Archive for June, 2010

June 28, 2010

PECOS verification needed or HHAs may face false claims liability, nonpayment

There is a regulation that will go into effect July 6, 2010, that could impact your ability to continue service to as many as 20-40% of the patients that you serve. This includes current patients in need of continued care, as well as new patients referred on or after that date.

PECOS is the electronic database of physicians enrolled in or opted-out of Medicare. A large percentage of physicians who have valid NPIs and are licensed doctors of medicine, osteopathy and podiatric medicine, are not enrolled in PECOS.

It takes 60-90 days after enrollment in PECOS before the verification of the physician’s enrollment appears. Until there is a PECOS record, home health agencies are at risk that they are without authorization to bill Medicare, and that any claim for payment will be denied on prepayment or post-payment review.

Home health agencies that knowingly bill Medicare for services ordered by a physician that is not enrolled in PECOS (including billing for visits made after July 6th during an episode that started before that date) face the following consequences:

  1. False claims act liability
  2. Non-payment by Medicare for billed services

The new regulation at 42 CFR 424.507 (Learn more about 42 CFR424.507.) stipulates that, effective July 6, 2010, in order for a home health agency to receive payment for services to a Medicare beneficiary:

  • The Part A or Part B home health services must have been ordered by a physician;
  • A claim for home health services must contain the legal name and the National Provider Identifier (NPI) of the ordering physician, and
  • The ordering physician must have an approved enrollment record or a valid opt-out record in the Provider Enrollment, Chain and Ownership System (PECOS)

The regulation goes on to say, “A Medicare contractor will reject a claim from a provider or a supplier for covered services described in paragraphs (a) and (b) of this section [referring to Part B services and home health care] if the claim does not…” meet the requirements as set forth above.

Action to Take NOW and June 28-30th:

1)     Check Medicare’s database for your referring physicians’ NPIs.
Or check this website for PECOS physicians: OAandP.

  • Click on the zip file for the more user-friendly database.
  • Click on Find in the upper right hand corner of the Excel file and type in the NPI number. If the physician is not listed in the excel spreadsheet, then the physician is not enrolled.

Any claims for patients for which that physician has signed the POC are in danger of being denied. Contact that physician immediately to educate and inform them of the requirements.

2)            Call your Congressional Representative and Senators and follow up with an electronic letter

3)     Fax Notice Letters and call Your Referring Physicians and Discharge Planners to alert them of the July 6th PECOS Registration Deadline. (This is not needed for physicians that are found in the database.)

3)     Submit formal comments electronically to the CMS Interim Final Rule on PECOS

We urge you to contact your members of Congress by phone or email in accord with the following instructions:

1) Urge CMS to delay implementation of the rule requiring that physicians ordering home health care be enrolled in the PECOS data base. Further, CMS should hold harmless home health providers until such time as physicians have had a reasonable opportunity to enroll, and

2) Urge Congressional leaders to intervene with CMS to resolve this issue.  Let them know that this is an important issue for you and your state as patients otherwise eligible for Medicare services will be denied care.

3) Utilize the sample letters below to fax to physicians and discharge planners to inform them of the impact the rule will have on their patients and the services you provide. Then follow up with phone calls to encourage PECOS registration.

4) Finally, we urge every home health agency to submit formal comments to the CMS Interim Final Rule that contains these new requirements and the July 6th deadline. The notice can be found at this link.  Instructions for submitting comments can be found on page 24437.

This is a critical issue, and much of the above call to action information is from the Texas Association for Home Care and Hospice.


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June 22, 2010

Assessment and the correct choice of V44 or V55

I recently received a great question: When your clinician is assessing a tracheostomy and ordering supplies, but the patient cares for the trach, which code is used?

As anyone who has heard me teach on V codes knows, there is a pretty easy line to draw between coding a V44 and a V55 code, but this has an interesting twist.

V44 codes are status codes, so you use them just to report the presence of a trach tube or another artificial opening. There is no clinical care involved, so you also code V44 when a patient is caring for the opening independently or with a caregiver’s help.

V55 codes are considered aftercare codes, according to the official coding guidelines, and are used when there is clinical intervention and care, such as cleaning or overall care.

Back to the question I received: We don’t have official guidance on this, but I would code the V55 code (V55.0, Attention to Tracheostomy) because only a nurse can assess the trach for infection or other issues.

Important Note: The official coding guidelines specifically say that V44 and V55 codes should not be coded together.

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June 18, 2010

Pressure Ulcer Tool Updated!

Here is a pressure ulcer tool I created a while ago, and have now updated with OASIS and coding guidance.

My tool shows you OASIS and coding information broken down by stage (or if it is unstageable) of the pressure ulcer, whether it is closed, if there is a suspected DTI, or if the ulcer is with a skin graft or muscle flap.

The tools gives you OASIS guidance across M1306, M1307, M1308, M1310, M1312, M1314, M1320, M1322, M1324.

It also gives gives you the coding guidance for each situation.

Check out the pressure ulcer tool: pressure ulcersOASIS0610

June 15, 2010

Those six OASIS slots, POC and patient diagnoses

I often hear frustration in trying to identify all of a patient’s diagnoses in the six OASIS slots, especially when multiple coding is required. It is tough to show the patient’s condition, but remember that the OASIS is just part of the comprehensive assessment. From that full assessment you will have the diagnoses that represent your patient’s condition. These conditions are listed in several places:

OASIS: The one we focus on the most, as this is the payment area. You need to code in the order that reflects the seriousness of the patient’s condition and what skilled services are provided, NOT for reimbursement.

Plan of Care: Your Plan of Care should list all of the patient’s pertinent diagnoses, and most POCs have room for a large number of diagnoses. Important: Anything you list in M1024 must be listed somewhere in the Plan of Care, included resolved diagnoses that appear in M1024. Those resolved M1024 diagnoses can be noted in Field 21, but that specific field number is my suggestion, not a requirement. There are other places to note these diagnoses, and they must be listed.

The Claim: Your claim should have nine slots for diagnoses. Again, make sure all of these are on your Plan of Care.

All diagnoses much match up across these three listings.

Sometimes coders will ask if if CMS will expand the number of slots on the OASIS for coding. I don’t know of any discussion within CMS to increase the number of diagnoses.

June 14, 2010

OASIS and Unstageable Pressure Ulcers

I receive a lot of questions on pressure ulcers, especially with all of the new OASIS specificity. One of the most common questions deals with  eschar covering the wound.

This type of question has a common theme: If the wound is covered in soft/brown eschar on assessment (it had been documented as a Stage III ulcer), should it be coded as unstageable? And what about M1314, the pressure ulcer depth?

My answer is that a pressure ulcer with eschar can’t have depth; it’s 0 (zero)  because it is covered. You can still measure the length and width, so M1310 and M1312 are straightforward.

Your healing status for M1320 is 3-Not Healing.
The answer to this question is NOT NA- No Observable Pressure Ulcer

Remember WOCN guidance on answering M1320  3 – Not healing:
o wound with ≥25% avascular tissue (eschar and/or slough) OR
o signs/symptoms of infection OR
o clean but non-granulating wound bed OR
o closed/hyperkeratotic wound edges OR
o persistent failure to improve despite appropriate comprehensive wound management

As for M1324, the answer is NA because the pressure ulcer cannot be staged because the wound bed is not visible.

Looking for the full WOCN guidance? We have it here.