Medicare Home Health Billing
Updates from CGS
PHA Annual Conference – State College, PA
May 17, 2012
CGS Home Health Claims Data
November 1, 2011 – March 31, 2012
Number of Home Health
“Claims” Submitted
Total of Top 6 HH “Claims”
Billing Error Reasons
1,052,833
83,455 (7.93%)
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Top Home Health Billing Errors
• Referred to as Claim Submission Errors (CSEs)
• Results in RAPs/claims being rejected (R BXXXX) or
returned to provider (RTPd) (T B9997)
• Assigned 5-digit reason code which defines error
• Impact of CSEs
» Creates additional work for billers
» Costs agencies $$
» Delays payment for services provided
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Top CGS Home Health Billing Errors
November 1, 2011 – March 31, 2012
Reason
Error Caused By
Code
38107 FISS can’t find matching RAP
38157/
38200
U538I
31755
31147
Duplicate billing – same
beneficiary/same dates of
service/same billing provider
Overlap another HHA’s episode
HIPPS code/LIDOS mismatch
HIPPS code/supply billing
mismatch
# of Errors
44,372
20,752
8,247
5,404
4,680
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Top Home Health Billing Errors
• ‘Top Claim Submission Errors (Reason Codes) and How
to Resolve’ web page,
www.cgsmedicare.com/hhh/education/materials/CSEs.
html
» Lists most common errors by RC
» Explains reason for error
» Provides suggestions for how to prevent/resolve
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Top HH+H Provider Inquiries
November 1, 2011 – March 31, 2012
Number of Home
Health/Hospice Provider
Telephone Questions
Handled
19,921
Sum of Top 5 Home
Health/Hospice Inquiry
Reasons
8,658
Percent of Total Inquiries
43.46%
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Inquiry Triage Process
Source of Information: CMS Pub. 100-09, Ch. 6, § 30.17
Top HH+H Provider Inquiries
Reason for
Call
Type of Issues
# of
Calls
Instructions for submitting MSP
Billing
claims, special billing
2,507
Instructions
situations, new billers
Provider
Enrollment Provider enrollment revalidation 2,208
Requirements
Understanding reason code
Claim
narrative; instructions for
1,949
Correction
correcting RAPs/claims
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Top HH+H Provider Inquiries (cont.)
Reason for
Call
Type of Issues
Beneficiary inpatient stay,
overlapping HH PPS
Claim Overlap
episodes/hospice benefit
periods
Address,
CGS mailing addresses, links
Phone, Fax, to information on CMS or CGS
Web Address Web sites
# of
Calls
1,006
988
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Provider Inquiry ‘Resources’
www.cgsmedicare.com/hhh/education/materials/
Resources_Most_Common_HHH_Questions.html

List of links, information

Review prior to contacting

Updated quarterly

Based on inquiry data
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CGS Website
• www.cgsmedicare.com
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CGS Website
• Primary links on left
• Quick links on right
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CGS Website
• Primary links
Primary Link Information Available
News &
Publication
Recent news, join/update listserv, CGS Bulletins,
Cahaba’s Newslines
Claims
Processing
Rates/fee schedules, checking claim status, FISS
Claims Processing Issues, common FISS
status/locations, RA/ERA, submitting paper
claims
EDI
Customer
Service
PC Print, GPNet, PC-ACE Pro32, FAQs
Phone numbers, Mailing addresses, IVR User
Guide, Website feedback, Duplicate remit form
Education
Calendar of events, educational materials, FAQs,
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Advisory Group, new provider resources
CGS Website
• Primary links (cont.)
Primary Link Information Available
Enrollment
Electronic funds transfer (EFT), Enrollment
packets, revalidation
Financial
LCDs &
Coverage
Audits, cost reports, PS&R, credit balance form,
rates/fee schedule
Levels of appeal, redetermination address,
reopenings, resources
Active LCDs, home health and hospice
coverage guidelines, OASIS
Medical
Review
ADRs, Overview of MR (edits, reason codes),
signature guidelines
Appeals
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‘News & Publications’ Page
Current/recent
ListServ messages
CGS monthly newsletter
Cahaba Newslines
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‘Customer Service’ Page
Telephone
numbers
Mailing addresses
IVR Guide
Duplicate Remit form
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‘Events & Education’ Page
Upcoming Events
CGS Resources
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‘Educational Materials & Resources’
Page
FISS Guide
MSP Resources
Scroll down for
provider-specific
resources
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‘Educational Materials & Resources’
Page
• www.cgsmedicare.com/hhh/education/materials/
index.html
Home Health
Education Resources
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‘HH Claims Filing’ Page
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‘HH Claims Filing’ Page
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‘HH Coverage Guidelines’ Page
www.cgsmedicare.com/hhh/coverage/Home_
Health_Coverage_Guidelines.html
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‘HH Quick Resource Tools’ Page
• www.cgsmedicare.com/hhh/education/materials/
HH_QRT.html
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‘FAQs’ Page
HH FAQs
MSP FAQs
Provider Enrollment FAQs
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‘LCDs & Coverage’ Page
HH PT LCD
HH Coverage
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‘Medical Review’ Page
ADR information
Signature requirements
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CGS Website Search Engine
• Accessible from top
of each web page
Enter search term
and click “Go”
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Online Provider Services (OPS)
• Coming soon!
• Another means to:
» Check patient eligibility
» Obtain claim status
» View/order remittance advices (RAs)
» Check payment floor status
» Verify dates/amounts of last 3 Medicare
payments
• Must have EDI Enrollment Agreement on file
• Watch CGS Bulletins, listservs for more details
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Questions
Home Health Provider Contact Center
(877) 299-4500
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