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March 16, 2016, "Home Health & Hospice: What's New" ACT

Topics and related resources discussed during the "Home Health & Hospice: What's New" ACT:

Ask-the-Contractor (ACT) Questions and Answers

March 16, 2016, "Home Health & Hospice: What's New" ACT

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  1. The physician's signature needs to immediately following the narrative on the face-to-face. Does that apply to both home health and hospice?

    • This applies only to hospice, not to home health.

      Reviewed: 09.27.16

  2. When a patient is on general inpatient (GIP) level of care and they are receiving medication adjustment to get the pain or symptoms under control, how do we know how long the patient can stay at the GIP level for monitoring for effective symptom relief?

    • Yes, you can keep the patient at GIP level of care while you're making sure the medication is going to work effectively. Use common sense and don't go overboard for an extended length of time. Usually 24 to 48 hours for monitoring for effective symptom relief is appropriate, depending on each individual case.

      Reviewed: 09.27.16

  3. Is there any information available about the fix for claims that have been overpaid for the SIA adjustment?

    • Yes, we have a claims processing log that's available on our website. If you go to CGSMedicare.com and go to the home health and hospice page. Click on Claims from the navigation side and you will see a link for the claims processing log. That is going to display all the issues that we are aware of and the status of those.

      We just recently updated that issue about the SIA overpayments and we did receive information from CMS that this has been fixed in the system and we are beginning to work on adjusting those claims. They issued that direction to us last week and I think we have about 45 days to make those adjustments for you.

      Reviewed: 09.27.16

  4. We had a patient that was disqualified for SIA and we did not get an extra payment so we did call CGS and they told us that we have to have underneath the covered benefits the last 7 days of life that we think we should be able to get payment for. My question is now do we have the non-covered up until that time and then we switched the days over for the last 7 days to the covered of category? So prior to January the 1st you know on all hospice claims you had to have all the non-covered services so Medicare would know actually what services you are performing so you had those on a non-covered because of course we're only going to be paid for our per diem but now since the last 7 days they're saying my 7 days should be moved over to the covered so that Medicare that those are the ones that we want you to calculate.

    • The only advice that I have for you right now is that you're suppose to be billing as normal, there's nothing that you're supposed to have to do extra so it may be one that I need to research.

      Provider was called and advised to follow instructions she was given by our Provider Contact Center (PCC) based on their claim situation. As previously mentioned, no special billing is needed for SIA payments for claims meeting the criteria outlined by CMS.

      Reviewed: 09.27.16

  5. A few weeks ago we received some probe and educate ADRs, but within a couple of days of receiving the ADRs the claim was paid by CGS before I even got the paperwork submitted. I'm fine with being paid but I'm just wondering what happened? We can't see any evidence in FISS yet, but I have the ADR printed out.

    • During a nightly system cycle, it is likely that more than five of your claims will move into a suspended location. CGS will work to release claims in excess of the five claim sample before those claims move to SB6001 and an ADR request is sent. Do not submit medical documentation unless your claim moves to SB6001 and you receive a MR ADR request. If you feel you have received more than 5 ADRs for the probe and educate edit, please contact the Provider Contact Center (PCC) with the specific claim information so that we may research the issue.

      MR ADR documentation may be submitted via the myCGS portal, electronic submission of medical documentation esMD, fax (1.615.660.5981) or mail.

      Reviewed: 09.27.16

  6. We have had two of our charts pulled for probe and educate, and we sent them in. One of them has not cleared and nothing has happened with it. Now the next episode for the same patient has been pulled. Does that indicate it's going to be the same face-to-face information that will be sent for that file?

    • It would be possible for two claims for the same beneficiary to be pulled, especially for a small provider. Yes, you would submit the same face-to-face documentation because for each review, we look to make sure there was a valid initial certification and face-to-face.

      Reviewed: 09.27.16

  7. The National Association for Home Care & Hospice (NAHC) recently released guidance to their members stating the actual face-to-face encounter, if performed by a non-physician provider (NPP) such as a nurse practitioner (NP) or a physician's assistant (PA), does not have to be cosigned by the certifying physician. I would like clarification because we thought even though the encounter was performed by the NPP, it would have to be cosigned by the physician. Our process says the physician has to cosign the encounter that the NPP had with the patient as evidence that the physician is agreeing the patient meets the Medicare requirements for service.

    • There is nothing in the guidelines issued by CMS that says that has to happen. You may have rules in the conditions of participation or your state rulings that say you do need to have the physician sign following an allowed NPP. As far as CMS is concerned, the physician doesn't need to sign following the allowed NPP, but if you have stricter regulations from someone else you need to follow the strictest of the regulations. The certifying physician signs the certification stating the patient meets the Medicare requirements for service.

      Reviewed: 09.27.16

  8. If a second round of probe and educate Additional Development Requests (ADRs) is conducted, and you don't fare well in the second round, will there be an additional round of probe and educate ADRs?

    • There has been no information provided that would allow for more than two rounds of probe and educate ADRs.

      Reviewed: 09.27.16

  9. In regard to the G codes for the LPN and RN, I wanted some clarification because it's my interpretation with the LPN use of the G code it's only specific for the direct skilled nursing service it would not be applicable to observation and assessment or teaching and training, am I correct?

    • We have received or heard about some confusion with the code but you are exactly right. You're only going to use those appropriately as a replacement for that G0154 everything else you would use the same nursing codes that you did in the past so your understanding is exactly correct.

      Reviewed: 09.27.16

  10. When I heard that you mentioned that myCGS portal that you can submit your request for redeterminations and attachments on that website, can you just give me a little more direction on how to access that area.

    • The best resource for you is going to be to go to the myCGS tab on our website. Once you get there we've actually created some new brochures you can find those under the myCGS Brochures/Resources section. We have one specific for each item within myCGS. You'll see Job Aids and down towards the bottom of the page there's one specific for Redetermination Requests and also another one Redetermination through myCGS Reminders as well.

      Reviewed: 09.27.16

  11. As far as uploading everything to myCGS can we do all of them at the same time or do we have to do a separate one for each ADR?

    • There is a certain limit as to how many attachments you can actually upload with myCGS. As far as submitting your request for redetermination, you can upload your attachment request up to 40 MBs in size but they cannot exceed a total attachment size of 150 MBs. So it's not really a page limit per se but based on the size of the attachment.

      Reviewed: 09.27.16

  12. We have yet to see any of the probe and educate ADRs for our agency and I'm wondering maybe our volume isn't enough or how they go about beginning to start with agencies.

    • All home health agencies who submit claims for Medicare home health services will be included in the probe and educate program. The claims are not pulled in any specific order, so it may take some time for all providers to see ADRs for probe and educate. Please be patient as the process moves along.

      Reviewed: 09.27.16

  13. I have a question about the hospice face-to-face encounter. The signature you said from the physician needs to be directly below their attestation, so if our nurse practitioner does the face-to-face and the physician routinely signs under the sentence that says that the nurse practitioner has communicated the results of the face-to-face assessment, would we have to redo our form? Is that what you were talking about or were you talking about the certification of terminal illness (CTI) attestation?

    • This is referring to the physician narrative which is part of the certification of terminal illness, not the face-to-face encounter form.

      Reviewed: 09.27.16

  14. Is the attending physician responsible for filling out the narrative or is the hospice medical director?

    • Either the attending physician or the hospice medical director can fill out the narrative.

      Reviewed: 09.27.16

  15. Is the primary physician or the hospice medical director or both responsible for signing the hospice recertifications?

    • On recertifications there just needs to be one signature. On the certification both the medical director and the attending physician (if there is an attending physician) need to sign. But on the recertification, there needs to be one signature from either the primary physician or the hospice medical director.

      Reviewed: 09.27.16

  16. If the hospice admission is really a recertification because previously the patient has used both 90 day initial certification periods, does the primary physician or hospice director or both sign the recertification?

    • Even though the patient is new to you with their admission, because they have used both of their 90 day periods, it will be an actual recertification and there needs to be just one signature.

      Reviewed: 09.27.16

  17. I have a question about my January claims submitted with the old G codes because the system that we were using it wasn't updated with the new G codes so fortunately all of our January claims were paid even though we had the old G codes, but my question is how do I adjust or do I need to make the adjustments with the correct G codes to get the SIA payments.

    • Yes, I'm going to say that you probably do have to do those adjustments, but I want you to call into our customer service and have them look at the situation so they can advise you what's the best route to resolve those.

      Reviewed: 09.27.16

  18. On our form the physician filled out a box where it has the narrative and underneath that narrative is an attestation that this narrative is based on examining the patient and then below that is a check box if there's an addendum to be attached and then below that is a signature. Is that acceptable or are you talking about the physician has to sign his/her name right below the written addendum or written narrative?

    • The physician signature needs to be directly following the narrative. This information is found in the Medicare Benefit Policy manual, Chapter 9, Section 20.1, entitled Timing and Content of Certification.

      • "If the narrative is part of the certification or recertification form, then the narrative must be located immediately above the physician's signature.
      • If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.
      • The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his or her examination of the patient. The physician may dictate the narrative."

      Reviewed: 09.27.16

  19. On the manual on page 7, it states the narrative shall include a statement directly above the physician's signature attesting that by signing, the physician confirms that he or she composed the narrative based on the findings, and so is that being removed from the manual?

    • This has not been removed from the manual. Please continue to follow all of the manual's resources.

      Reviewed: 09.27.16

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