Medicare Home Health & Hospice Claims Processing Errors: Is Your Agency Paid Correctly?

Thoughtware Article Published: May 01, 2016
Nurse and patient holding hands

On October 16, 2015, the Centers for Medicare & Medicaid Services (CMS) issued Change Request 9369

(CR 9369), which retired Healthcare Common Procedure Coding System (HCPCS) code G0154 as of December 31, 2015. On January 1, 2016, the code was replaced with two new codes—G0299 and G0300—for reporting skilled nursing visits for home health and hospice services on all Medicare claims. CMS defined these codes as follows:

  • G0299 – Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting
  • G0300 – Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting

The purpose of separating RN from LPN services was to allow for the calculation of the newly implemented Medicare service intensity add-on payment (SIA) for hospice. The SIA provides additional payment to hospice providers for RN and social work (SW) visits during the last seven days of life for those patients at the routine home care (RHC) level of care. The SIA amount is in addition to the RHC per diem and is paid in 15-minute increments at the same rate as continuous home care, for up to four hours per day of combined RN and SW visits. You can download these rates for your service area here.

Implementation of the new codes triggered some unexpected claims processing errors. Prior to January 1, 2016, nonhome health and nonhospice Medicare providers used HCPCS codes G0299 and G0300 to bill for defibrillator services. An existing CMS claims processing edit requiring that specific diagnosis codes be present on the claim to support the defibrillator services caused home health and hospice claims to be returned to providers for correction. In addition, an edit existed that required revenue code 055X to be paired with HCPCS code G0154 when reporting skilled nursing visits on hospice claims.

CMS has instructed the home health and hospice Medicare Administrative Contractors (MAC) to temporarily deactivate the problematic claims processing edits to facilitate the processing of claims with dates on or after January 1, 2016.

There also have been errors in the calculations of home health Low Utilization Payment Adjustments (LUPA) related to the new coding. LUPA claims corresponding to the patient’s first episode in a series of adjacent episodes or the patient’s only episode are eligible for a LUPA add-on payment. Add-on payments are calculated based on the discipline of the earliest visit date on the claim, which according to Medicare coverage requirements must be a skilled nursing, physical therapy or speech pathology visit. Since CMS claims processing edits are currently recognizing the retired HCPCS code G0154 as skilled nursing, some claims are not receiving LUPA add-on amounts or are receiving the add-on payment based on the wrong discipline of service.

On February 5, 2016, CMS issued Change Request 9474 (CR 9474) to address the suspended edits and LUPA calculation errors. CR 9474 revises the suspended edits so they can be reactivated without issue and can correct the LUPA payment calculation error. The implementation date for CR 9474 is July 5, 2016. CMS has instructed MACs to adjust LUPA claims impacted by the error within 60 days of the implementation date.

For more information, contact your BKD advisor.

Related Thoughtware

Kate & Ben — How can we help you? Contact Us!

How can we help you?