01-301 Home Health Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Home Health services billed on dates of service from January 1, 2020 through December 31, 2020. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers may wish to consult when submitting claims.

Background

The Bipartisan Budget Act of 2018 (BBA of 2018) included several requirements for home health payment reform, effective January 1, 2020. The mandated home health payment reform resulted in the Patient-Driven Groupings Model, or PDGM. The PDGM is designed to emphasize clinical characteristics and other patient information to better align Medicare payments with patients’ care needs.

Under the PDGM, the national, standardized 30-day payment amount is adjusted to account for patient characteristics and other information; including the principal diagnosis, secondary diagnoses, and functional impairment level. The need for therapy services under PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits. Under the new PDGM, a possible drop in therapy utilization and/ or the manipulation of other combinations of care to maximize payments could create potential vulnerabilities.

Reason for Review

The SMRC is tasked with performing claim review on a sample of Home Health claims from January 1, 2020 through December 31, 2020. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance. Applicable waivers and flexibilities established during the PHE will be utilized during claim review activities.

Claim Sample Detail

Type of Bill (TOB)
  • 032X Home Health Services Under A Plan of Treatment
  • 034X Home Health Services Not Under A Plan of Treatment

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Acute/post-acute care document to support home health eligibility
  2. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  3. History and Physical reports (include medical history and current list of medications)
  4. Documentation of all face-to-face (FTF) encounters and/or Signed Attestations from start of care
  5. Copy of physician’s or authorized non-physician provider’s order or referral for home health services if separate from plan of care
  6. Signed Consent Form
  7. Home Health start of care assessment
  8. All Physician or authorized non-physician provider’s orders, including medications and any DME prescribed for the beneficiary
  9. Initial certification and all re-certifications from start of care
  10. Homebound/not homebound status
  11. OASIS documentation (certifications, recertifications, follow-ups and significant change).
  12. Copy of the current medication list
  13. Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care
  14. Home Health Plan of Care
  15. PT/OT/SLP – Initial evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
  16. Home Health skilled nursing, home health aide, or rehabilitation therapy notes including initial evaluations, re-evaluations, progress notes, and actual therapy minute grids
  17. Any other documentation supporting the beneficiary’s need for the home health services being provided
  18. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  19. If medical record documentation is submitted via esMD:Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  20. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  21. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  22. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1814 (a)(2)(C), (a)(7). Conditions of and Limitations on Payment for Services.
  • SSA, Title XVIII, Section 1815(a). Providers must furnish information.
  • SSA, Title XVIII, Section 1833(e). Payment of Benefits.
  • SSA, Title XVIII, Section 1835(a)(2)(A). Procedure for Payment of Claims of Providers of Services.
  • SSA, Title XVIII, Section 1861(m). Definitions of Services, Institutions, etc.
  • SSA, Title XVIII, Section 1862. Exclusion from Coverage and Medicare as a Secondary Payer.
  • SSA, Title XVIII, Section 1879(a)(1). Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed.
  • SSA, Title XVIII, Section 1895. Prospective Payment for Home Health Services.
  • Balance Budget Act (BBA) 2018 (Pub. L. 115-123) Division E, Title II, Section 50202 Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy
  • Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-136). Supporting America’s Health Care System in the Fight Against the Coronavirus.
  • Code of Federal Regulations (CFR) Title 42, Section 409. Hospital Insurance Benefits.
  • CFR, Title 42, Section 424. Conditions for Medicare Payment.
  • CFR, Title 42, Section 424.516(f). Additional Provider and Supplier Requirements for Enrolling and Maintaining Active Enrollment Status in the Medicare Program.
  • CFR, Title 42, Section 424.535. Revocation of Enrollment in the Medicare Program.
  • CFR, Title 42, Section 484. Home Health Services, Subpart A General Provisions, Subpart B Patient Care, Subpart C Organizational Environment and Subpart E Prospective Payment System for Home Health Agencies.
  • Medicare General Information, Eligibility and Entitlement Manual (MGIEE), Publication 100-01, Chapter 1, Section 10.2. Home Health Services.
  • MGIEE, Publication 100-01, Chapter 4, Section 30. Certification and Recertification by Physicians and Allowed Practitioners for Home health Services.
  • MGIEE, Publication 100-01, Chapter 4, Section 80. Summary Table for Certifications/Recertifications.
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 7. Home Health Services.
  • MBPM, Publication 100-02, Chapter 16, Section 20. Services Not Reasonable and Necessary.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 10. Home Health Agency Billing.
  • MCPM, Publication 100-04,Chapter 23, Section 10. Reporting ICD Diagnosis and Procedure Codes.
  • MCPM, Publication 100-04, Chapter 30, Section 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN).
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3. Verifying Potential Errors and Taking Corrective Actions.
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements.
  • MPIM, Publication 100-08, Chapter 6. Medicare Contractor Medical Review Guidelines for Specific Services.
  • Outcome and Assessment Information Set (OASIS)-D1 Guidance Manual. Effective January 1, 2020-current.
  • Local Coverage Determination (LCD) L33942. Physical Therapy – Home Health. Effective October 1, 2015.
  • LCD L34560. Home Health Occupational Therapy. Effective October 1, 2015.
  • LCD L34561. Home Health – Psychiatric Care. Effective October 1, 2015.
  • LCD L34562. Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective October 1, 2015.
  • LCD L34563. Home Health Speech-Language Pathology. Effective October 1, 2015.
  • LCD L34564. Home Health Physical Therapy. Effective October 1, 2015.
  • LCD L34565. Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective October 1, 2015.
  • LCD L35132. Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus. Effective October 1, 2015.
  • Local Coverage Article (LCA) A52845. Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances – Medical Policy Article. Effective October 1, 2015.
  • LCA A53050. Case Scenario 1 Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015.
  • LCA A53051. Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015.
  • LCA A53052. Billing and Coding: Home Health Speech-Language Pathology. Effective October 1, 2015.
  • LCA A53055. Home-Based Fall Evaluations and Interventions. Effective October 1, 2015.
  • LCA A53057. Billing and Coding: Home Health Occupational Therapy. Effective October 1, 2015.
  • LCA A53058. Billing and Coding: Home Health Physical Therapy. Effective October 1, 2015.
  • LCA A56641. Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective July 4, 2019.
  • LCA A56648. Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective July 4, 2019.
  • LCA A56674. Billing and Coding: Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus. Effective July 4, 2019.
  • LCA A56756. Billing and Coding: Home Health – Psychiatric Care. Effective August 1, 2019.
  • LCA A57311. Billing and Coding: Physical Therapy – Home Health. Effective September 26, 2019.
  • The Centers for Medicare & Medicaid Services (CMS). Home Health Patient-Driven Groupings Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.
  • CMS. Medicare Learning Network ICN MLN20190214 February 2019. Overview of the Patient-Driven Groupings Model (PDGM). https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-02-12-PDGM-Presentation.pdf.
  • CMS. Covid-19 Emergency Declaration Blanket Waivers for Health Care Providers. Home Health Agencies: CMS Flexibilities to Fight COVID-19.
  • CMS. Additional Emergency and Disaster-Related Policies and Procedures That May be Implemented Only with a SS 1135 Waiver. Additional Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a § 1135 Waiver (cms.gov).

Last Updated Nov 4, 2021