The How-To Guide To Home Health Billing, HOME HEALTH .
The How-To Guide t oHOME HEALTH BILLINGSECOND EDITIONJoan L. Usher, BS, RHIA, ACE
Th e H o w - To Guide toHOME HEALTH BILLINGSECOND EDITIONJoan L. Usher, BS, RHIA, ACE
The How-To Guide to Home Health Billing, Second Edition is published by HCPro, a division of BLR.Copyright 2016 HCPro, a division of BLRAll rights reserved. Printed in the United States of America.5 4 3 2 1ISBN: 978-1-68308-082-4No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or theCopyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy.HCPro provides information resources for the healthcare industry.HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.Joan L. Usher, BS, RHIA, ACE, AuthorTami Swartz, EditorErin Callahan, Vice President, Product Development & Content StrategyElizabeth Petersen, Executive Vice President, HealthcareMatt Sharpe, Production SupervisorVincent Skyers, Design Services DirectorVicki McMahan, Sr. Graphic DesignerJake Kottke, Layout/Graphic DesignPhilip Couch, Cover DesignerAdvice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.Arrangements can be made for quantity discounts. For more information, contact:HCPro100 Winners Circle Suite 300Brentwood, TN 37027Telephone: 800-650-6787 or 781-639-1872Fax: 800-785-9212Email: customerservice@hcpro.comVisit HCPro online at www.hcpro.com and www.hcmarketplace.com
ContentsAbout the Author. viiChapter 1: Home Health Billing Overview.1Biller’s Role and Required Skills.1Home Health Billing Overview.2Who Is Your MAC?. 14Types of Insurance Plans. 14Medicare Health Benefit. 16The Prospective Payment System (PPS). 17Health Insurance Prospective Payment System (HIPPS). 21Calculating the Episode. 21PC Pricer .23Chapter 2: Home Health Benefit Verification.25Medicare Verification: Through the FISS System.27Which Insurance Is Primary?.29Chapter 3: Billing Requirements.35Billing Software 101.36Medicare Secondary Payer (MSP) Claims.37 2016 HCProThe How-To Guide to Home Health Billing, Second Editioniii
CONTENTSChapter 4: Clinical Documentation Requirements for Billing. 41Eligibility. 41Documents Needed Before Billing.46Tracking of Home Health Certification and Plan of Care (485). 51Home Health Care CAHPS.52Chapter 5: Diagnosis Coding and the Billing Process.55ICD-10-CM Specifics.56Diagnosis Specifics. 58Coding Specifics. 59Value-Based Purchasing (VBP).62Chapter 6: Claim Submission.65Paper Claim Versus Electronic Submission.65Direct Billing by the Provider.77Clearinghouse.77Chapter 7: Mastering the Fiscal Intermediary Shared System.79FISS Main Menu.80Cancelling a Claim.90Claim Correction.91Online Reports.93Chapter 8: Working the Remittance Advice.95Forward Balances.96Collections.96Medicare Credit Balance Report (From CMS 838).97ivThe How-To Guide to Home Health Billing, Second Edition 2016 HCPro
CONTENTSChapter 9: Medical Review: ZPIC/RAC/CERT/ADR. 101False Claims Act . 102Fraud and Abuse Specifics. 103Levels of Appeals . 105Additional Development Request (ADR). 105MAC Top Denial Reasons. 106Chapter 10: Resources. 107Helpful Listservs for Providers. 107Website Information. 107Acronyms. 109 2016 HCProThe How-To Guide to Home Health Billing, Second Editionv
About the AuthorJoan L. Usher, BS, RHIA, ACEJoan L. Usher, BS, RHIA, ACE, president of JLU Health Record Systems in Pembroke, Massachusetts(www.jluhealth.com), is a nationally recognized expert in the field of health information management andhome health ICD coding. She has a degree in health information management and is a registered healthinformation administrator. Her career began at a visiting nurse association, and she has been president ofJLU for more than 29 years. She has been a certified Outcome and Assessment Information Set (OASIS)specialist in the clinical realm for more than nine years.Usher is a past president of the Massachusetts Health Information Management Association (MaHIMA),a component state organization of the American Health Information Management Association (AHIMA).She was the recipient of the 2008 Professional Achievement Award from MaHIMA. Usher is on the boardof directors of the Home and Health Care Alliance of Massachusetts and for the Hospice and PalliativeCare Federation of Massachusetts. She is also a regular lecturer in Massachusetts, Connecticut, RhodeIsland, and New Hampshire. Usher has taught ICD coding in home health for more than 24 years and haseducated more than 15,000 people nationwide. She has authored several publications, including the RapidReference Coding Guide, which provides homecare and hospice organizations with an easy way to lookup the most frequently used ICD-10-CM codes in home health care, ICD-9 Coding for Home Health: AGuide to Medical Necessity & Payment (HCPro, 2010), ICD-9 Coding for Home Health: A Comprehensive Guide (HCPro, 2008), and ICD-10 Essentials for Home Care: Your Guide to Preparation & Implementation (HCPro, 2011), ICD-10 Coding for Home Health: A Guide to Medical Necessity and Payment(HCPro 2014). Usher is the author/editor of three online e-learning coding courses for AHIMA: HomeHealth Diagnostic Coding, Home Health Reimbursement Methods, and Home Health Documentation &Health Record Requirements, 2011. She was also a contributing author to Schraffenberger & Kuhn, Effective Management of Coding Services (AHIMA, 2010) and the MaHIMA Medicolegal Guide to HealthRecord Information (MaHIMA 2016). Usher’s other accomplishments include multiple presentations, teleconferences, and webinars on ADRs, electronic health records (EHR), HIPAA, performance improvement,and data quality. She also serves on the Beacon Institute’s Ask-the-Expert Panel. 2016 HCProThe How-To Guide to Home Health Billing, Second Editionvii
ACKNOWLEDGEMENTSAcknowledgementsI would like to acknowledge and give thanks Marylynne Maloney for her work on the first edition ofthe How-to Guide to Home Health Billing (HCPro, 2012). My appreciation also is extended to John G.Albert, President/CEO, Home Health Foundation in Lawrence, MA, for contributing job descriptions forbillers in home health.viiiThe How-To Guide to Home Health Billing, Second Edition 2016 HCPro
1Home Health BillingOverviewA biller has an important role in homecare: to ensure that the information submitted on claims is preciseand appropriate. Medical billing translates all of the healthcare service provided to a patient into a billingclaim. The billing department is responsible for ensuring that the homecare agency has received accuratereimbursement based on information submitted. The billing department is the last quality control checkbefore submitting the claim to the insurance company.Biller’s Role and Required SkillsThe financial health of an agency is dependent on the performance of the billing department. Billers mustunderstand requirements for eligibility, the claims submission and payment process, and how to participatein the appeals process.Many skills are needed to be a home health biller. Billers should know how to do the following: Establish eligibility with the understanding of a variety of insurance rules Verify patients’ insurance coverage Reduce risk of late or nonpayment by following timely filing guidelines Creating a clean claim (i.e., one that follows rules and is accurate) for submission Develop procedures to reduce accounts receivable (AR) days as much as possible Follow a claim from initial payment to zero balance Identify any appeals/denials and unpaid claims on remittance advice 2016 HCProThe How-To Guide to Home Health Billing, Second Edition1
CHAPTER 1 Understand requirements for refunds/paybacks Handle collections on unpaid accounts Use data and reports as performance indicators for potential areas of improvement Answer patients’ billing questions Manage the agency’s accounts receivable reportsSee Figures 1.1 and 1.2 for examples of some billing job descriptions.Home Health Billing OverviewA certified home health agency is authorized by the Centers for Medicare & Medicaid Services to acceptMedicare and Medicaid reimbursement. Certified home health agencies must follow the Conditions ofParticipation 42 CFR 484 requirements.Certified home health agencies provide skilled and intermittent services to individuals in their home environment. Home health allows people to stay in the comfort of their own home while receiving active treatment or routine care during the healing and recovery phase of their illness or injury.Certified home health agencies offer many services, including the following: Skilled nursing Physical therapy Occupational therapy Speech language pathology Social worker services Home health aide servicesHome health providers negotiate contracts with private health insurances. The contract will have a list ofthe reimbursement rates along with the specific billing codes required for the claims. The federal government determines the reimbursement rate for Medicare and Medicaid. Medicare releases the reimbursementrates each year. These rates are found in the annual Prospective Payment System (PPS) home health final2The How-To Guide to Home Health Billing, Second Edition 2016 HCPro
HOME HEALTH BILLING OVERVIEWFigure 1.1: Lead Biller Job Description and Performance Appraisal ExampleHOME HEALTH FOUNDATIONCOMPETENCY BASEDJob Description and Performance AppraisalPOSITION:LEAD BILLERReports To:Patients Account ManagerEmployee Name:Appraisal Period:FromToPosition Definition: Acts as a resource to billing staff for problem solving different accounts,computer issues and specific training needs. Assists Patient Accounts Manager in dailycoordination of billing process. Responisble for being cross-trained in all billing staff dutiesEvaluation Guidelines: Circle one of the grades or indicate not applicable for eachresponsibility.1. Performance needs focusedimprovement in order forcompetence to be reached.2. Competent and dependable level ofperformance. Meets the competence-basedperformance standards of the job.3. Results clearly exceed mostposition requirements. Performanceis of particularly high quality and isachieved on a consistent basis.N/AThis standard is not applicable to thisindividual’s daily activities.Source: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission. 2016 HCProThe How-To Guide to Home Health Billing, Second Edition3
CHAPTER 1Figure 1.1: Lead Biller Job Description and Performance Appraisal Example (cont.)RESPONSIBILITIES:1. Provides billing staff with guidanceregarding general work flow processes.123N/A2. Demonstrates ability to provide coveragefor all billing staff in the event of absences.123N/A3. Provides additional training to staff asneeded when new processes areimplemented by the agency or third partypayers.123N/A4. Acts as an intermediary for resolvingcustomer requests, inquiries or concerns.123N/A5. Provides assistance to billing staff toresolves issues with clients and payers.123N/A6. Acts as a resources to agency employees inthe absence of the Patient AccountsManager.123N/A7. Assists in development and revision ofdepartmental operating procedures.123N/A8. Recommends solutions with process issuesthat need improvement.123N/A9. Review all outstanding AR balances toensure collection activity apprioraite andmentor staff with guidance on solutions.123N/A10. Prepare schedule on all claims over 90days and report to Patient AccountManager. Status of claims, potentionalrisk(s), and payment should be included.123N/A11. Review and reconcile credit balances forquarterly Medicare review.123N/A12. Run “Pending List” daily to ensure SLAfor verifications are met.123N/A13. Maintains all necessary HW tables peragency protocol. This would include (butnot limted too: fee schedule, insurance).123N/A14. Alerts Patient Account Manager to any123N/ASource: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission.4The How-To Guide to Home Health Billing, Second Edition 2016 HCPro
HOME HEALTH BILLING OVERVIEWFigure 1.1: Lead Biller Job Description and Performance Appraisal Example (cont.)financial, staff, or agency risk(s).15. Keeps current with all incoming cash andunapplied via the cash log for visibility tothe staff and assistance in the collectionprocess.123N/AFundamental Employment Responsibilities1. Demonstrates knowledge of the CQIprocess.123N/A2. Demonstrates a knowledge andunderstanding of what to report to thesupervisor or Director of QualityImprovement when concerns ofcorporate compliance arise.123N/A3. Ensures compliance within guidelinesset forth by regulatory agencies(JCAHO, DPH, ERISA etc.) anddemonstrates compliance with HomeHealth Foundation policies andprocedures.123N/A4. Practices confidentiality principles setby the agency and federal HIPAAguidelines.123N/A5. Maintains professionalism withcolleagues, peers and customers. Putsforth a positive agency image.123N/A6. Participates in all mandatoryinservices.123N/ANOTE:SKILL AND ABILITY LEVELS: Evaluate the employee on the following factors:Source: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission. 2016 HCProThe How-To Guide to Home Health Billing, Second Edition5
CHAPTER 1Figure 1.1: Lead Biller Job Description and Performance Appraisal Example (cont.)1. Judgment/Decision Making:identifies/evaluates issues; reaches soundconclusions; generates alternatives;understands consequences; makes accurateand timely decisions; attends to details.123N/A2. Drive and Commitment: tackles toughassignments; strives for personalimprovement and success.123N/A3. Initiative: self-starting; creative; searchesfor new ideas; takes calculated risks.123N/A4. Interpersonal skills: establishes andmaintains effective relationships withrelevant individuals and groups.123N/A5. Communication Skills: presentsinformation verbally and in written formthat is clear, concise and accurate; keepsassociates and supervisors informed;listens.123N/A6. Adaptability: adjusts practices in changingenvironment; adapts to new ideas andprocedures.123N/ANOTE:QUALIFICATIONS:1. Three years medical billing experience-preferably in a home health agency.2. Demonstrated organizational skills and proven ability to multi-task and work effectively in afast-paced, high volume environment.3. Proven ability to work independently with moderate supervision.4. High school graduate or equivalent-Associates degree in business or related field a plus.5. Current knowledge of rules and regulations governing third party payers and workingknowledge of various billing tasks.6. Knowledge of computerized billing and A/R systems and various PC based programs (Excel,MS Word)7. Demonstrated excellence in interpersonal skills, and effective oral and writtencommunication skills.8. Positive customer service skills9. Ability to work effectively as a member of an interactive team.Source: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission.6The How-To Guide to Home Health Billing, Second Edition 2016 HCPro
HOME HEALTH BILLING OVERVIEWFigure 1.2: Patient Accounts Rep/Medical Collector Job Description and PerformanceAppraisal ExampleHOME HEALTH FOUNDATIONCOMPETENCY BASEDJob Description and Performance AppraisalPOSITION:PATIENT ACCOUNTS REPRESENTATIVE/MEDICALCOLLECTORReports To:Patients Account ManagerEmployee Name:Appraisal Period:FromToPosition Definition: Responsible for timely submission of home health and hospice billing formultiple third party payers including, but not limited to, Medicare, Medicaid, commercial carriersand self pays. Manages accounts receivables from admission through satisfaction of balance.Evaluation Guidelines: Circle one of the grades or indicate not applicable for eachresponsibility.1. Performance needs focusedimprovement in order forcompetence to be reached.2. Competent and dependable level ofperformance. Meets the competence-basedperformance standards of the job.3. Results clearly exceed mostposition requirements. Performanceis of particularly high quality and isachieved on a consistent basis.N/AThis standard is not applicable to thisindividual’s daily activities.Pt Accounts Rep.docSource: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission. 2016 HCProThe How-To Guide to Home Health Billing, Second Edition7
CHAPTER 1Figure 1.2: Patient Accounts Rep/Medical Collector Job Description and PerformanceAppraisal Example (cont.)GOALSFORNEXTpg. 2 -JobDescription&YEAR:AppraisalGOALSFORNEXTYEAR:Pt. Account RepRESPONSIBILITIES:A. Generation of monthly insurance invoices.1. All payer source changes andadditional information edited in systemas directed by the Patient AccountsManager or when identified with otherpatient accounts staff.123N/A2. Generate claims immediately as soonas directed by Patient AccountsManager once knowledge that allDAR’s are verified.123N/A3. Screen bills for correct rates, policyinsurance company/HMO names andaddresses.123N/A4. Enter information in HW collectionscreen identifying batch and assign adue date to follow-up on collectionactivity.123N/A5. Enter payor authorizations in HW/URmodule as needed (Elder Services etc.).123N/A6. Generate RAP’s and final invoices on aStaffweekly basisfor Medicare billing.Staff127. Screen invoicing for 485’s and VFO’sDateand for variousQA rules and d:2/15Revised:2/15B. Daily review of explanation of benefits summaries.1. Review accounts listed on theHealthWyse collections report andprioritize accounts that need inquiry for1Source: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission.8The How-To Guide to Home Health Billing, Second Edition 2016 HCPro
HOME HEALTH BILLING OVERVIEWFigure 1.2: Patient Accounts Rep/Medical Collector Job Description and PerformanceAppraisal Example (cont.)pg. 3 -JobDescription& AppraisalGOALSFORNEXT YEAR:Pt. Account Repcollection of accounts and to preventuntimely filing. Match against EOB’s.2. Bill secondary copay immediately uponreceipt of payer source EOB ifnecessary.123N/A3. Act immediately on all requests frompayer sources for additionalinformation in order to process claims.123N/A4. Resubmit claims or adjustment formsfor unpaid claims when appropriate.123N/A5. Researches error claims and makesnecessary correction for clean claimproductions.123N/A1. Review accounts listed on outstandingInvoice Report or HW CollectionsReport over 60 days and prioritizeaccounts. StaffFor Medicare, use FISS toverify inquiries.123N/ADate2. Prepare informationon all claims over90 days and report to supervisor asrequired.123N/A123N/A123N/ANOTE:C. Monthly review of aged receivables3. Telephone insurance companies andHMO's to discuss status of unpaid, pastInitial Approval:5/08 Follows up on deliquentdue claims.Revised: accounts2/15according to establishedpolicies and procedures.4. Submit write-off and/or allowanceadjustment requests to supervisor forSupervisorSource: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission. 2016 HCProThe How-To Guide to Home Health Billing, Second Edition9
CHAPTER 1Figure 1.2: Patient Accounts Rep/Medical Collector Job Description and PerformanceAppraisal Example (cont.)GOALSFORNEXT YEAR:pg. 4 -JobDescription& AppraisalPt. Account Repapproval and processing.5. Run FISS generated reports on aweekly basis to check RAP’s andclaims that are in a return to providerlocation and work to release into apayment status for Medicare claims.123N/A6. Review credit balances for quarterlyMCR review.123N/A1. Runs pending list daily to determinepriority of insurance verification.123N/A2. Verifies Commercial/HMO eligibilityin cases where there is an insurancechange.123N/A3. Electronically verifies insuranceeligibility to ensure appropriateinsurances are billed to avoid the needfor re-bills.Staff123N/A4. Verifies enrollment in other insurancesDate is listed as a payor forwhen Medicarepatient.123N/A5. Calls on all other third party payers andidentifes home care coverage. Makesinquiries of co-payments andInitial Approval:5/08deductibles.Revised:2/156. Sends certified mail indicating fiscalresponsibility to clients with insurancesthat require co-pays and deductibles.123N/A123N/ANOTE:E. Insurance verificationSupervisorSource: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission.10The How-To Guide to Home Health Billing, Second Edition 2016 HCPro
HOME HEALTH BILLING OVERVIEWFigure 1.2: Patient Accounts Rep/Medical Collector Job Description and PerformanceAppraisal Example (cont.)pg. 5 -Job& AppraisalGOALSFORDescriptionNEXT YEAR:Pt. Account Rep7. Maintains insurance screen in systemper agency protocol.123N/A8. Alerts Patient Accounts Manager ofissues concerning questionablecoverage or potential non-payment.123N/A9. Keeps all involved departmentsinformed of verifications on all newadmissions.123N/ANOTE:F. Maintenance of commercial and HMO patient billing files1. Keeps all folders with adjustments,resubmissions (if appropriate) andEOB’s orderly and easy to acquire.123N/A1Supervisor23N/A123N/A123N/ANOTE:G. Fundamental Employment ResponsibilitiesStaff1. Demonstrates knowledge of the CQIprocess.Date2. Demonstrates a knowledge andunderstanding of what to report to thesupervisor or Director of QualityImprovement when concerns ofcorporate compliance arise.Initial Approval: 5/08compliance within guidelinesRevised:3. Ensures2/15set forth by regulatory agencies(JCAHO, DPH, ERISA etc.) anddemonstrates compliance with HomeHealth Foundation policies andSource: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission. 2016 HCProThe How-To Guide to Home Health Billing, Second Edition11
CHAPTER 1Figure 1.2: Patient Accounts Rep/Medical Collector Job Description and PerformanceAppraisal Example (cont.)GOALS FOR NEXT YEAR:pg. 6 -Job Description & AppraisalPt. Account Repprocedures.4. Practices confidentiality principles setby the agency and federal HIPAAguidelines.123N/A5. Maintains professionalism withcolleagues, peers and customers. Putsforth a positive agency image at alltimes.123N/A6. Participates in all mandatoryinservices.123N/ANOTE:SKILL AND ABILITY LEVELS: Evaluate the employee on the following factors:1. Judgment/Decision Making:identifies/evaluates issues; reaches soundconclusions; generates alternatives;Staffunderstandsconsequences; makes accurateand timely decisions; attends to details.12. Drive and DateCommitment: tackles toughassignments; strives for personalimprovement and success.13. Initiative: self-starting; creative; searchesInitial Approval:for new 5/08ideas; takes calculated 4. Interpersonal skills: establishes andmaintains effective relationships withrelevant individuals and groups.Source: Home Health Foundation, Lawrence, MA (Home Health VNA, Merrimack Valley Hospice, Homecare, Inc.)www.homehealthfoundation.org. Reprinted with permission.12The How-To Guide to Home Health Billing, Second Edition 2016 HCPro
HOME HEALTH BILLING OVERVIEWFigure 1.2: Patient Accounts Rep/Medical Collector Job Description and PerformanceAppraisal Example (cont.)GOALSFORNEXT YEAR:pg. 7 -JobDescription& AppraisalPt. Account Rep5. Communication Skills: presentsinformation verbally and in written formthat is clear, concise and accurate; keepsassociates and supervisors informed;listens.123N/A6. Adaptability: adjusts practices in changingenvironment; adapts to new ideas andprocedures.123N/ANOTE:QUALIFICATIONS:1. High school graduate or equivalent-Associates degree in business or related field a plus.2. Current knowledge of rules and regulations governing third party payers and workingknowledge of various billing tasks.3. Knowledge of computerized billing and A/R systems and various PC based programs (Excel,MS Word)4. Demonstrated excellence in interpersonal skills, and effective oral and writtencommunication skills.5. Positive customer service skills6. Ability to work effectively as a member of an interactive team.ESSENTIAL CAPABILITIES:StaffSup
Vincent Skyers, Design Services Director Vicki McMahan, Sr. Graphic Designer Jake Kottke, Layout/Graphic Design Philip Couch, Cover Designer Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for
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