2020 Home Health Data Map for Texas

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 Texas.

  • Total claims reviewed: 334
  • Total dollars reviewed: $657,023.52 
  • Total claims paid: 249
  • Total dollars paid: $482,402.02
  • Total claims denied: 85
  • Total dollars denied: $175,165.88
  • Claims with error code 21 — Not Medically Necessary: 42
  • Claims with error code 25 — Not Medically Necessary: 34
  • Claims with error code 31 — Insufficient Documentation: 4
  • Claims with error code 91 — Insufficient Documentation: 1
  • Claims with error code 99 — Insufficient Documentation: 3
  • Claims with error code 16 — Insufficient Documentation: 1

 CERT Reviewer Error: 21 — Insufficient Documentation

Error Subcategory: 00166 — Home Health — Face-to-Face Documentation and/or Attestation Is Missing or Inadequate
Sufficient face-to-face documentation which meets Medicare guidelines for billed subsequent home health episode. "The documentation must include ...a brief narrative composed by the certifying physician who describes how the patient's clinical condition as seen during that encounter supports the patient's homebound status and need for skilled services.”

Avoid Errors for Insufficient Documentation for Home Health — Plan of Care
The certifying physician must document that he/she or an allowed nonphysician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter. The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services. The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification.

CERT Reviewer Error: 21 — Insufficient Documentation

Error Subcategory: 00203 — Home Health — Medical Records are Missing or Inadequate
The submitted documentation is insufficient to meet Medicare requirements. Missing HHA documentation incorporated into the certifying physician’s medical records.

Avoid Errors for Insufficient Documentation for Medical Records Missing or Inadequate
It is the billing provider’s responsibility to obtain and necessary information required for the record review, regardless of the location of the documentation.

  • Make sure that both sides of double-sided documents are submitted
  • Ensure the documentation has legible signatures and dates
  • Ensure the correct CPT/HCPCS code is used, if applicable
  • Ensure physician orders and documents the interventions were performed
  • Include test results and lab results, if applicable
  • Make sure the copy sent to the CERT contractor is legible
  • Number the pages before making a copy, so it will be easy to see if one of the pages are missing
  • Use a checklist to ensure all of the essential pieces are included in the record

CERT Reviewer Error: 21 — Insufficient Documentation

Error Subcategory: TD — Home Health — Face-to-Face Evaluation Is Inadequate
There is insufficient documentation to support the billed home health episode for DOS XXXX. This is a subsequent episode with a start of care date of XXXX. Documentation to support homebound status and/or need for skilled services was missing in the physician’s medical record, acute/post-acute facility record and/or HHA documentation incorporated into the physician’s medical record. Per Medicare guidelines, “The certifying physician and/or the acute/post-acute care facility medical record for the patient must contain information that justifies the referral for Medicare home health services, including the need for the skilled services initially ordered and the patient’s homebound status.” In addition, the certifying physician’s and/or acute/post-acute care facility’s medical record for the patient must demonstrate that the visit occurred within the required timeframe, was related to the primary reason the patient requires home health services, and was performed by either: (1) The certifying physician; (2) a physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health; or (3) an allowed NPP as set out in §424.22(a)(1)(v)(A).” If the initial certification, which includes the face-to-face encounter documentation, is not valid, then the subsequent recertification episode would also be denied. If this entire claim was not being denied for face-to-face then it would be denied for lack of medical necessity. The beneficiary was open to home health since XXXX with skilled nursing seeing every week for observation/assessment and teaching. Beneficiary was hospitalized in the prior episode secondary to shingles and cellulitis which was documented as improved and scabbed with no drainage prior to review episode. No changes in treatment or medications requiring skilled interventions and there has been ample time to render teaching.

Home Health is not Reasonable and Necessary — Avoid Errors for Face-to-Face Evaluation Is Inadequate
The certifying physician must document that he/she or an allowed nonphysician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter. The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services. The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification.

CERT Reviewer Error: 21 — Insufficient Documentation — Policy Requirement Error

Error Subcategory: T5 — Home Health — Documentation Supporting the HIPPS Code Is Missing or Inadequate
Complete OASIS assessment to support billed HIPPS code was not received; only received the even pages.

Avoid Errors for Policy Requirement Error for Home Health — OASIS Not in Repository/Medical Record
Under the Prospective Payment System (PPS), an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

CERT Reviewer Error: 21 — Insufficient Documentation

Error Subcategory: T7 — Home Health Orders
The physician signed and dated order to support RN visit billed was missing.

Avoid Errors for Insufficient Documentation for Home Health — Plan of Care
Ensure that the appropriate plan of care (POC) is included and that it is legibly signed and dated by the physician prior to billing. A plan of care refers to the medical treatment plan established by the treating physician with the assistance of the home health skilled professional. The POC contains all pertinent diagnoses, the patient’s mental status, the types of services, supplies, and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and any additional items the HHA or physician chooses to include. The physician must certify that the home health services were required because the individual was confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy; a plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and the services were furnished while the individual was under the care of a physician.

CERT Reviewer Error: 21 — Insufficient Documentation

Error Subcategory: T8 — Home Health — MD Certification/Recertification Is Missing or Inadequate
The services billed were not covered because the home health agency HHA did not have the plan of care established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.

Avoid Errors for MD Certification/Recertification Is Missing or Inadequate

  • Ensure that the appropriate plan of POC is included and that it is legibly signed and dated by the physician prior to billing
  • A plan of care refers to the medical treatment plan established by the treating physician with the assistance of the home health skilled professional. The POC contains all pertinent diagnoses, the patient’s mental status, the types of services, supplies, and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and any additional items the HHA or physician chooses to include.
  • Ensure that the signed certification or recertification is submitted when responding to an ADR
  • The physician must certify that:
    • The home health services were required because the individual was confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy;
    • A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
    • The services were furnished while the individual was under the care of a physician
  • Since the certification is closely associated with the POC, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible. There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary.
  • The physician must recertify at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the POC is reviewed and must be signed by the same physician who signs the plan of care. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary.

CERT Reviewer Error: 21 — Insufficient Documentation

Error Subcategory: T9 — Home Health — Progress Notes Supporting Billed DOS by Specific Specialist Is Missing or Inadequate
There is insufficient documentation to support the billed home health SOC episode for DOS XXXX. “Missing the certifying physician’s attestation of a F2F encounter performed by an allowable provider within Medicare time frame guidelines and was related to the primary reason the patient requires home health services. In addition, the F2F documentation/clinical note does not match the primary reason for initiation of home health services. The encounter note signed by NP dated 07/29/2016 listed the reason for the visit as mixed hyperlipidemia, hypertension, DM II, and fatigue; however the initial HH certification/POC lists the primary diagnosis as aortic valve stenosis and the secondary diagnosis as CKD. Per CMS, the certifying physician must attest that the Face-to-Face encounter occurred no more than 90 days prior to the HH SOC or within 30 days of the SOC date, the F2F was related to the primary reason the patient requires HH services, and the F2F was performed by a physician or allowed nonphysician practitioner. If this entire claim was not being denied due to insufficient F2F documentation, it would be denied due to missing/incomplete visit notes. No response to tech stop request. Home health services were reasonable and necessary for beneficiary needing SN and PT services, however, the face-to-face requirements were not met.”

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.

CERT Reviewer Error 91 — Billing Requirement Error — Other
Billing requirement necessary for Medicare payment was not met. All or part of the claim was billed in error by the provider. Documentation does not support the claim as billed.

Tips to Prevent this Error

  • Use the most appropriate ICD/CPT/HCPCS codes
  • Verify the dates of service are correct
  • Verify the services are billed for the correct beneficiary
  • Ensure documentation to support medical necessity is included in documentation submitted for review

CERT Reviewer Error 99 — No Response — No Documentation
No response to the medical record documentation request was received.

Tips to Prevent this Error

  • Aim to submit medical records within 30 days of the date on the bar coded cover scan sheet from the CERT contractor. You have 45 days from the first letter to submit documentation. However, CERT will continue to send an additional three letters requesting records up until the 60th day. If no records are received by the 75th day, CERT will direct Palmetto GBA to recoup the payment for that claim.
  • Gather all information needed for the claim and submit it all at one time
  • Be sure to attach the bar coded cover sheet to the front of each individual medical record
  • Once you have collected all the documentation to support services billed such as orders, visit notes (make sure signatures are legible and if not, you will need a signature log) and anything else to support medical necessity of services on the claim, place the Bar coded Cover Sheet on top of the records and send to the CERT contractor. [Record should not be sent to Palmetto GBA].

The following options are available, but you are encouraged to fax or mail documentation in:

  • Fax to 804–261–8100
  • Mail to:
    CERT Documentation Center
    Attn: CID _________
    1510 East Parham Road
    Henrico, VA 23228

If you are submitting by CD (it must be encrypted) or esMD (electronic submission) to the CERT contractor, there are certain requirements that need to be followed.

Please contact CERT directly at 888–779–7477 for assistance or you can go to the CERT website at https://certprovider.admedcorp.com/. This website has the specific information on how to submit either by encrypted CD or esMD. 

CERT Reviewer Error 16 — No Documentation
The medical record documentation was not received.

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