Healthcare Provider Solutions

With the ushering in of 2016 there comes a great many changes that will affect both home health and hospice.

1. New G-Codes to distinguish between RN (G0299) and LPN/LVN (G0300) for “hands on care” visits in Home Health, for Hospice this will be for all nursing visits. These new codes go into effect on January 1, 2016 with ANY visit dated January 1, 2016 or later must have these codes. For home health this may mean that there are visits on the same claim with G0154 for 2015 dates for service and G0299 or G0300 for 2016.

2. Retirement of Transitional CBSA CODES will be effective January 1, 2016. Home Health Agencies that have been using a transitional CBSA Code for 2015 will begin using the “permanent” CBSA codes again with all episodes ENDING January 1, 2016 and later.

3. Hospice Payment Reform Routine Home Care Rates will be different than in the past in that the rate will be reduced for all days billed after 60 days of routine at the high rate. In addition, the Service Intensity Add-On (SIA) will be in effect for the last seven days of life.

4. VBP Pilot While all these 2016 issues are on the forefront of your minds, the ever daunting Probe & Educate is looming! MLN Matters Number SE15245 was issued and included that CMS has directed Home Heath MACs to select a sample of 5 claims for pre-payment review from each HHA within their jurisdiction. If this hasn’t happened yet, it will soon. As they are completing the Probe and Educate reviews, MACs will focus on the HHA’s compliance with the policy outlined in CMS-1611-F, as well as to make sure all other coverage and payment requirements are met.

Based on the results of these initial reviews, MACs will conduct provider specific educational outreach. CMS has instructed MACs to deny each non-compliant claim and to outline the reasons for denial in a letter to the HHA, which will be sent at the conclusion of the probe review. We will also instruct the MACs to offer individualized telephone calls/education to all providers with errors in their claim sample. During such calls, the MAC will discuss the reasons for denials, provide pertinent education and reference materials, and answer questions.

In addition to these educational outreach efforts, for those providers that are identified as having moderate or major concerns, the MACs will repeat the Probe and Educate process for dates of services occurring after education has been provided. The following table outlines MAC actions following HHA probe reviews.

If agencies receive 1 denial they are subject to additional review at the instruction of CMS. Agencies that have 2+ denials are required to repeat the probe with 5 more charts. They are required to only pull 5 additional charts that have dates of service after the date of education provided by the MAC. This refers to education that was required as a result of the previous round of audits.

Following are the links to PGBA, CGS NGS website links to the Probe Educate: