Posts tagged ‘hhs pps’

August 16, 2012

Open Door Forum transcripts now available

There was a delay on the blog post regarding the recent Medicare Open Door Forums … the post didn’t publish until after the forums had happened!
No problem. Transcripts and audio are now available.

From the August 9, 2012 Medicare Fee-For-Service Recovery Auditor Prepayment Review Demonstration Special Open Door Forum.

From the August 7, 2012 Manual Medical Review of Therapy Claims Special Open Door Forum.

May 25, 2012

Denials begin for PoC without physician approval

The National Association for Home Care & Hospice (NAHC) recently learned that home health agencies have begun to receive Medicare denials because they provide services and treatments in accord with a plan of care developed after assessing the patient, without obtaining prior approval from the physician for the treatments and services in the plan. In these cases, nurses and therapists conduct patient assessments, initiate care in accord with the referral and create a written plan of care based on assessed needs. They then mail or fax this plan of care to the physician without first receiving approval from the physician for visits and treatments included in the plan of care.

As a result, services that were provided after the initial visit and up to the date of the physician’s signature on the plan of care are denied for lack of physician orders.

The Conditions of Participation (CoP) at 42 CFR 484.18(a) requires that the plan of care be developed in consultation with the agency staff, and that the physician be consulted to approve additions or modifications to the original plan. Further, the CoP require that therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration.

The Medicare coverage rules at 42 CFR § 409.43 specify that the plan of care must contain those items listed in the CoP at 42CFR §484.18(a) and that physician’s orders for services in the plan of care must specify the medical treatments to be furnished as well as the type of home health disciplines that will furnish the ordered services and at what frequency the services will be furnished.

See the Medicare Benefit Policy Manual ( for more specific information, including guidance on oral orders.

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April 19, 2012

Comment period on potential ICD-10 delay is now open

You can read the proposed rule to delay ICD-10 until Oct. 1, 2014.

CMS has released a fact sheet outlining the proposed rule.

The comment period closes at 5pm ET on May 17.

To submit comments:

The 30-day comment period for this rule is an important way to provide feedback to HHS about the proposed ICD-10 compliance date change. You can submit comments in the following ways:

  • Electronically by following the ‘‘Submit a comment’’ instructions on
  • By regular mail to:

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–0040–P
P.O. Box 8013
Baltimore, MD 21244–8013

April 17, 2012

CMS has two new focuses for medical reviews

CMS to focus on 2 new areas for reviews

At the NAHC conference in Washington, DC, recently, Latesha Walker of CMS said that CMS will begin medical reviews in two new areas:

  • Episodes that barely exceed the low utilization payment adjustment (LUPA) threshold of five visits with document reviews.
  • Review situations where an agency billed a low HHRG code for a first episode, but a higher one later.

Just because there are two new additions doesn’t mean that the old reviews shouldn’t be paid attention to anymore!

A few other things discussed at the meeting:

  • CMS has already set a 1.32 percent cut for case-mix in 2013 because of case-mix creep. CMS is moving ahead with its PPS rebasing project.
  • Confused on assessments and billability of visits with therapy? You’re not the only one. NAHC is still asking for clarification on when an assessment visit is billable (ever?) what is billable if you don’t do the assessment at exactly 30 days or the 13th or 19th visit. What if it’s the 14th visit? When does a visit become billable?
  • New CoP? Really? We’ll believe it when we see it, but Pat Sevast said new Conditions of Participation are on CMS’s to-do list.

Thanks, again, to HCLA for its update in its News Alert!