Sunday, March 20, 2011

Updates from the CMS front.... timely filing, GZ mod, Home Health certification

Just some quick info that you might need to know.....

 On March 23, 2010, President Obama signed into law the Patient
Protection and Affordable Care Act (PPACA), which amended the
time period for filing Medicare fee-for-service (FFS) claims.

 The Timely Limit to file claims was reduced to one year for the date of
service. (i.e. if the DOS was June 8, 2010, the claim must be filed by
June 8, of 2011.)

 Additional information can be found in MLN Matters article MM6960.



Auto denial of claim line(s) items submitted with a GZ Modifier

This Change Request requires that, effective for dates of service on and after July 1, 2011, all Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractors (RACs), Program Safeguard Contractors (PSCs) and ZPICs Zone Program Integrity Contractors (ZPICs) must automatically deny claim line(s) items submitted with a GZ modifier.

Contractors should not perform complex medical review on claim line(s) items submitted with the GZ modifier.

The GZ modifier indicates that an Advance Beneficiary Notice of Non-coverage (ABN) was not issued to the beneficiary and signifies that the provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy.

All MACs must make all language published in educational outreach materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ modifier must be denied automatically and will not be subject to complex medical review.

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2148, February 4, 2011 and Program Integrity Manual, Pub. 100-08, Transmittal No. 366, February 4, 2011.



A new Medicare home health law went in to effect on January 1st, 2011 that affirms the role of the physician as the person who orders home health care based on personal examination of the patient. Effective in January, a physician who certifies a patient as eligible for Medicare home health services must see the patient. The law also allows the requirement to be satisfied if a non-physician practitioner (NPP) sees the patient, when the NPP is working for or in collaboration with the physician.

As part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and document how the patient’s clinical condition supports a homebound status and need for skilled services. The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care.

While the long-standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition. In situations when a physician orders home health care for the patient based on a new condition that was not evident during a recent visit, the certifying physician or NPP must see the patient within 30 days after admission.

The new requirement includes several features to accommodate physician practice. In addition to allowing NPPs to conduct the face-to-face encounter, Medicare allow a physician who attended to the patient but does not follow patient in the community, such as a hospitalist, to certify the need for home health care based on their face to face contact with the patient in the hospital and establish and sign the plan of care. Medicare will also allow such physicians to certify the need for home health care based on their face to face contact with the patient, initiate the orders for home health services, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care. Finally, in rural areas, the law allows the face-to-face encounter to occur via tele-health, in an approved originating site.

Certification and Recertification of Home Health Services

G0180 - Physician services for the initial certification of Medicare- covered home health services, for a patient's home health certification period

G0179 - Physician services for the recertification of Medicare-covered home health services, for a patient's home health certification period

These two codes are used to report the work involved in new certification and recertification paperwork

Keep in mind-These codes can not be used in the Medicare rural health care clinics as they do not meet the requirements of a face to face visit unless done at the time of the face to face visit.

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