Archive for January, 2014

January 29, 2014

Jurisdiction 11 Home Health and Hospice (Palmetto) Service Specific Probe Review for Select Home Health HIPPS Codes

Palmetto GBA will be performing service-specific prepay probe reviews on claims billed for selected Home Health HIPPS codes. Based on identified CERT errors, OIG and Med PAC reports, internal analysis and prioritization, as well as past experience, selected HIPPS codes have been identified as major risk services for J11.

Palmetto GBA will also be setting three service-specific probe medical review edits for HIPPS Code 5AHK* (variable last digit of HIPPS Codes.) These edits will be set to select 100 claims from Florida; 100 claims from the following state grouping: Illinois, Louisiana, Mississippi and Texas; and 100 claims from all the remaining 11 states within the jurisdiction.

Palmetto GBA will be setting four service-specific probe medical review edits for HIPPS code 5BGK* (variable last digit of HIPPS Codes.) These edits will be set to select 100 claims from each of the following states: Florida, Texas; 100 claims from the following state grouping: Illinois, Louisiana, Mississippi; and 100 claims from all the remaining 11 states within the jurisdiction.

Palmetto GBA will also be setting four service-specific probe medical review edits for HIPPS Code 5AGK* (variable last digit of HIPPS Codes.) These edits will be set to select 100 claims from each of the following states: Florida, Texas; 100 claims from the following state grouping: Illinois, Louisiana, Mississippi; and 100 claims from all the remaining 11 states within the jurisdiction.

Palmetto GBA will be setting one service-specific probe medical review edit for HIPPS code 5BFK* (variable last digit of HIPPS Codes.) This edit will be set to select 100 claims from all 16 states within the jurisdiction.

Palmetto GBA will be setting one service-specific probe medical review edit for HIPPS code 5AFK* (variable last digit of HIPPS Codes.) This edit will be set to select 100 claims from all 16 states within the jurisdiction.

[End of Palmetto article]

The ‘5’ at the beginning of the HIPPS code indicates that 20 or more therapy visits were provided. The rest of the HIPPS code translates to the following HHRG scores:

A=C1

B=C2

F=F1

G=F2

H=F3

This means that Palmetto is looking at patients with lower clinical scores who have 20 or more therapy visits. Agencies with lower clinical scores and 20 therapy visits should take the time to review OASIS accuracy as well as coding accuracy. If the agency finds HIPPS codes such as those above you may be chosen for these probe edits.

Palmetto is also interested in patients who have 20 therapy visits with lower functional scores. Obviously, if the patient requires that many therapy visits a lower functional score does not support that number of therapy visits. Documentation to support could include the necessity of providing 2 or more types of therapy (e.g., PT and OT). Because the functional OASIS items are some of the most difficult to understand, education may be needed to answer these OASIS items correctly.

Although Palmetto’s probe review may only look at 100 charts in a lot of states, remember if there is a problem with a chart from your agency, that probe edit can turn into a large number of claims being reviewed.

Selman-Holman & Associates, LLC can help with responding to medical review requests, as well as, educating your staff on coding and OASIS. Call us at 214-550-1477 for all your consulting and education needs.