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Home Health Coding
Presented by
LeeAnn M. Logan
Co-founder of Epiphany Medical Services LLC.
Agenda
• Background
• What is Home Health?
• Home health coding
• Medicare Fraud
• Frequently used forms
Objectives
• Increased knowledge
• Better comprehension of Medicare forms
• Identify possible red flags in Medicare
What is Home Health?
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Nursing
Physical Therapy
Occupational Therapy
Medical Social Worker
Dietitian
•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.
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).
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
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.
Types of Bills
• RAP
•Final Claim
•LUPA
•PEP
RAPs
• Request for Anticipated Payment
• 60% of complete payment
• Type of bill 322 UB-92
Final Claims
• At the end of certification
• Final 40% of complete payment
• Type of bill 329 UB-92
LUPA
• Fewer than 5 visits
• Approximately $120.00 per visit
• Type of bill 329 UB-92
PEP
• Partial Episode Payment
• Patient goes to another agency within cert. period
• Type of bill 329 UB-92
Nursing
• HCPCS -G0154
•Revenue Code – 055X
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.
Physical Therapy
• HCPCS G01541
•Revenue Code – 042X
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
Occupational Therapy
• HCPCS - G0151
•Revenue Code – 043X
Medical Social Worker
• HCPCS - G0155
•Revenue Code – 056X
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
Speech Therapy- Language
Pathology
• HCPCS - G015
•Revenue Code – 044X
Speech Therapy- Language
Pathology
G0161 – Services performed by a qualified speechlanguage pathologist, in the home health setting, in the
establishment or delivery of a safe and effective speechlanguage pathology maintenance program, each 15
minutes.
Nutritional Therapy
• HCPCS -G0155
•Revenue Code – 056X
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:
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
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 100-04;
Medicare Claims Processing Manual; Chapter 11 - Processing
Hospice Claims; Section 30.3. Scroll down to
HCPCS/Accommodation Rates/HIPPS Rate Codes.
Medicare Fraud
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.
Common Types of Fraud
•Stark Law
•Cycling patients
• Billing for patients that are not eligible for home
health
States That Are High-Risk for
Fraud
• Florida,
•Texas
• Louisiana
• California
• Illinois
•New York
•Michigan
4646546
•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
Medicare’s Fight Against Fraud
• Additional Data Requested (36 months)
•Increased surveys
•Surveys to survey the last survey
•Radio announcements in different languages
ADRs
• Plan of Care and Certification
•Face to Face Encounter
•Documentation of Services Rendered
•Itemized supply list if billed
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.
Frequently Used
Forms
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.
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. ***
• 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.
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.
Questions & Answers