2020 Home Health Data Map for Tennessee

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2020 annual report, here is the home health CERT information for Tennessee.

  • Total claims reviewed: 27
  • Total dollars reviewed: $83,440.30 
  • Total claims paid: 25
  • Total dollars paid: $81,008.34
  • Total claims denied: 2
  • Total dollars denied: $3,426.26
  • Claims with error code 25 — Not Medically Necessary: 1
  • Claims with error code 31 — Insufficient Documentation: 1

CERT Reviewer Error: 25 — Not Medically Necessary — Medical Necessity
There is no medical necessity for this home health episode: “beneficiary is stable; minimal risk of exacerbation of condition; no change in treatment; issues are chronic; HEP established some time ago. Home health services are not reasonable & necessary for this beneficiary open to home health for almost three years. Her primary diagnosis has been abnormal gait since the episode starting a year ago & she has been receiving both skilled nursing and physical therapy services since that time. Documented patient therapy goals are to increase functional strength, mobility and endurance. PT documents she lives alone, ambulates with a cane or a walker and is able to safely manage the equipment. She is able to tolerate 30 minutes of treatment. SN provides weekly visits for teaching on disease processes, long standing medications & energy conservation. She [beneficiary] complained of dizziness at times however this has been an ongoing problem and her physician is aware. Beneficiary has chronic, stable appearing conditions and there has been ample time to render teaching.”

Avoid Errors for Medically Unnecessary Service or Treatment
Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services. Use the most appropriate diagnosis codes to identify the beneficiary’s medical diagnosis/diagnoses. Submit documentation to support the need for skilled care. Some reasons for services may include, but are not limited to, the following:

  • New onset or acute exacerbation of diagnosis (include documentation to support signs and symptoms and the date of the new onset or acute exacerbation)
  • New and/or changed prescription medications. New medications: those the beneficiary has not taken recently, i.e., within the last 30 days. Changed medications: those which have a change in dosage, frequency, or route of administration within the last 60 days.
  • Hospitalizations (include date and reason)
  • Acute change in condition (be specific and include changes in treatment plan as a result of changes in medical condition, e.g., physician contact, medication changes)
  • Changes in caregiver status or an unstable caregiving situation (e.g., involvement of many services or community resources, unsafe or unclean environment which interferes with putting the plan into action)
  • Complicating factors (i.e., simple wound care on lower extremity for a beneficiary with diabetic peripheral angiopathy)
  • Inherent complexity of services; therefore, the services can be safely and effectively provided only by a skilled professional
  • Lack of knowledge or understanding of the beneficiary’s care, which requires initial skilled teaching and training of a beneficiary, the beneficiary’s family or caregiver on how to manage the beneficiary’s treatment regime
  • Reinforcement of previous teaching when there is a change in the beneficiary’s physical location (i.e., discharged from hospital to home)
  • Any type of re-teaching due to a significant change in a procedure, the beneficiary’s medical condition, when the beneficiary’s caregiver is not properly carrying out the task, or other reasons which may require skilled re-teaching and training activities
  • The need for a nurse to administer an injection of a self-injectable medication such as insulin or Calcimar. Clinical documentation needs to indicate: (a) the beneficiary’s inability to self-inject and the non-availability of a willing/able caregiver; (b) the appropriate diagnosis to warrant administration of the medication; (c) laboratory results (if required to meet Medicare criteria); and (d) dosage of the medication.
  • The need for foley/suprapubic catheter changes and/or assessment/instruction regarding complications
  • The need for gastrostomy tube changes and/or assessment/instruction regarding complications
  • The need for administration of IM/IV medications based on medical necessity, supporting diagnosis, and accepted standards of medical practice
  • Dressing changes for complicated wound care including documentation (at least weekly) of wound location, size, depth, drainage, and complaints of pain
  • The need for management and evaluation of a complex care plan. Answering “yes” to the following questions may be helpful in determining this need:
    • Is the patient at high risk for hospitalization or exacerbation of a health problem if the plan of care is not implemented properly (e.g., multiple medical problems or diagnosis, limitations in activities of daily living or mental status, cultural barriers, history of repeated hospitalizations)?
    • Does the patient have a complex, unskilled care plan (e.g., many medications, treatments, use of complex or multiple pieces of equipment, unusual variety of supplies)?
    • Is there an unstable caregiving situation (e.g., involvement of many services or community resources, unsafe or unclean environment that interferes with putting the plan into action)?
    • Does it require the skills of a registered nurse or a qualified therapist to ensure safe and appropriate implementation of the plan of care?

CERT Reviewer Error: 31 — Service Incorrectly Coded — Incorrect Coding
The billed HIPPS code is incorrectly coded. Documentation supports a change in HIPPS code for home health subsequent episode for billed DOS. Billed was 1BGKS which was adjusted per therapy threshold edit to 1BGMS. Provider had projected no rehab visits and had billed for seven (7) therapy visits. However, there are no orders to cover four (4) of these therapy visits.

Avoid Errors for Service Incorrectly Coded
To avoid down codes for this reason, the documentation should paint a consistent picture of the patient’s condition.

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