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November 12, 2015

Home Health Probe and Educate

The goal of CGS's medical review (MR) program is to reduce errors by preventing the initial payment of claims that do not comply with Medicare's coverage, coding, payment and billing policies. Pursuant to instructions provided by the Centers for Medicare & Medicaid Services (CMS) CGS will be implementing a Home Health Probe and Educate project. The Medicare Learning Network® (MLN) article, SE1524External PDF, recently issued by CMS instructs all home health and hospice MAC's to sample five pre-pay claims from each home health agency that submit claims to that MAC.

As a result, CGS will be initiating a service- specific probe for all home health providers that bill to CGS. The topic code for this review will be 5013W, and the probe will select any start of care home health claim excluding demand bills. Once selected, the claims will be reviewed for valid patient eligibility including certification requirements, face-to-face encounter documentation, medical necessity, along with compliance with correct billing and coding associated with updates in the CMS-1611-F, Calendar Year (CY) 2015 Home Health Prospective Payment System (HH PPS) Final Rule).

Provider Action Needed to Prepare for the Edit

HHAs should take action now to ensure that they have procedures and processes in place to appropriately identify and respond to claims that are selected for Medical Review by this edit, including:

  • Checking for claims in the Additional Development Request (ADR) status/location S B6001 in the Fiscal Intermediary Standard System (FISS) at least weekly.
  • Be advised that depending on your daily billing volume, more than five claims may initially suspend for this probe. Any suspended claims, over the required five, with edit code 5013W, will be released by CGS to continue processing within 24-48 business hours.
  • Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency.
  • Ensure that your documentation is received by CGS within 45 days.

Refer to the following resources for assistance with responding to ADRs.

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