Posts tagged ‘42 CFR 424.507’

September 8, 2010

Non-PECOS physician claims will be processed before Jan. 1

This is a PECOS update from TAHC

PECOS Update

The Centers for Medicare & Medicaid Services (CMS) has issued Transmittal 765 regarding expansion of claims editing to meet the July, 6 PECOS requirement. The transmittal states that the claims editing will be implemented in two phases. The initial phase begins October 1, 2010, and the second phase is set to begin on or after January 1, 2011.  These edits are being put into place to begin verification of physician’s name and NPI number as they appear on the “Medicare Ordering Referring File.” Agencies that bill the Medicare program must ensure that claims contain accurate information from the “Medicare Ordering Referring File.” The following describes the two phases and if you wish to read Transmittal 765, please click here.

Phase 1 (October 1, 2010 –December 31, 2010) – When a claim is received, CMS will determine if the attending physician is required for the billed service. If the attending physician’s NPI is on the claim, Medicare will verify that the attending physician is on the national PECOS file. If the attending physician NPI is not on the national PECOS file during Phase 1, the claim will continue to process but a message will be included on the remittance advice notifying the billing provider that claims may not be paid in the future if the attending physician is not enrolled in Medicare or if the attending physician is not of the specialty eligible to be an attending physician for HHA services.

Phase 2 (On or after January 1, 2011) – As stated above, Medicare will determine if the attending physician’s NPI is required for the billed service. If the billed service requires an attending physician and the attending physician’s NPI is not on the claim, the claim will not be paid. If the attending physician’s NPI is on the claim, Medicare will also verify that the attending physician is on the national PECOS file. If the attending physician is on the PECOS file, but not as a specialty eligible to be an attending physician, the claim, during Phase 2, will not be paid.

July 19, 2010

CMS wants to clarify therapy plans and skilled service roles

CMS is proposing major changes in therapy qualifications, documentation and “effectiveness” of therapy in the 2011 proposed HHPPS rule. I will cover the main points of the therapy requirements over several posts.

Establishing plans and clarifying skilled service roles

In the 2011 proposed  HHPPS rule, CMS works to clarify  “accepted practice” and “effective treatment” so HHAs know the agency’s expectations regarding PT, SLP, and OT. This section of changes deals with assessment documentation and reassessment requirements for therapists and assistants.

This proposal language specifically also calls out that therapy is NOT reasonable and necessary if the patient’s function is temporarily lost and would be regained as a patient’s health improves (watch out, those of you who have been using generalized weakness as a code to “justify” therapy). It also looks at the need for assistants vs. therapists in maintenance plans and with regard to setting up plans.

Current language for §409.44(c)(2)(iii) links therapy and reasonable improvements in the patient’s condition or a safety management maintenance program. The current language is:

(iii) There must be an expectation that the beneficiary’s condition will improve materially in a reasonable (and generally predictable) period of time based on the physician’s assessment of the beneficiary’s restoration potential and unique medical condition, or the services must be necessary to establish a safe and effective maintenance program required in connection with a specific disease, or the kills of a therapist must be necessary to perform a safe and effective maintenance program. If the services are for the establishment of a maintenance program, they may include the design of the program, the instruction of the beneficiary, family, or home health aides, and the necessary infrequent re-evaluations of the beneficiary and the program to the degree that the specialized knowledge and judgment of a physical therapist, speech-language pathologist, or occupational therapist is required.”

Regarding the first sentence, in the proposed rule, CMS would clarify the concept of rehabilitative therapy to include “recovery or improvement in function and, when possible, restoration to a previous level of health and well-being.”  

… “We are proposing to clarify the regulatory text so that if an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration of therapy services required to achieve such potential, therapy would not be considered reasonable and necessary, and therefore would not be covered as rehabilitative therapy services.”

CMS also proposes to clarify the regulatory text to describe that therapy is covered as rehabilitative therapy when the skills of a therapist are necessary to safely and effectively furnish or supervise a recognized therapy service whose goal is improvement of an impairment or functional limitation.

Under proposals, therapy would not be covered where a patient suffered a “transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.”   Also, if at any point in an episode treatment is not rehabilitative or legitimately require a qualified service, therapy ceases to be covered.

§409.44(c)(2)(iii) currently covers OT, PT or SLP if the services are “necessary to establish a safe and effective maintenance program required in connection with a specific disease.” CMS wants to add text stating that the specialized skill of a therapist is required to develop a maintenance plan. That plan should include patient, family and caregiver training, and re-evaluation plans. Maintenance plans should be included where applicable.

The proposal also talks about maintenance in a skilled nursing case: “We propose that when a patient qualifies for Medicare’s home health benefit based on an intermittent skilled nursing need, a qualified therapist may develop a maintenance program to maintain functional status or to prevent decline in function, at any point in the episode.  The services of a qualified therapist would not be necessary to carry out a maintenance program, and would not be covered under ordinary circumstances.  The patient could perform such a program independently or with the assistance of unskilled personnel or family members.”

However, if carrying out a maintenance plan required complex therapy procedures, “to be delivered by the therapist himself/herself (and not an assistant) in order to provide both a safe and effective maintenance program and to ensure patient safety, those reasonable and necessary services would be covered, even if the skills of a therapist were not ordinarily needed to carry out the activities performed as part of the maintenance program.

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July 1, 2010

PECOS rejections will de delayed

It looks like CMS will delay the rejection of claims and announces that CMS will develop a contingency plan regarding PECOS.


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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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