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CuriositykNOwMore
Joseph Newsome, CPC, COC, CPCO, CPMA, CPPM, CPC-I, CEMC, AAPC Fellow
New RulesCode ChangesCurrent Events
Agenda
A final rule effective July 13, 2017, which the Centers for Medicare & Medicaid Services (CMS) maintains will improve home health care while streamlining providers’ requirements.CMS said there are more than 5 million Medicare and Medicaid beneficiaries receiving home health care from nearly 12,600 Medicare and Medicaid participating home health agencies, nationwide. The new rule includes a number of changes CMS proposed that it explained reflects current best practices.
CMS: New Home Health Rules and Beneficiary Protections
Source: https://www.aapc.com/blog/37374-cms-new-home-health-rules-and-beneficiary-protections
Extensive ChangesA comprehensive patient rights condition of participation that clearly enumerates the rights of home health agency patients and the steps that must be taken to assure those rights.An expanded comprehensive patient assessment requirement that focuses on all aspects of patient well being, including psychosocial, functional, and cognitive.
CMS: New Home Health Rules and Beneficiary Protections
Source: https://www.aapc.com/blog/37374-cms-new-home-health-rules-and-beneficiary-protections
Extensive Changes ContinuedA requirement assuring that patients and caregivers have written information about upcoming visits, medication instructions, treatments administered, instructions for care that the patient and caregivers perform, and the name and contact information of a home health agency clinical manager.A requirement for an integrated communication system that ensures that patient needs are identified and addressed, care is coordinated among all disciplines, and  there is active communication between the home health agency and the patient’s physicians.
CMS: New Home Health Rules and Beneficiary Protections
Source: https://www.aapc.com/blog/37374-cms-new-home-health-rules-and-beneficiary-protections
Extensive Changes ContinuedA requirement for a data-driven, agency-wide quality assessment and performance improvement (QAPI) program that  evaluates and improves agency care for all patients at all times.A new infection prevention and control requirement focusing on the use of standard infection control practices, and patient/caregiver education and teaching.
CMS: New Home Health Rules and Beneficiary Protections
Source: https://www.aapc.com/blog/37374-cms-new-home-health-rules-and-beneficiary-protections
Extensive Changes ContinuedA streamlined skilled professional services requirement focusing on appropriate patient care activities and supervision across all disciplines.An expanded patient care coordination requirement making a licensed clinician responsible for all patient care services, such as coordinating referrals and assuring  plans of care meet each patient’s needs at all times.
CMS: New Home Health Rules and Beneficiary Protections
Source: https://www.aapc.com/blog/37374-cms-new-home-health-rules-and-beneficiary-protections
Extensive Changes ContinuedRevisions to simplify the organizational structure of home health agencies while continuing to allow parent agencies and their branches.New personnel qualifications for home health agency administrators and clinical managers.
CMS: New Home Health Rules and Beneficiary Protections
Source: https://www.aapc.com/blog/37374-cms-new-home-health-rules-and-beneficiary-protections
CMS implements the fourth and final year of the four year phase-in of the rebasing adjustments to the HH PPS payment rates as required by the Affordable Care Act.In addition, CMS will decrease the national, standardized 60-day episode payment amount by 0.97 percent in calendar year (CY) 2017 to account for nominal case-mix growth between CY 2012 and CY 2014, which was not accounted for in the rebasing adjustments finalized in the CY 2014 HH PPS final rule.
The Centers for Medicare & Medicaid Services Final Rule
https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html
CMS is also changing the methodology used to calculate outlier payments to a per-unit approach. The CY 2017 final rule will result in a 0.7 percent decrease (-$130 million) in payments to HHAs.
The Centers for Medicare & Medicaid Services Final Rule Continued
https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html
How Does this effect us as Coders, Auditors and/or Compliance Officers?
CMS: New Home Health Rules and Beneficiary Protections
The Centers for Medicare & Medicaid Services (CMS) has released corrections toHCPCS Level IIcodes. Although fewer than in some years, they are again too late to make it into publishers’ 2017 HCPCS Level II coding books, which were rushed to print after the codes were released November 5th. Please keep these updates with your books.
CMS Makes Corrections to 2017 HCPCS Level II
https://www.aapc.com/blog/37214-cms-makes-corrections-to-hcpcs-level-ii/
C1842AddedRetinal prosthesis, includes all internal and external components; add-on to C1841E0627Removed reference code Q0080E0628Removed reference code Q0078E0629Removed reference code Q0079
CMS Makes Corrections to 2017 HCPCS Level II
https://www.aapc.com/blog/37214-cms-makes-corrections-to-hcpcs-level-ii/
G0477DeletedG0478DeletedG0479Deleted
CMS Makes Corrections to 2017 HCPCS Level II
https://www.aapc.com/blog/37214-cms-makes-corrections-to-hcpcs-level-ii/
G0480Revise Long DescriptionDrug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarilystereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcoholdehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed
CMS Makes Corrections to 2017 HCPCS Level II
https://www.aapc.com/blog/37214-cms-makes-corrections-to-hcpcs-level-ii/
G0481Revise Long DescriptionDrug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarilystereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcoholdehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed
CMS Makes Corrections to 2017 HCPCS Level II
https://www.aapc.com/blog/37214-cms-makes-corrections-to-hcpcs-level-ii/
U.S. Attorney for the District of Maryland, Rod J. Rosenstein announced December 20 that Elma Myles pled guilty to defrauding Medicaid and other health benefit programs by conspiring to have durable medical equipment provider RX Resources and Solutions (RXRS) bill for supplies that were never provided or were medically unnecessary, and to overcharge for materials that were actually delivered.
Billers Convicted in Fraud Schemes
https://www.aapc.com/blog/37280-billers-convicted-in-fraud-schemes/
An analysis of RXRS billing revealed that from 2007 through 2014, Medicaid lost roughly $1.2 million just for incontinence supplies, the release said.RacielLeon, 42, of Miami, was convicted after a two-week jury trial of one count of conspiracy to commit health care fraud and wire fraud and one count of conspiracy to defraud the United States and pay and receive health care bribes and kickbacks.
Billers Convicted in Fraud Schemes
https://www.aapc.com/blog/37280-billers-convicted-in-fraud-schemes/
According to evidence presented at trial, between approximately October 2014 and June 2015, Leon was the manager of Mercy Home Care Inc. (Mercy) and a billing employee for D&D&D Home Health Care Inc. (DDD), both of which were home health agencies in Miami-Dade County, Florida.The evidence showed that Leon and his co-conspirators used the companies to submit false claims to Medicare that were based on services that were not medically necessary, not actually provided and for patients that were procured through the payment of illegal kickbacks to doctors and patient recruiters.
Billers Convicted in Fraud Schemes
https://www.aapc.com/blog/37280-billers-convicted-in-fraud-schemes/
In an attempt to support the false claims, Leon’s co-conspirators forged prescriptions and other medical records, and Leon submitted claims to Medicare based on the falsified documentation.As is evident, fraud liability attached to the billers in these cases because of their ACTIVE INVOLEMENT as decision-makers and conspirators in the scheme to defraud.
Billers Convicted in Fraud Schemes
https://www.aapc.com/blog/37280-billers-convicted-in-fraud-schemes/
Billing for services that were not actually performed or provided;Billing for services that were performed by another provider;Billing for non-covered services using an incorrect diagnosis code in order to have services covered;Billing a patient more than the co-pay amount for services provided for under the health insurance plan;
Common Examples of Billing Issues
https://www.nhcaa.org/resources/health-care-anti-fraud-resources/consumers-frequently-asked-questions.aspx#9
Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary;Upcoding - billing for a more costly service than the one actually performed;Unbundling - billing each stage of a procedure as if each were a separate procedure; andWaiving patient co-pays or deductibles and over-billing the insurance plan.
Common Examples of Billing Issues
https://www.nhcaa.org/resources/health-care-anti-fraud-resources/consumers-frequently-asked-questions.aspx#9
What other billing issues have you encounter?
Common Examples of Billing Issues

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