Home Health and Hospice Coalition Questions and Answers: June 6, 2022

Published 07/14/2022

Review Choice Demonstration (RCD) Meeting — 9 a.m. ET
Main Meeting — 10 a.m. ET
 

Attachments

RCD Pre-Meeting

1. Question: We have been seeing variations in what is and what is not allowed for face-to-face documentation in Review Choice Demonstration (RCD) Pre-Claim Review (PCR). Does Palmetto GBA expect the home health primary diagnosis to be the primary focus of the qualifying face-to-face encounter? Or do they just expect the home health primary diagnosis to be addressed in the encounter but not necessarily require it to be the focus?

Answer: The clinical encounter note must be related to the primary reason for home health. It doesn’t have to be the main focus, but it does need to be addressed (more than just being on a list of diagnoses). 

2. Question: Providers going on or coming off UPIC review do not always know whether or not they should submit a PCR, so they are submitting the claim without a Unique Tracking Number (UTN) and they receive an ADR.

Answer: The eServices portal is updated with UPIC information, and a letter is also generated with directions for the provider. If the provider comes off UPIC review during the cycle, they will start in their UPIC choice in the next cycle.

Resources:

3. Question: Is 10 days for a determination on the initial submission and 20 days for a resubmission still the standard?

Answer: Yes, that is still the standard. There were some JavaScript issues that caused a bit of a delay, all of that has been resolved.

Main Meeting 

1. Question: What home health parameters are being used to select agencies for Targeted Probe and Educate (TPE)? The edit listed by Palmetto GBA is very generic. Is there more that can be shared as to what edits are being applied? Also, we are seeing providers under TPE more frequently receiving 40 ADRs compared to when TPE was conducted pre-pandemic, which was more often only 20 claims. Is the “new norm” 40 claims?

Answer: Our home health edit is not targeting a specific diagnosis or HIPPS code, so we do not list that information. We have also completed a 40-claim ADR sample for TPE since 2017 (TPE launch). If a provider had a smaller sample collected, it would have been based on a particular reason. A broad example of this would have been a provider transitioning to RCD — we would have initially targeted 40 claims but may have stopped collecting claims so that we could complete edit effectiveness prior to RCD start in a particular state.

2. Question: Electronic Data Interchange (EDI) enrollment — The EDI enrollment process is very cumbersome because it’s in the process that it’s often identified that a provider has a different name or address on file with Palmetto GBA’s EDI department vs. the information the provider believes to be correct. It is a guessing game to identify the exact provider name and/or address on file with Palmetto GBA EDI. Is there a way to make this process more efficient? Why is a provider’s exact name or address considered to be so sensitive that it isn’t shared?

Answer: The provider address is initially pulled from the Provider Enrollment file. Two addresses are used — a physical address and a mailing address. Either address can be used to enroll in EDI. Once a provider enrolls in EDI, they can request for the EDI address to be changed, typically to their billing or IT department, and this is managed by the EDI contact with the provider. If there is a change with the provider and the new EDI contact does not have the information, they may contact the EDI Helpdesk and we will work with them to make updates. If a provider makes a name or address update with Provider Enrollment, they should also make that update with EDI if it is applicable

3. Question: Regarding the new update to Chapter 7 of the Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual, MLN Matters article number: MM12615 Revised. A couple of coalition members have asked for discussion on this. What would be required for documentation in the plan of care regarding this new update?

Answer: CMS revised this MLM on June 7. CMS removed information on the definition of an allowed practitioner from the CR and article. Looking for the collaboration statement is not of the medical review process.

Claims Processing Issues Log

  1. Home Health Core-Based Statistical Area (CBSA) Code 50007 Payment Issue: TDL 210530 CBSA code 50007 has incorrect effective date (1/1/2022) that causes claims to pay incorrectly. HHH MACs will suspend claims with value code 61 amounts of 50007 and change it to 28020 (same assigned wage index value of 0.9434 as 50007) so the claim will calculate an accurate payment.
     
  2. Home Health: 32G Adjustments Are Recoding the Health Insurance Prospective Payment System (HIPPS) Codes from Late to Earlier Periods on Home Health Claims When There Is Separation Between the Periods of Less than 60 Days. This was causing overpayments. The fix to this issue, FS2377, promoted to PRODUCTION effective 06/02/2022. We initiated three test claims to ensure the fix worked and as of 6/20, one claim has processed and correctly processed as late. 
     
  3. Home Health: Incorrect Partial Period Payment Adjustments on Claims: Some home claims are receiving incorrect partial period payment adjustments when the situations are not present. MEDA System Request submitted May 16.
     
  4. Some Home Health RCD Postpayment Adjustments, 32I Type of Bill, Are Incorrectly Changing Patient Status to 01: Discharge to Home. Not all postpayment providers were impacted by this concern. Palmetto GBA has resolved this issue for postpayment adjustments processed by Palmetto GBA from 4/19/22 forward. You may see some activity on your claims as we adjust them to correct patient status. Please do not submit a new NOA or take any claim action to work around this issue. Palmetto GBA will provide additional updates when available.

In research: Home Health Notice of Admission (NOA) Reason Code U537F is still affecting some NOAs. Palmetto GBA, CGS and NGS have all escalated to CWF.

Reference — VBID article: Value-Based Insurance Design Model Hospice Benefit Component Overview. 


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