How to use CCI edit when procedure denied as bundled service

If I receive a denial for a procedure bundled into another service, and I cannot find this code pair in the column 1/column 2 correct coding list of edits, where else should I look?


Look in the mutually exclusive code list. The mutually exclusive code edits in the printed version of the CCI Edits Manual are in the same chapter but separate from the column 1/ column 2 correct coding edits. The electronic version of the mutually exclusive code edits that is available on the CMS website can be found in a separate listing at http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp, which are arranged by specific chapters.


What exactly does "column 1" mean in the column 1/column 2 correct coding edits table and in the mutually exclusive edits table?

Formerly known as the "comprehensive code" within the column 1/column 2 correct coding edits table, the column 1 code generally represents the major procedure or service when reported with the column 2 code. When reported with the column 2 code, "column 1" generally represents the code with the greater work RVU of the two codes.

However, within the mutually exclusive edits table, "column 1" code generally represents the procedure or service with the lower work RVU, and is the payable procedure or service when reported with the column 2 code




Claims Review for Global Surgeries


A.Relationship to Correct Coding Initiative (CCI)


The CCI policy and computer edits allow A/B MACs (B) to detect instances of fragmented billing for certain intra-operative services and other services furnished on the same day as the surgery that are considered to be components of the surgical procedure and, therefore, included in the global surgical fee. When both correct coding and global surgery edits apply to the same claim, A/B MACs (B) first apply the correct coding edits, then, apply the global surgery edits to the correctly coded services.

B.Prepayment Edits to Detect Separate Billing of Services Included in the Global Package

In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:

*Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or

*Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;

and -
*Services that were furnished within the prescribed global period of the surgical procedure;

*Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and

*Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.”

A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244,
99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275
have been transferred from the excluded category and are now included in the global surgery edits.

Evaluation and Management Codes for A/B MAC (B) Edits
92012    92014    99211    99212    99213    99214
99215    99217    99218    99219    99220    99221
99222    99223    99231    99232    99233    99234
99235    99236    99238    99239    99241    99242
99243    99244    99245    99251    99252    99253
99254    99255    99261    99262    99263    99271
99272    99273    99274    99275    99291    99292
99301    99302    99303    99311    99312    99313
99315    99316    99331    99332    99333    99347
99348    99349    99350           
99374    99375    99377    99378       

NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used to indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.

C.Exclusions from Prepayment Edits

A/B MACs (B) exclude the following services from the prepayment audit process and allow separate payment if all usual requirements are met:
Services listed in §40.1.B; and
Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.” Exceptions

See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services.

Exclude the following codes from the prepayment edits required in §40.3.B.

92002    92004    99201    99202    99203    99204
99205    99281    99282    99283    99284    99285
99321    99322    99323    99341    99342    99343
99344    99345                

Patient waiver form - Example and requirements

WAIVER FORM


NOTE: The waiver cannot be utilized for services considered to be content of another service provided.

A. SITUATIONS REQUIRING A WAIVER

1. Medical necessity denials
2. Utilization denials
3. Deluxe features (Applicable to deluxe orthopedic or prosthetic appliances as specified in the member contract)
4. Patient demanded services
5. Experimental/investigational procedures

B. THE WAIVER FORM MUST BE

1. Signed before receipt of service.
2. Patient, service, and reason specific.
3. Date of service and dollar amount specific.
4. Retained in the patient's file at the provider's place of business. (The waiver form is no longer required with claims submission. Use the GA modifier for all electronic and paper claims.)
5. Presented on an individual basis to the patients. It may not be a blanket statement signed by all patients.
6. Acknowledged by patient that he or she will be personally responsible for the amount of the charge, to include an approximate amount of the charge at issue.

NOTE: If the waiver is not signed before the service being rendered, the service is considered a contracting provider write-off, unless there are extenuating circumstances

LIMITED PATIENT WAIVER Form

Patient’s Name:
Provider Name:
Identification Number:
Provider Address:
Provider Number:
The provider must document in the patient record the discussion with the patient regarding the following service(s).


patient waiver form

what is retrospective claim review and denied claim appeal

RETROSPECTIVE CLAIM REVIEWS

The contracting provider shall have the right to a retrospective review of any claim denied in whole or in part. The purpose of a retrospective review is to allow the provider to contact customer service to determine whether the original adjudication was correct.

A. All requests for retrospective review must be submitted (in writing or by phone) to and received by BCBSKS Customer Service within 120 days from the date of the remittance advice.

B. The provider will be given a response to the request for a retrospective review as soon as possible, but no later than 60 days from receipt date. In cases where claims are adjusted, the remittance advice will serve as the response


I. CORRECTED CLAIM

A request made from a contracting provider to change a claim, (e.g., changing information on the service line, modifier addition, diagnosis correction, etc.) that has previously processed is considered a corrected claim. The submission of a corrected claim must be received by BCBSKS within the 15-month timely filing deadline. Claims denied requesting additional information (e.g. by letter or adjustment reason code) should never be marked "corrected claim" when resubmitted. Instead, providers should submit a new claim with the requested information.

When a claim denial or adjustment is made as a result of a BCBSKS audit, the provider may not submit a corrected claim to reverse the decision. The provider’s next course of action is to enter into the appeal process.

DENIED CLAIMS APPEALS PROCEDURE

After completion of the retrospective review process (see Section II. Retrospective Claim Reviews), contracting providers may appeal certain pre and post-service claim denials. Only claims denied as not medically necessary may be appealed on the provider’s own behalf as set forth in the policies and procedures. When BCBSKS requests records to support a claim denial, but does not receive them within the 45-day time limit, the service will be denied not medically necessary and will be a provider write-off. The provider may be designated as the member’s authorized representative for appeal purposes according to the terms of the member’s contract.

NOTE: Medical policies including Content of Service (COS) as described in BCBSKS Policy Memos 1-12 or provider’s obligations specified in their provider contracts are not considered eligible claims appeals as outlined in Section III. DENIED CLAIMS APPEALS PROCEDURE. Annually, BCBSKS outlines any changes to the Policy Memos and forwards them to providers for their review. Once providers accept these changes, they are part of the provider’s contract and therefore not considered for claims appeals. Providers disagreeing with any policies should submit their position and supportive documentation to BCBSKS staff for future consideration.


Appeals as the Member’s Authorized Representative: Appeals that you can make as the member’s authorized representative according to the terms of the member’s contract are claims for which the member is financially responsible. When you act as the member’s authorized representative, you are not separately entitled to any appeals pursuant to this Contracting Provider Agreement. Appeals Pursuant to Contracting Provider’s Agreement

First Level: Written notification of disagreement highlighting specific points for reconsideration of a claim denied not medically necessary shall be provided to BCBSKS within 60 days from the date of the retrospective review determination. This notice shall be considered an initial appeal and be forwarded with all pertinent medical records to BCBSKS Customer Service. Medical records submitted with the request for initial appeal will be referred to the appropriate consultant and a determination will be rendered. This decision will be binding unless the provider files a second-level appeal within 60 days of notification of such decision.

Second Level: Forward a written request for the second-level appeal to BCBSKS customer service within 60 days following the first-level appeal denial notification. The second and final appeal determination shall be made by a physician or clinical peer. The contracting provider agrees to abide by the second-level appeal determination.

All appeal decisions under this agreement must be provided within 60 days of receipt of the provider's request. Any appeals decision not provided within the aforementioned time frames shall be considered as decisions made in favor of the provider and claim payments will be adjusted accordingly.

A contracting provider agrees to accept the determination made at each level or to appeal the determination at the next step of the appeals process. If throughout the appeals process the decision on the claim changes in the provider's favor, an additional payment will be made. However, a refund will be requested if the decision reverses a previous determination (either partially or totally).

The result of the appeals process shall be binding on the provider and BCBSKS subject only to the provision for binding arbitration previously stated herein.

Nursing Care services Billing overiview


NURSING SERVICES

Nursing services are covered on an intermittent (separated intervals of time) basis when provided by, or under the direct supervision of, a registered nurse (RN).

A nursing visit may include, but is not limited to, one or more of the following nursing services:

* Administering prescribed medications that cannot be self-administered.

* Changing an indwelling catheter.

* Applying dressings that require prescribed medications and aseptic techniques.

* Teaching the beneficiary, available family member, willing friend or neighbor, or caregiver (paid or unpaid) to carry out all or some of the services, as detailed below.

* Observation and evaluation, as detailed below.

Intermittent (separated intervals of time) nurse visits are intended for beneficiaries who generally require nursing services on a short-term basis (typically 60 days or less) for the treatment of an acute illness, injury, or disability and who cannot receive these services in an outpatient setting. Intermittent nursing visits may last from 15 minutes to one or two hours and are reimbursed at a flat rate (i.e., Medicaid feescreen for a visit) regardless of the length of the visit.

Intensive care (for cases that require five or more visits per week or beyond 60 days) may be reviewed by MDHHS during post-payment audit to determine if home care was medically appropriate and a cost effective alternative to institutional care.

Intermittent nurse visits are not covered for a beneficiary receiving Private Duty Nursing Services.


COVERED NURSING SERVICES

The following nursing services are covered home health care services. Limitations, conditions and special considerations are noted when applicable. (Refer to the Billing & Reimbursement for Institutional Providers Chapter of this manual for billing information.)

BLADDER TRAINING

When use of a catheter is temporary, visits made by the nurse to change the catheter must also include instruction to the beneficiary in bladder training methods. The actual bladder training (e.g., forcing fluids or other measures) does not require the skills of a nurse. After the catheter is removed, a limited number of visits (maximum two visits per month) are allowed to observe and evaluate the effectiveness with which the bladder training has been accomplished (e.g., the degree to which the bladder is emptying).

BLOOD LEAD POISONING NURSING ASSESSMENTS/INVESTIGATION VISITS

A physician’s order is required for a HHA to make home visits regarding blood lead poisoning. Medicaid reimburses up to two nurse visits per child, regardless of the number of children in the home diagnosed with blood lead poisoning.


HHAs who suspect beneficiaries may have evidence of blood lead poisoning or blood lead levels above accepted state levels in the home should refer the beneficiary to the local health department (LHD).



ENEMAS

Giving enemas usually does not require the skills of a nurse, and Medicaid does not cover such visits unless the physician has ordered that a nurse give the enema because of clinical indications.


 EYE DROPS AND TOPICAL OINTMENTS

Two nurse visits are allowed to teach the administration of eye drops and topical ointments. Nurse visits solely to perform these services are not covered.


 INTRAVENOUS INFUSIONS


If the beneficiary is in need of intravenous infusion and an infusion clinic or ancillary Medicaid provider (who has no nurse) does not cover the service, or family member/care giver will not accept this task, the HHA may perform this service and bill accordingly.

Medicaid will reimburse claims for professional services (e.g., nursing services) associated with the administration of Medicare Part D drug(s) to dually eligible Medicaid/Medicare beneficiaries.


NEONATAL JAUNDICE

Nurse visits related to neonatal jaundice require supporting documentation in the beneficiary's medical record that the nurse visits are required for a specific medical condition. Supporting documentation should include pertinent laboratory values.

OBSERVATION/EVALUATION

If the attending physician determines that the beneficiary’s condition is unstable and that significant changes may occur, Medicaid covers nurse visits for observation/evaluation. Once the beneficiary’s condition has stabilized and there has been no significant change (e.g., no change in medication or vital signs, no recent exacerbation in the beneficiary’s condition) for a period of three weeks, and no other necessary nursing services are being furnished, nursing visits solely for observation/evaluation are no longer covered. Visits for observation/evaluation to ensure stability of a beneficiary who has an established disability or frail condition are covered by Medicaid if circumstances, conditions, or situations exist that prevent the beneficiary from obtaining services from a physician’s office or outpatient clinic as described in the Home Setting Section of this chapter. Such visits are limited to two visits per month.

Nurse visits for observation/evaluation to insure stability of a beneficiary’s condition cannot be billed within a 30-day period of an initial/subsequent postpartum/newborn follow-up nurse visit, suspected abuse nurse visit or aide visit.



ORAL MEDICATIONS

Administration of oral medications does not usually require the skills of a nurse in the home setting. Visits are covered only if the complexity of the beneficiary’s condition and/or the number of drugs prescribed require the skill or judgment of a nurse to detect and evaluate side effects (adverse reactions) and/or provide necessary teaching and instruction.

Placing medication in envelopes/cups, giving reminders, etc., to assist the beneficiary in remembering to take them does not constitute a nursing service.


POSTPARTUM/NEWBORN FOLLOW-UP NURSE VISIT

Home visits for assessment, evaluation and teaching are covered for women and newborns following delivery when a physician has determined the mother or newborn may be at risk. The goals of these services include:

* Fostering a positive outcome for the mother and newborn by detecting medical complications manifested during the
postpartum/newborn period;

* Instructing the mother in newborn care; and

* Identifying situations that may require intervention with medical and community resources.

The HHA must assess and document, in writing, that the beneficiary is receiving services by a Maternal Infant Health Program (MIHP) provider. If the HHA is also an enrolled MIHP provider, services for the mother and newborn cannot be billed as home health care but must be billed as MIHP services. If the beneficiary is receiving MIHP services from another provider and the HHA is also providing services, the POC must clearl  identify why home health services are needed in addition to MIHP and that the two providers do not duplicate services.

Medicaid allows one initial postpartum visit, one initial newborn visit, and one subsequent visit to mother and newborn for a total of three visits per pregnancy.

* The initial postpartum visit must be billed using the mother’s Medicaid ID number.

* The initial newborn visit must be billed using the newborn’s Medicaid ID number.

* The subsequent visit may be billed under either the mother’s ID number or newborn’s ID number, based on the most time spent with each beneficiary.



PRENATAL NURSE VISIT

Medicaid covers home visits for a specific pregnancy related medical condition provided by a HHA.

Home visits provided for preventive health services which address psychosocial issues, provide education, provide transportation, etc. and that do not provide treatment for an illness or injury are a covered service of the MIHP, not Home Health.

ROUTINE PROPHYLACTIC AND PALLIATIVE SKIN CARE

The recognized stages of decubitus ulcers are classified as:

* Stage I - Inflammation or redness of the skin;

* Stage II - Superficial skin break with erythema of surrounding area;

* Stage III - Skin break with deep tissue involvement; and

* Stage IV - Skin break with deep tissue involvement with necrotic tissue present.

The existence of Stage III or IV decubiti or other widespread skin disorders may necessitate the skills of a nurse. The physician’s orders for treating the skin determine the need for this service.

The presence of Stage I or II decubiti, rash, or other relatively minor skin irritations do not indicate a need for nursing care unless ordered by a physician. Bathing the skin, applying creams, etc. are not covered nursing services.

Home Health care billing - Detailed overview


GENERAL INFORMATION

This chapter applies to Home Health providers.

Home health is a covered Medicaid benefit for beneficiaries whose conditions do not require continuous medical/nursing and related care, but do require health services on an intermittent basis in the home setting for the treatment of an injury, illness, or disability. Medicaid covered services may be provided in the home only if circumstances, conditions, or situations exist which prevent the beneficiary from being served in a physician’s office or other outpatient setting. Except as detailed in this chapter, the beneficiary’s primary need must be for nursing care and/or physical therapy, rather than personal care or physician’s care.

A Home Health Agency (HHA) is an organization that provides home care services, such as skilled nursing care, physical therapy (PT), occupational therapy (OT), speech therapy (ST) and care by home health aides. The HHA must be Medicare certified to enroll as a Medicaid provider and must comply with the Medicare/Medicaid Conditions of Participation (42 CFR § 484) and the policies outlined in this manual.

Services solely to prevent an illness, injury or disability are only covered for women/newborns following delivery. For postpartum/newborn follow-up nurse visits, a nursing diagnosis can be used to establish medical necessity. Otherwise, a medical diagnosis is required to establish medical necessity. Medicaid beneficiaries are expected to be an active participant in the planning for their home health care. For beneficiaries enrolled in a Medicaid Health Plan (MHP), the HHA must contact that health plan for authorization to provide services to their members.

Medicaid home health services must be ordered, in writing, by the beneficiary’s attending physician (MD, DO) as part of a written plan of care (POC) and reviewed by this physician every 60 days. The physician’s order and POC must be only for functions that are within the scope of his current medical practice and Medicaid guidelines.

This chapter includes information about services covered for Medicaid and Children’s Special Health Care Services (CSHCS) beneficiaries unless otherwise noted.

FACE-TO-FACE ENCOUNTER

A physician certifying eligibility for home health services must provide documentation of a face-to-face encounter with the beneficiary within 90-days prior to or 30-days after the start of care. The face-to-face encounter may occur through telehealth in compliance with Section 1834(m) of the Social Security Act. NOTE: The face-to-face encounter requirement pertains only to initial certification for home health services.

Only a physician may order home health services and certify a beneficiary's eligibility for the benefit. The face-to-face encounter ensures that the orders and certification for home health services are based on current knowledge of the beneficiary's clinical condition, and will identify the primary reason for home health services.

In a situation where a physician orders home health services based on a new condition that was not evident during a visit within the 90-days prior to the start of care, the certifying physician or nonphysician practitioner (NPP) must see the beneficiary within 30 days of admission to home health services.

The certifying physician must document the face-to-face encounter regardless of whether the physician or a permitted NPP performed the encounter. When the face-to-face encounter is performed by a NPP, he/she must document the clinical findings of the face-to-face encounter and communicate those findings to the physician; the physician must then sign the certification.

Permitted NPPs include:

* A nurse practitioner or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act) who is working in collaboration with the physician in accordance with state law;

* A certified nurse-midwife (as defined in section 1861(gg) of the Social Security Act, as authorized by State law); or

* A physician assistant (as defined in section 1861(aa)(5) of the Social Security Act) under the supervision of the physician.

The face-to-face beneficiary encounter must be a separate and distinct section of, or an addendum to, the certification and must be clearly titled, dated and signed by the certifying physician. Use of a specificform for the certification or the plan of care is not required.

Documentation of the face-to-face encounter must reflect the certifying practitioner’s assessment of the beneficiary and include:

* Date of the encounter,

* Primary reason for the encounter (medical condition),

* Clinical findings that support the need for skilled nursing or therapy services, and

* Clinical findings that support home health eligibility.

An addendum may consist of clinical documents from a hospital or post-acute facility (e.g., emergency visit record or discharge summary). It is allowable for the certifying physician to use such a document as an addendum for the face-to-face encounter if:

* The addendum contains all of the documentation requirements for face-to-face documentation;

 * The addendum document, which is serving as the face-to-face documentation, is clearly titledand dated as such; and

* The certifying physician signs and dates the addendum, demonstrating that the certifying physician received that information from the allowed NPP or physician who performed the faceto- face encounter, and that the certifying physician is using that addendum document as his/her documentation of the face-to-face encounter.

While typically the same physician will certify, establish and sign the POC, it is allowable for physicians who attend to the beneficiary in the acute and post-acute settings to certify the need for home health care based on their face-to-face contact, initiate the orders (POC) for home health services, and "hand off" the beneficiary's care to the community-based physician to review and sign off on the plan of care.



HOME SETTING


Home health services are intended for beneficiaries who are unable to access services (nursing, OT, PT, speech and language pathology therapy [ST]) in an outpatient setting. However, it is not required that beneficiaries be totally restricted to their home. A determination and documentation is required by the HHA that the home is the most appropriate setting in which to provide the service(s). Home health services are not provided solely on the basis of convenience.

All covered home health services must be rendered in a beneficiary’s home, except for those services listed below. Home may be the beneficiary’s owned/rented home, an apartment, Assisted Living Facility, Adult Foster Care (AFC) facility, or home of another family member (secondary residence of the beneficiary, i.e., joint custody situation for a minor child).

* Home Health aide services are not a covered benefit for beneficiaries who reside in a Home for the Aged (HFA) or Adult Foster Care (AFC) facility as this would be duplication of personal care services already provided by staff of these facilities.


* Michigan Department of Health and Human Services (MDHHS) does not cover any Home Health services rendered to a beneficiary in a hospital, nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), Intermediate Care Facility for the Mentally Ill (ICF/MI), school or adult day care.

To determine if services in the home, rather than in an outpatient setting, are most appropriate, consider the following:

* Is in-home care necessary for the adaptation, training or teaching of nursing or treatment procedures, plans, equipment, appliances or prosthetics in the home setting*

* Is in-home care necessary to prevent undue exposure to infection and/or stress for the beneficiary as identified and documented by a health care professional*

* Is leaving the home medically contraindicated, as identified and documented by a health care professional*

* Is in-home care necessary to prevent a documented problem with access to services, continuity of care or provider, or coordination of services, as documented by a health care professional*

* Is in-home care the most cost-effective method to provide care*

Services must be appropriate and necessary for the treatment of an identified illness, injury or disability. The services provided must be consistent with the nature and severity of the beneficiary’s illness, injury or disability, his particular medical needs and accepted standards of medical practice. Beneficiaries with established frail conditions may need assessments by skilled nurses to prevent further decline of the frail condition.


PLAN OF CARE

The plan of care (POC) must include the following:

* Date of most recent hospitalization.

* Medical diagnosis and impact of functional limitation.

* Specific circumstances, conditions, or situations that require services to be provided in the home and not in a physician’s office or outpatient clinic.

* Date of the HHA’s first visit for this admission.

* The date for which the HHA began providing home care. (This date remains the same on subsequent POCs until the beneficiary is discharged from home health care services.)

* Detailed description of each service to be provided, including frequency and duration of services.

* Detailed description of current goals as related to the services provided and the goal for discharge planning.

* A full description of the reason(s) that initial and/or continued home care is needed (e.g., pertinent laboratory values, medications, wounds, abnormal vital signs).

* Environment status (e.g., electricity, telephone, indoor plumbing).

* Identification of other resources used by the beneficiary (e.g., Area Agency on Aging, Protective Services, Home Help Services).

* Date of physician’s last contact.

* Role of family or support person.

* HHA’s name, address and provider NPI number, and beneficiary’s name, date of birth, and Medicaid ID number.

* The attending physician’s signature and date he signed the POC. The POC must be signed and dated by the beneficiary’s attending physician before the HHA submits a claim to MDHHS for payment.


If the attending physician signs the POC after the service(s) is rendered, there must be a pre-existing written or verbal order for the service(s) to be covered by Medicaid. If the service(s) is rendered prior to the date the physician dated the POC and there is no pre-existing written or verbal order, Medicaid does not cover the service(s) provided. The verbal order obtained from the ordering physician must contain the signature of the HHA staff person who obtained the verbal order and the date the verbal order was received. All verbal orders must be countersigned and dated by the ordering physician before the claim is submitted to MDHHS for payment.

Ordering physicians must determine that medical/health services are medically necessary and/or appropriate. Any increase in the frequency of services, addition of new services, or modifications of treatment during a certification period must be authorized by the attending physician and documented in the beneficiary’s medical record by way of a verbal order or written order prior to the provision of the increased, additional, or modified treatment.

The POC signed by the attending physician, along with any written or verbal orders as needed, and progress notes must be retained in the beneficiary’s medical record.



OUTCOME AND ASSESSMENT INFORMATION SET

The Centers for Medicare & Medicaid Services (CMS) requires Medicare certified HHAs to use a standard assessment data set, referred to as the Outcome and Assessment Information Set (OASIS). The requirement to collect and submit OASIS clinical data applies to all beneficiaries receiving Medicare and/or Medicaid home health services. This means beneficiaries under Medicaid traditional fee-for service (FFS), MHP, Children’s Waiver, Home and Community Based Services Waiver for the Elderly and
Disabled (MI Choice Waiver), Habilitation Supports Waiver, Healthy Michigan Plan, and CSHCS who receive home health services are to have OASIS information collected by the HHA. Assessments for all beneficiaries are to be conducted in compliance with Medicare certification requirements.

HHAs are also required to electronically transmit the OASIS data to the designated state agency responsible for collecting OASIS data in accordance with CMS specifications. MDHHS contracts with a vendor to provide OASIS transmission assistance. HHAs needing assistance with transmitting data to the state repository should contact the MDHHS contractor. (Refer to the Directory Appendix for contact information.)


The CMS rules for OASIS are published in the Federal Registers that are available online at the OASIS website. (Refer to the Directory Appendix for website information.)



POST-PAYMENT REVIEW

Ordering physicians must determine that medical/health services are medically necessary and/or appropriate. All home health services ordered are subject to review for conformity with accepted medical practice and Medicaid coverage and limitations. Post-payment reviews of paid claims may be conducted to assure that the services provided, as well as the type of provider and setting, were appropriate, necessary, and compliant with Medicaid policy. Post-payment review also includes verification that appropriate procedure codes were used to bill the services provided.

Post-payment review includes verification that all third-party resources were utilized to their fullest extent prior to billing MDHHS. If post-payment review reveals that MDHHS was billed prior to utilizing these resources and the HHA knew the beneficiary had other insurance coverage for the service rendered, it may be considered fraud.

The General Information for Providers Chapter of this manual contains additional information regarding post-payment review and fraud.

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