Thursday, August 29, 2013

August 26, 2013

DRILL DOWN – MS-DRG Length of Stay (LOS) Greater or Equal to Geometric Mean Length of Stay (GMLOS)

RAC Region B contractor CGI posted an inpatient complex audit issue regarding MS-DRG’s without complications and comorbidities or without major complications and comorbidities where the length of stay is equal to or greater than the geometric length of stay. Per CGI, the purpose of this MS-DRG validation is to review DRGs without complication or comorbidity that have a length of stay (LOS) greater than or equal to the geometric mean length of stay (GMLOS). These charts will be reviewed to identify conditions missed that would equate to the intensity of service provided. The reviewer will validate for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG per Medicare guidelines.

Below is an example for MS-DRG 310 - Cardiac Arrhythmia & Conduction Disorders W/O CC/MCC where the LOS is 2.3 days and GMLOS is 2.0 days. This table is located on the Centers for Medicare & Medicaid (CMS) website under Acute Inpatient PPS, FY 2013 IPPS Final Rule Home Page and can be found here: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html

Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2013-IPPS-Final-Rule-Home-Page-Items/FY2013-Final-Rule-Tables.html

RAC issues for the week of August 26^th – August 30^th 2013:

RAC Region A Performant

Independent Therapy Provider

§ Home Health Consolidated Billing and Therapy Services - JK - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (A) (Home Health Services Consolidated Billing), therapy services (physical, occupational, and speech-language pathology) are bundled into the Home Health Prospective Payment System (HH PPS) reimbursement made to the Home Health Agency (HHA), while the patient is under a home health plan of care. Medicare does not make separate payment to the independent therapy provider.

Outpatient Hospital

§ Home Health Consolidated Billing and Therapy Services - JK/JL - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (A) (Home Health Services Consolidated Billing), therapy services (physical, occupational, and speech-language pathology) are bundled into the Home Health Prospective Payment System (HH PPS) reimbursement made to the Home Health Agency (HHA), while the patient is under a home health plan of care. Medicare does not make separate payment made to the outpatient hospital therapy provider.

Physician/Non-Physician Practitioner

§ Maximum Allowed Units for Part B Drugs and Biologicals - JK - Potential incorrect billing occurred for claims billed in excess of the maximum allowed units for Part B drugs and biologicals, when no additional supporting documentation is received from the provider for complex review within the 45-day response period.

RAC Region B CGI

Inpatient

§ MS-DRGs without CC/MCC and LOS greater than or equal to GMLOS (Medical Necessity Excluded) - The purpose of this MS-DRG validation is to review DRGs without complication or comorbidity that have a length of stay (LOS) greater than or equal to the geometric mean length of stay (GMLOS). These charts will be reviewed to identify conditions missed that would equate to the intensity of service provided. Reviewer will validate for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG were met per Medicare guidelines.

RAC Region D HDI

Inpatient Acute Care Hospital

§ Pre-Payment Review of MS-DRG 392 - Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 392, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.

Professional Services (Physician/Non-Physician Practitioner)

§ Incorrect Billed Drug and Biological HCPCS Code - Providers are required to report appropriate HCPCS codes for the drugs and biologicals administered and billed. Medical documentation will be reviewed to determine that the appropriate HCPCS code was billed. (At this time, Medical Necessity will be excluded from this review.)

August 19, 2013

Drill Down – Glucose Monitors Excessive Units Billed

RAC Region A contractor Performant has posted an automated review regarding beneficiaries receiving diabetic supplies above the maximum allowable limits. The supplies in question are the glucose monitor test stripes and lancets in quantities greater than maximally allowed and medically necessary every three months for beneficiaries who are currently being treated with insulin injections and who have not seen their physician within six months prior to having ordered the supplies. This audit issues references both the NHIC Local Coverage Determination (LCD) and its corresponding Local Coverage Article.

Local Coverage Determination (LCD): Glucose Monitors

To be eligible for coverage of home blood glucose monitors and related accessories and supplies, the beneficiary must meet both of the following basic criteria (1) – (2):

1. The beneficiary has diabetes (ICD-9 codes 249.00-250.93); and

2. The beneficiary’s physician has concluded that the beneficiary (or the beneficiary’s caregiver) has sufficient training using the particular device prescribed as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing.

The quantity of test strips (A4253) and lancets (A4259) that are covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus.

Coverage of testing supplies is based on the following guidelines:

Usual Utilization

· For a beneficiary who is not currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every 3 months are covered if the basic coverage criteria (1) –

(2) (above) are met.

· For a beneficiary who is currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every 3 months are covered if basic coverage criteria (1) – (2) (above) are met.

High Utilization

· For a beneficiary who is not currently being treated with insulin injections, more than 100 test strips and more than 100 lancets every 3 months are covered if criteria (a) – (c) below are met.

· For a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every 3 months are covered if criteria (a) – (c) below are met.

A. Basic coverage criteria (1) – (2) listed above for all home glucose monitors and related accessories and supplies are met; and,

B. The treating physician has seen the beneficiary, evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines and has documented in the beneficiary's medical record the specific reason for the additional materials for that particular beneficiary; and,

C. If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the beneficiary is actually testing or a copy of the beneficiary's log) that the beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the beneficiary is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria (A) – (C) are not met, the amount in excess will be denied as not reasonable and necessary.

NHIC Local Coverage Article: Glucose Monitors - Policy Article - Effective July 2011

For glucose test strips (A4253), 1 unit of service = 50 strips. For lancets (A4259), 1 unit of service = 100 lancets.

Manufacturers often include sample amounts of glucose test strips, lancets and other supplies with a new glucose monitor. Claims for supplies included in the new monitor “kits” must be coded A9900.

RAC issues for the week of August 19^th – August 23^rd 2013:

RAC Region A Performant

DME Supplier

§ Beneficiaries Receiving Diabetic Supplies Above the Maximum Allowance - Jurisdiction A - Potential incorrect billing occurred for claims reporting quantities of test strips and lancets greater than the maximum amounts that are considered to be medically necessary every three months for beneficiaries who are currently being treated with insulin injections and who have not seen their physician within six months prior to having ordered quantities of strips and lancets that exceed the utilization guidelines, per NHIC's Local Coverage Determination (LCD) L11530 and related article A33614.

§ Home Health Consolidated Billing and Medical Supplies - DME Supplier - Jurisdiction A - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (B) (Home Health Services Consolidated Billing), all medical supplies (routine and non-routine) are bundled to the Home Health Agency (HHA) episode payment rate while the patient is under a home health plan of care. Payment is made to the HHA and there is no separate payment to the DME Suppliers.

RAC Region C Connolly

Inpatient Hospital

§ CMS Pre-Pay Demonstration: MS-DRG-391- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w MCC - The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: • CMS approves all issues for review; and • The issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (FIs)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: • Billed with MS-DRG-391- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w MCC • Length of stay is two days or less; • From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

Inpatient PPS

§ Minor Surgery and Other Treatment Billed as an Inpatient Stay - IOM 100-02, Chapter 1, Section 10, states “Minor Surgery or Other Treatment - When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.” Claims billed for minor surgical or other treatment are identified for medical record review based on risk of improper payment for inpatient care when outpatient care was provided. Claims for patients admitted through the emergency department are excluded. RACs WILL ALSO REVIEW documentation for DRG Validation, requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

IP Hospital

§ CMS Pre-Pay Demonstration: MS-DRG-392- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w/o MCC - The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: • CMS approves all issues for review; and • The issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (FIs)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: • Billed with MS-DRG-392- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w/o MCC • Length of stay is two days or less; • From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

August 12, 2013

DRILL DOWN – Minor Surgery and Other Treatment Billed as Inpatient

RAC Region A Performant posted a complex review issue this week regarding minor surgery and other treatment billed as an inpatient stay. Perfomant sites the Centers for Medicare & Medicaid (CMS) publication 100-02 – Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A, “Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital. In certain specific situations coverage of services on an inpatient or outpatient basis is determined by the following rules:

Minor Surgery or Other Treatment - When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.”

Claims that will be reviewed under this approved issue are for minor surgical procedures and treatments that are at risk of improper payment for inpatient care when outpatient care was provided however, claims for patients admitted through the emergency department are excluded.

RAC issues for the week of August 12^th – August 16^th 2013:

RAC Region A Performant

Psychiatric Facility (IPF) (Inpatient Psychiatric Hospital and Inpatient Psychiatric Unit)

§ Inpatient Psychiatric Hospital and Inpatient Psychiatric Unit Services (Medical Necessity Review of MDC 19: Mental Diseases and Disorders, and Medical Necessity Review of MDC 20: Alcohol/Drug and Alcohol/Drug-Induced Organic Mental Disorders) - Medicare pays for inpatient psychiatric hospital and inpatient psychiatric unit services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of: •MS-DRG 876 O.R. Procedure with Principal Diagnosis of Mental Illness •MS-DRG 880 Acute Adjustment Reaction and Psychosocial Dysfunction •MS-DRG 881 Depressive Neuroses •MS-DRG 882 Neuroses Except Depressive •MS-DRG 883 Disorders of Personality and Impulse Control •MS-DRG 884 Organic Disturbances and Mental Retardation •MS-DRG 885 Psychoses •MS-DRG 886 Behavioral and Developmental Disorders •MS-DRG 887 Other Mental Disorder Diagnoses •MS-DRG 894 Alcohol/Drug Abuse or Dependence, Left Against Medical Advice •MS-DRG 895 Alcohol/Drug Abuse or Dependence with Rehabilitation Therapy •MS-DRG 896 Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy with MCC •MS-DRG 897 Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy without MCC

Inpatient Hospital

§ Minor Surgery and Other Treatment Billed as an Inpatient Stay - IOM 100.02 Chapter 1, Section 10, states "Minor Surgery or Other Treatment - when patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came in to the hospital, whether they used a bed, and whether they remained in the hospital past midnight." Claims billed for minor surgical or other treatment are identified for medical record review based on risk of improper payment for inpatient care when outpatient care was provided. Claims for patients admitted through the emergency department are excluded. • PLEASE NOTE: DISREGARD THE STATEMENT IN THE “DATES OF SERVICE” SECTION BELOW. FOR THIS ISSUE, CLAIMS HAVING A “CLAIM PAID DATE” WHICH IS MORE THAN 2 YEARS PRIOR TO THE ADR DATE WILL BE EXCLUDED.

RAC Region B CGI

Comprehensive Outpatient Rehabilitation Facilities

§ Comprehensive Outpatient Rehabilitation Facilities Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Home Health

§ Home Health Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Inpatient

§ Minor Surgery and Other Treatment Billed as an Inpatient Stay (Medical Necessity) - IOM 100-02, Chapter 1, Section 10, states “Minor Surgery or Other Treatment – When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.” Claims billed for minor surgical or other treatment are identified for medical record review based on risk of improper payment for inpatient care when outpatient care was provided.

Outpatient Hospital

§ Outpatient Hospitals Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Outpatient Professional

§ Outpatient Professional Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Outpatient Rehabilitation Facility

§ Outpatient Rehabilitation Facilities Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Skilled Nursing Facility

§ Skilled Nursing Facility Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

RAC Region D HDI

DME Non-Physician

§ No-Power Option Power Wheelchairs Incompatible With Any Power Seating System - Power seating systems may not be used with any Group 1 Power Wheelchairs and any Group 2, 3 or 4 Power Wheelchairs that are classified as ‘no power option’ wheelchairs.

§ Excessive Units of Diabetic Supplies - Lancets and Test Strips - LCD L196 limits the number of allowed units for HCPCS code A4259 (Lancets) and A4253 (Test Strips). Quantities that exceed the maximum allowance without evidence of physician evaluation within the prior six months are not considered reasonable and necessary.

Tuesday, August 13, 2013

August 5, 2013

DRILL DOWN – Maximum Allowable Units

RAC Region B contractor CGI posted a semi-automated issue that targets Professional drug claims which have quantities beyond the maximum allowable units based on the Palmetto GBA Drugs & Biologicals: Maximum Allowed Units (MAU) list. Palmetto GBA developed maximum allowed units (MAU) modeled from the medically unlikely edits (MUE) implemented by Centers for Medicare & Medicaid Services (CMS).

Why did Medicare Administrative Contractors Palmetto GBA make its own MAU? Since drug calculations require accurate conversion of drug units supplied, the total amount given to a patient and the units billed, these multiple mathematical conversions by the billing staff caused errors on claims submitted. Palmetto GBA therefore decided to create a maximum allowed units table modeled from the CMS MUE table.

Palmetto used specific guidelines to create the table, such as:

Lethal dose per package insert
For multiple dose drugs, MAU allows expected dose for 12 hour period and appropriate for clinic/office environment
For weight based calculations, MAU allows the following:

- 2.4 m2 BSA maximum

- 110 kg lean body weight maximum

For emergency injectables, MAU allows one dose, plus one repeat dose to cover patient move from the clinic/OP setting to ER and IH
For multiple use drugs, MAU reflects maximum for all uses. Note that based on the varied parameters, Palmetto GBA expects the average patient may receive dosage below the MAU and will continue to monitor utilization outliers for further action.

For a complete list and billing instructions being referenced by this RAC issue on Palmetto GBA’s website at the following: http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/7REJY56858

To read the multiple tables contained on the website, I will provide an example. On the web page, you will see the table titled MAU Legend with numbers in the first column that describe how the code is handled. For example, #5 means Special Instructions (select HCPCS code to view instructions) and in this case I will use HCPCS code J1170. In the table titled Maximum Allowed Units List the second column is the HCPCS code, followed by the code description and then the MUA in the fourth column, which in this case it is 300 MAU. The fifth column is the release date of the code and the sixth column is the reassessment date.

Special Instructions, as mentioned above for HCPCS code J1170, are as follows for submitting paper or electronic claims.

HCPCS Code J1170 - Hydromorphone
For Hydromorphone implantable pump use, providers must submit the invoice with the total units that are used to fill the pump.

For paper claim submissions, enter 'compound prescription, invoice attached' in Item 19 and include a copy of the pharmacy invoice
For electronic claim submission, enter 'fax' in the narrative field and include a copy of the pharmacy invoice with the appropriate cover sheet

This is a semi-automated review edit to identify professional drug claims which were submitted with quantities beyond the maximum allowable amount first and then request any supporting documentation required per Special Instructions or for individual consideration.

RAC issues for the week of August 5^nd – August 9^th 2013:

RAC Region B CGI

DME Claim Types

§ DME Home Health Consolidated Billing - NGS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.

Outpatient Hospital Claim Types

§ Outpatient Home Health Consolidated Billing - CGS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.

§ Outpatient Home Health Consolidated Billing - WPS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.

Professional Claim Types

§ Drug - Maximum Allowable Units - This semi-automated edit is to identify professional drug claims which were submitted with quantities beyond the maximum allowable amount based on the Palmetto Drug & Biologicals: Maximum Allowed Units (MAU) list.

§ Professional Home Health Consolidated Billing - CGS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.

§ Professional Home Health Consolidated Billing - WPS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.