CMS Issues a New Condition Code for Home Health Claims
February 12, 2016 09:29 AM
The Centers for Medicare & Medicaid Services (CMS) has issued Change Request(CR) 9497 which adds a new condition code for home health (HH) claims, addresses unintended consequences of the implementation of new Healthcare Common Procedure Coding System (HCPCS) codes for skilled nursing visits, and contains a number of routine maintenance revisions to home health billing instructions manual.
CMS will be implementing a new condition code 54 “No skilled HH visits in billing period” effective on July 1, 2016, that permits HH claims for subsequent episodes to process even if they do not contain any skilled services. Currently, any HH claim submitted without a skilled visit is automatically returned to the provider. Although this is always appropriate for claims for episodes that are the first episode in a sequence of episodes or are the only episode of care, claims for subsequent episode are also being returned if they do not include a skilled visit.
There may be circumstances which prevent the home health agency (HHA) from delivering the skilled services planned for a subsequent episode, such as an unexpected inpatient admission.
Determining whether payment is allowable requires the agency to submit supporting documentation to the Medicare Administrative Contractor (MAC) for review, which is a burdensome process for both the agency and the MAC.
Condition code 54 will streamline claims processing for both the payer and provider. Claims without skilled visits that are submitted without the new condition code will be returned to the provider. This will allow the HHA to either:
Add any accidentally omitted skilled services to the claim;
Submit the claim as non-covered, if appropriate; or
Append the new condition code.
These actions will prevent unnecessary reviews and denials for the HHA and allow Medicare to better target medical review resources.
The CR also corrects an unintended consequence of terminating HCPCS code G0154 and replacing it with two new codes, G0299 and G0300. During the implementation of this change which went into effect Jan 1, 2016, CMS discovered several other processes affected by this coding change:
G0299 and G0300 were previously used to describe defibrillator services. An edit in Medicare systems requires certain diagnosis codes appropriate to support the need for a defibrillator. This edit would set inappropriately on all home health and hospice claims with dates of service on or after January 1, 2016.
Another edit in Medicare systems currently requires that revenue code 055x is always reported with HCPCS G0154 on hospice claims. This edit would set inappropriately on all hospice claims with dates of service on or after January 1, 2016.
CMS had instructed the contractors to temporarily deactivate these two edits to prevent Medicare from returning claims in error.
In addition, Medicare systems also use HCPCS code G0154 in the criteria for identifying skilled nursing as the earliest visit when calculating low utilization payment adjustments (LUPA) add-on amounts. Since HHAs can no longer report G0154, skilled nursing visits reported with G0299 or G0300 cannot be used in the calculation. This has resulted in some claims not receiving LUPA add-on amounts or receiving a payment based on the wrong service discipline. The error has been corrected and contractors have been instructed to adjust home health claims.
Lastly, the CR contains a number of routine maintenance revisions to home health billing instructions. The revisions include reformatting the presentation of remittance advice codes and ensuring code pairs are compliant with industry standards. They also include an update to the Pricer logic section to reflect case-mix scoring changes for calendar year 2016 and to correctly reflect LUPA add-on calculations which were effective January 1, 2014.