1. Co-founder of Epiphany Medical Services LLC.
Home Health Coding
Presented by
LeeAnn M. Logan
Co-founder of Epiphany Medical Services LLC.

2. Agenda Background What is Home Health? Home health coding
Medicare Fraud
Frequently used forms

3. Objectives Increased knowledge Better comprehension of Medicare forms
Identify possible red flags in Medicare

4. What is Home Health? Nursing Physical Therapy Occupational Therapy
Medical Social Worker
Dietitian

5. Home health services are covered under Parts A and B of Medicare.
Part A covers home health services for individuals enrolled in Part A only, and Part B covers home health services for individuals enrolled in Part B only.
Although there are copayments for most other Medicare services, there are generally no beneficiary copayments for home health services.

6. Requirements For Home Health
be confined to the home (i.e., homebound);
• be in need of intermittent skilled nursing care or physical, speech, or continuing occupational therapy;
• be under the care of a physician; and
• be under a plan of care established and periodically reviewed by a physician (every 30 days).

7. Home Health PPS
Medicare makes payment under the Home Health Prospective Payment System (HH PPS) generally on the basis of a national standardized 60-day episode payment rate that includes the six home health disciplines (skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social

8. Home Health PPS
G0151 – Services of physical therapist in home health setting, each 15 minutes;
G0152 – Services of an occupational therapist in home health setting, each 15 minutes;
G0153 – Services of a speech language pathologist in home health setting, each 15 minutes; and
G0154 – Skilled services of a nurse in the home health setting, each 15 minutes to report the provision of skilled nursing services in the home.

11. Types of Bills
RAP
Final Claim
LUPA
PEP

12. RAPs Request for Anticipated Payment 60% of complete payment
Type of bill 322 UB-92

13. Final Claims At the end of certification Final 40% of complete payment
Type of bill 329 UB-92

14. LUPA Fewer than 5 visits Approximately $120.00 per visit
Type of bill 329 UB-92

15. PEP Partial Episode Payment
Patient goes to another agency within cert. period
Type of bill 329 UB-92

16. Nursing
HCPCS -G0154
Revenue Code – 055X

17. Nursing
G0162 – Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting).
G0163 – Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting).
G0164 – Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.

18. Physical Therapy
HCPCS G01541
Revenue Code – 042X

19. Physical Therapy
G0159 – Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes;
G0157 – Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes; and

20. Occupational Therapy
HCPCS - G0151
Revenue Code – 043X

21. Medical Social Worker
HCPCS - G0155
Revenue Code – 056X

22. Medical Social Worker
G0158 – Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.
G0160 – Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes; and

23. Speech Therapy- Language Pathology
HCPCS - G015
Revenue Code – 044X

24. Speech Therapy- Language Pathology
G0161 – Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes.

25. Nutritional Therapy
HCPCS -G0155
Revenue Code – 056X

26. New “Q Codes”
On April 2, 2013 The Center for Medicare and Medicaid Services (CMS) issued Change Request which adds new data reporting requirement for Home Health Agencies must report new codes indicating the location of where services were provided.
Effective for home health agencies (HHA), beginning on or after July 1, 2013, HHAs are to use the HCPCS codes Q5001, Q5002, or Q5009, which were revised effective April 1, 2013 as follows:

27. HCPCS Code
Definition
Q5001
Hospice or home health care provided in patient’s home/residence
Q5002
Hospice or home health care provided in assisted living facility
Q5009
Hospice or home health care provided in place not otherwise specified

28. Is there a list of 'Q' codes that identifies the place of service for hospice line item billing?
Answer:
A list of Q Codes, along with the definition of each code can be found in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (CMS),Publication ; Medicare Claims Processing Manual; Chapter 11 - Processing Hospice Claims; Section Scroll down to HCPCS/Accommodation Rates/HIPPS Rate Codes.

29. Medicare Fraud

30. Medicare Fraud – Home Health
HHAs are considered to be particularly vulnerable to fraud, waste, and abuse.
One in four home health agencies had questionable billing
In 2010, Medicare paid $19.5 billion to 11,203 home health agencies (HHA) for home health services provided to 3.4 million beneficiaries.

31. Common Types of Fraud Stark Law Cycling patients
Billing for patients that are not eligible for home health

32. States That Are High-Risk for Fraud
Florida,
Texas
Louisiana
California
Illinois
New York
Michigan

34. 22 percent of claims in error because services were unnecessary or claims were coded inaccurately, resulting in $432 million in improper payments. That review assessed HHAs’ medical records for beneficiaries but did not determine whether those records accurately reflected beneficiaries’ medical conditions

35. Medicare’s Fight Against Fraud
Additional Data Requested (36 months)
Increased surveys
Surveys to survey the last survey
Radio announcements in different languages

36. ADRs Plan of Care and Certification Face to Face Encounter
Documentation of Services Rendered
Itemized supply list if billed

41. ABN
ABN (Advanced Beneficiary Notice of Noncoverage) must be signed when:
You believe Medicare may not pay for an item
or service,
Medicare usually covers the item or service, and
Medicare may not consider it medically
reasonable and necessary for this patient in this
particular instance.
If you do not issue a valid ABN to the beneficiary when Medicare requires, you cannot bill the beneficiary for the service and you may be financially liable.

42. Frequently Used Forms

44. Medicare Secondary Payer Form (MSP)
The MSP provisions protect the Medicare Trust Fund by ensuring that Medicare does not pay for services and items that certain other health insurance or coverage is primarily responsible for paying. The MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage.

46. Medicare would be considered a secondary payer
If a beneficiary is covered under any of the following insurance plans, :
Group Health Insurance (employer has 20 or more employees) - This insurance is provided by an employer to a policyholder who is actively working. Laws affecting this type of insurance include TEFRA, DEFRA, OBRA, COBRA and ESRD.
Automobile or Liability Insurance - This insurance is applicable in cases where an accident has occurred, whether it is a car accident, a fall or medical malpractice.
Worker's Compensation - Worker's Compensation covers injuries on the job. The employer's Workmen's Compensation carrier is responsible for the claim first. ***

47. Federal Black Lung Program - This program covers Black Lung claims
Federal Black Lung Program - This program covers Black Lung claims. Medicare cannot pay claims submitted with a Black Lung Diagnosis code unless a copy of the Explanation of Benefits from the Black Lung Program is submitted showing that no payment was made.
Veterans Administration - Services rendered at a Veterans Administration facility are not covered under Medicare. If services are rendered at a non-VA facility, Medicare may consider payment for the covered part of the services that the VA didn't pay.
End Stage Renal Disease (ESRD) - For beneficiaries covered through an employer sponsored health plan through their own or a family member's current or former employment, Medicare is secondary for 30 months for those beneficiaries entitled to Medicare based solely on ESRD from March 1, 1996.

48. Medicare Supplement/Medi-Gap
The term "Medicare Secondary Payer" is sometimes confused with "Medicare Supplement." You may hear Medicare Supplement referred to as a "Medigap."
Medigap is a private health insurance policy designed to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer.

49. Questions & Answers