1. Do secondary diagnosis codes need to be listed in a specific order for the purposes of the comorbidity adjustment?
No, the ordering of the secondary diagnoses does not impact comorbidity adjustment. It is also important to note that the comorbidity does not change based upon the Clinical Grouping.
2. Who determines “Early” versus “Late”? Is the agency responsible, or does it come from CMS? If the agency is inaccurate, will CMS correct it?
Episode timing of early or late will be determined based on the number of subsequent billable payment episodes that have occurred without a 60-day break in care. This will ultimately be based on CMS claims data, and while agencies may classify the patient as early on the RAP, CMS will adjust based on claims data, if needed.
While CMS will no longer use M0110 to influence payment under PDGM, other payers may be using this data in their PPS-like payment model. In such cases, agencies should follow instructions from individual payors directing data collection by patient. Agencies may code M0110 Episode Timing with NA – Not Applicable for assessments where the data is not required for the patient’s payer (including all Medicare FFS assessments).
To streamline operation, Axxess clients have a direct connection to the Medicare Common Working File. At Intake, agencies can run Medicare eligibility and view claims data to view claims that would indicate whether the patient will fall in early vs. late category.
3. How do you recommend we handle a situation where the face-to-face does not match the primary diagnosis on the claim?
In instances where the encounter documentation used to fulfill the face-to-face encounter requirement does not identify the same primary reason for home health care as the admitting clinician’s determined primary reason for care, the agency staff would need to coordinate with the referral source to update this information, either through a subsequent visit with the physician in charge, or as an addendum to the clinical note as dictated by agency policy.
4. How will the RAP be calculated without the OASIS?
RAPs will be based on the HIPPS code as submitted by the agency. Axxess’ home health software will calculate this based on the information provided by the agency. This is different than how the final claim will be calculated, as CMS requires the MACs to verify the HIPPS code being paid by using a combination of the OASIS data on file in the QIES system (for the functional status), eligibility information and claims data. The OASIS must be submitted timely and on file when the final is billed to receive a final claim payment.
5. Is there such a thing as a no-RAP LUPA?
No-RAP LUPAs will remain in PDGM but will be applied to each 30-day billing period.
6. How long will it take for the 20% RAP to be paid and the 80% Final for each 30-day billing period?
RAPs are not considered to be a claim, so they are not subject to the 14-day Medicare claim payment floor. Medicare Fiscal Intermediaries should continue to process both RAPs and claims in the normal timeframes from submission date.
However, agencies can expect a delay early in the transition to PDGM from PPS, as evidenced by PDPM transition (in Skilled Nursing Facilities October 2019) information reported to date.
7. For Recerts, what will happen with the RAP on LUPA patients?
Agency process will dictate whether the agency will bill a no-payment RAP for known LUPA episodes versus submitting RAPs for payment as usual. If a RAP payment is received and the payment period becomes a LUPA period, CMS will adjust payment with the Final Claim as needed. If the RAP payment was more than the LUPA payment rate, the agency will show a recoupment of the difference in payment on the Remittance Advice.
8. Describe auto cancellation and resubmission of claims process of claims per 30- day PDGM billing.
The RAP cancellation process will remain the same for PDGM. If a Final has not been submitted within 60 days from the end of the 30-day billing period or 60 days from the time the RAP was paid, it will be automatically cancelled by Medicare.
9. How can you bill two 30-day episodes at the same time?
PDGM will have two independent 30-day billing periods, each with its own RAP and Final that can be billed as soon as the billing requirements have been met. If the first billing period and second period billing requirements are met at the same time, then both claims can be billed. There is no condition that they must be billed sequentially.
10. After 30 days, do we need to submit a new RAP? If yes, what documents are needed for the second 30-day RAP?
Yes, a RAP is required for each 30-day billing period and each billing period will keep the same current requirements. To bill a RAP, the OASIS must be completed, the plan of care must have been sent to the physician, and a first billable visit must have been completed. These requirements will be the same for the first and second 30-day payment periods.
11. Will the UTN for RCD be the same for both 30-day billing periods?
Under RCD’s Pre-Claim Review option, agencies will submit supporting documentation for each PDGM 30-day period and will receive a Unique Tracking Number (UTN) for each of these 30-day periods. The UTN will NOT be the same for both periods.
12. If diagnosis codes change within a 30-day period, how would you change those codes in the final claim without doing another OASIS or another plan of care?
Should a patient’s focus of care change in the second 30-day period, the home health agency will need to change the primary diagnosis, and possibly the secondary diagnoses, on the claim. Unlike current requirements, the OASIS, plan of care, and the claim will not be required to match under PDGM. Therefore, no OASIS is required to be performed just to ensure the diagnoses match across these documents. No new plan of care is required before the recertification cycle as long as interventions and goals are covered on the original plan of care or supplemental orders.
Axxess has streamlined operations for its clients through the Change of Focus form. This form will help agencies improve compliance as it provides easy access to update goals and the plan of care. In addition, it will increase revenue by allowing the new primary diagnosis to flow directly to the billing claim form.
13. If a patient is discharged before the end of the 60-day episode and before the LUPA threshold has been met, will agencies be paid?
Yes, just as we are accustomed to under PPS, the agency will be paid for LUPAs for either or both 30-day payment periods at an adjusted rate reflective of how many visits have been provided.
14. Is it mandatory to bill at the new 30-day payment period mark? Or could you wait if you wanted and bill the entire 60 days at the end of the episode?
You are required to submit claims in 30-day increments, but there is not a requirement for you to bill every 30 days. If an agency chooses, they may bill at the end of the 60 days but will still be required to bill 2 RAPs and 2 Finals.
15. Can we bill insurance for telehealth?
Medicare does not provide reimbursement for telemonitoring; however, some state Medicaid plans (for example Texas) do provide reimbursement for telemonitoring. Agencies will need to check with individual plans to determine if telemonitoring is a covered benefit.
16. What is the FISS System? How is this related to recent hospitalizations?
The Fiscal Intermediary Standard System (FISS) is the standard Medicare Part A claims processing system. It allows you to enter, correct, adjust, or cancel your Medicare billing transactions. The FISS System will be checked by CMS for recent hospital stays that may adjust final claim payment for home health payments under PDGM.
17. Will there be a reduction of payment if a patient is readmitted in fewer than 60 days?
Partial Episode Payment, or PEP, rules will remain the same under PDGM. However, rather than considering the 60-day OASIS certification period, they will occur based on 30-day billing periods.
18. How will orders be affected in PDGM?
In order to file a final 30-day claim at the end of each billing cycle, all orders must be signed and back to the agency. Orders management will be a crucial piece of successful PDGM management.
Axxess has streamlined orders management through the Physician’s Portal within the home health software, as well as an integration partnership with WorldView.
19. Will all physician’s orders need to be signed to be able to bill the 30-day period?
Yes. All physician’s orders, including plans of care, must be signed prior to billing the final claim.
20. Will there be any change in the billing of outlier patients?
Outlier payment calculations will still be based on high cost periods and will be applied to 30-day payment periods rather than 60-day episodes.
21. How will CMS implement the 4.36% behavioral adjustment?
The 2020 National Standardized Payment Rates have been adjusted like any annual increases or decreases.