CMS has issued new guidance to Medicare administrative contractors (MACs) on how to select home health claims for further review after they pull five claims for all agencies for episodes beginning on or after Aug. 1, 2015.
 
The federal Medicare agency expects MACs to begin sending additional documentation requests (ADRs) after Oct. 1, 2015, and that the first round of claim reviews and provider education will conclude in about a year, CMS notes in a MLN Matters article released Nov. 9, 2015.
 
Remember, the narrative requirement was eliminated in the 2015 PPS final rule for episodes beginning Jan. 1, 2015, and beyond. But documentation in the physician’s medical records, and/or the acute/post-acute care facility’s medical records if the patient was directly admitted to home health is going to be used as the basis for certification of home health eligibility.
 
Further, the certifying physician can incorporate information from or generated by the agency into his or her medical record to support a patient’s homebound status and need for skilled care by including it in the doctor’s documentation and signing and dating it to demonstrate review and concurrence, CMS says.
 
CMS will direct MACs to select a sample of five claims for pre-payment review from every agency nationwide, the federal Medicare agency notes. MACs will then deny each non-compliant claim and outline the reasons for denial(s) in a letter and telephone calls to all providers with errors in the claim sample.
 
For agencies identified as having two to five claims out of compliance, the MACs will repeat the probe and educate process, CMS notes.
During the calls, MACs will discuss “the reasons for denials, provide pertinent education and reference materials, and answer questions,” CMS says.
 
Related link: Read the MLN Matters article here: http://tinyurl.com/qgnlohq.
 
Note: See upcoming issues of Home Health Line for more details about the probe and educate review.