/2017 Therapy97139 Physical medicine procedure 1/1/2017 Therapy97140 Manual therapy 1/1/2017 Therapy97150 Group therapeutic procedures 1/1/2017 Therapy97161 PT Eval Low Complex 20 Min 1/1/2017 Therapy97162 PT Eval Mod Complex 30 Min 1/1/2017 Therapy97163 PT Eval High Complex 45 Min 1/1/2017 Therapy97164 PT Re-eval Est Plan Care 1/1/2017 Therapy97165 OT Eval Low Complex 20 Min 1/1/2017 Therapy97166 OT Eval Mod Complex 30 Min 1/1/2017 Therapy97167 OT Eval High Complex 45 Min 1/1/2017 Therapy97168 OT Re-eval Est Plan Care 1/1/2017 Therapy97530 Therapeutic activities 1/1/2017 Therapy97532 Cognitive skills development 1/1/2017 Therapy97533 Sensory integration 1/1/2017 Therapy97535 Self care mngment training 1/1/2017 Therapy97537 Community/work reintegration 1/1/2017 Therapy97542 Wheelchair mngment training 1/1/2017 Therapy97545 Work hardening 1/1/2017 Therapy97546 Work hardening add-on 1/1/2017 Therapy

97597debridement;surface area less than or equal to 20 square centimeters 1/1/2017 Therapy

97598debridement; total wound(s) surface greater than 20 square centimeters 1/1/2017 Therapy

97602 Wound care non-selective 1/1/2017 Therapy

97605

Negative pressure wound therapy (eg vacuum assisted drainage collection); total wound(s) surface area less than or equal to 50 square centimeters 1/1/2017 Therapy



97606

Negative pressure wound therapy (eg vacuum assisted drainage collection); total wound(s) surface area greater than 50 square centimeters 1/1/2017 Therapy

97607

Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters 1/1/2017 Therapy

97608

Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters 1/1/2017 Therapy

97750 Physical performance test 1/1/2017 Therapy

97755

Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report, each 15 minutes 1/1/2017 Therapy

97760

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes 1/1/2017 Therapy

97761Prosthetic training, upper and/or lower extremity(s), each 15 minutes 1/1/2017 Therapy

97762Checkout for orthotic/prosthetic use, established patient, each 15 minutes 1/1/2017 Therapy

97799 Physical medicine procedure 1/1/2017 Therapy


C:\Documents and Settings\nkhorozova\Desktop\MEDICARE SECONDARY PAYER QUESTIONNAIRE.doc

MEDICARE SECONDARY PAYER QUESTIONNAIRE What is the Medicare Secondary Payer questionnaire?

MEDICARE SECONDARY PAYER

A statutory requirement that private insurers providing general health insurance coverage to Medicare beneficiaries pay beneficiary claims as primary payers.

Use: Completion required for any situation where another payer or insurer pays your medical bills before Medicare.

We ask that you complete this form with either a “Y” for yes or “N” for No, dates and address required where indicated. Part I Government Program Coverage: 1. Is the patient receiving Black Lung Benefits? __________ Date benefits began: ______/______/_______ 2. Are services covered by a government program (research)? _______ 3. Has Dept of Veteran Affairs agreed to pay for care? ________ 4. Was illness due to work related accident/condition? ________ If yes, name and address of workers compensation plan: ________________________________________________ ________________________________________________ ________________________________________________ (Please note: If you answered “yes” to any questions, then that plan is primary to Medicare. If you answered “no” to all, then go to the next section). Part II Accident Related Injuries: 1. Was illness/injury due to non-work related accident? _______ If “No”, then go to the next section If “yes, date:_____/_____/_____ 2. Was accident caused by automobile______, non-automobile _____ or another party? _______ If yes, provide name, address, phone, claim # of no-fault or liability insurer: ___________________________________________________ ___________________________________________________ ___________________________________________________ Part III Reasons for Medicare Benefits: 1. Is beneficiary entitled to Medicare benefits based on Age:________ Disability: _________; if yes, go to Part V End Stage Renal Disease: _______, if yes, go to Part VI 2. Is beneficiary part of a Medicare HMO? _________ If yes, then the HMO replaces Medicare. Turn Over to Complete

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C:\Documents and Settings\nkhorozova\Desktop\MEDICARE SECONDARY PAYER QUESTIONNAIRE.doc

Part IV Employment Status: 1. Does patient have current employment status? _____ if no, what was the Date of retirement?_____/_____/______ (Office use only: If yes, provide the named and address of employer on registration screens. If no, record the date of retirement on the occurrence code). 2. Does patient’s spouse have current employment status? ______ if no, what was the spouse’s Date of retirement ?_____/_____/______ (Office use only: If yes, provide the named and address of spouse’s employer on registration screens. If no, record the spouse’s date of retirement on the occurrence code). If no to both questions, then Medicare is primary. If health insurance exists through employment

and there are 20 or more employees, health insurance is primary. If unable to obtain retirement date, note why? ______________________________________________________________ Part V Disability: Is patient RETIRED disability? _______ If yes, date of disability retirement ______/______/______ (Medicare is primary unless spouse employed with benefits) If disability, does patient or spouse have current employment status? _______ (Office use only: If yes, provide the named and address of employer on registration screens. If no to employment questions, Medicare is primary. If health insurance exists, plan is primary). Part VI End Stage Renal Disease: Does patient have current insurance coverage? _______ (Office use only: if yes, record information on insurance screens, that plan becomes primary). Has patient received a kidney transplant? _______ If yes, date of transplant: _____/_____/______ Has patient received dialysis? _____ If yes, date dialysis began: _____/_____/______ If self dialysis, date of training: _____/_____/______ Is patient within the 30 month coordination period? _______ If yes, insurance is primary until 30 months is up. Was patient’s initial entitlement to Medicare based on ago or disability? ______ (Office use only If yes, Medicare primary. In no, insurance coverage primary until 30 months is up).

23