NAHC Submits Comments to CMS on Proposed Home Health Cost Report Changes

The National Association for Home Care & Hospice (NAHC) and the Home Health Financial Managers Association (HHFMA) submitted comments on the Centers for Medicare & Medicaid Services (CMS) proposed changes to the home health cost report (Form CMS-1728-19) and cost reporting instructions.

On April 16, 2019, the CMS published notice in the Federal Register of plans to revise the existing home health freestanding cost report forms and instructions. CMS also posted online several documents related to the proposed cost report revisions, including the proposed forms and instructions, a crosswalk of the proposed changes, and a document outlining CMS’ justification for making the proposed changes.

Following are comments and recommendation submitted on several of the key areas proposed for revision.

  • Requested the effective date be six months after the cost report changes and instructions have been finalized, rather than the proposed January 1, 2020 effective date.
  • Recommend CMS permit the agency’s designated “Authorized Official” to sign the cost report rather than limit the signature requirement to the agency’s Chief Financial Officer or the Administrator
  • Recommend CMS modify the instructions for Worksheet S-3, Part I  to clearly indicate how Medicare Advantage and Medicaid Managed Care census statistic should be reported
  • Clarify instructions on Worksheet S-3, Part IV with the implementation of the Patient Driven Grouper Model
  • Highlighted concerns regarding a new worksheet (Worksheet S-3, Part V) which captures salaries, fringe benefits, paid hours, and then computes an average hourly wage by occupational category.
  • Clarify instructions for a new general service cost center for remote patient monitoring and telehealth reporting.
  • Request CMS explain how it plans to use the information reported on Worksheet A-7- Analysis of Changes in Capital Asset Balance.
  • Clarification needed on several cost reporting items regarding home health agencies with HHA-based hospices
  • Recommend CMS maintain Worksheet F-2 (Fund Balance / Equity Rollover) in the revised cost repot
  • Noted inconsistency between Worksheet A and Worksheet O

CMS will issue another information collection notice on the cost report changes which provides, another, a 30 day comment period. There is no scheduled time frame for when CMS will issue the second notice, other than some time after they have reviewed the comments submitted in response to the first notice.

Source: NAHC

How will the EMPOWER Care Act affect HHAs?

The Empower Care Act (Ensuring Medicaid Provides Opportunities for Widespread Equity, Resources, and Care) was re-introduced to the senate early in 2019. This bill is intended to expand as well as renew/reauthorize funding and participation in the transitioning of Medicaid beneficiaries from hospital or institutional settings to home and community-based services under the Money Follows the Person (MFP) Demonstration Program implemented in 2016.

The overall purpose of the MFP was to grant individuals the freedom to age in place rather than nursing homes. The funds are intended to provide more options for those wishing to remain at home.

Short-term funding of MFP transitions is slated to end in September 31, 2019. The new bill hopes to extend the program for an additional five years.

How would funds benefit home health services?

Because MPF’s funding expired in 2018, the Empower Care Act hopes to provide approximately $450 million for every fiscal year between 2018 and 2022, with the bulk of those funds going to state Medicaid programs.

The funds would aid in moving Medicaid beneficiaries from nursing homes and other institutional settings into community or home-based care scenarios.

It’s also designed to aid individuals with disabilities as well as seniors to return to a home environment following institutional care (hospital, long-term care center, rehab facility, and so forth).

A major benefit to individuals is that long-term home-based care costs less than institutional care. Based on past statistics, participants in MFP experience an average of 25% decline in monthly care expenses after transitioning from a LTC facility to Home & Community Based Services (HCBS).[1]

A brief summary of the bill specifies that CMS must award grants to state Medicaid programs in order to facilitate and assist in rebalancing long-term care systems. The bill – if passed – expands sustainability for transitions from institutional to ‘qualified community settings’ to be carried out under state-based MFP projects. The goal is to improve health outcomes and person-centered care and planning scenarios.

It has since been referred to the Committee on Finance.

Precision Medical Billing is closely following the status of the bill, still in the very early stages of the legislative process. For information on billing services for home healthcare needs, contact us today.


Program for Evaluating Payment Patterns Electronic Report

New Home Health Agency PEPPER Available

The Q4CY18 release of the Home Health Agency (HHA) Program for Evaluating Payment Patterns Electronic Report (PEPPER) with statistics through December 2018 is now available for download through the PEPPER Resources Portal. To obtain your agency’s PEPPER, the Chief Executive Officer, President, Administrator or Compliance Officer should:

  1. Review the Secure PEPPER Access Guide.
  2. Review the instructions and obtain the information required to authenticate access. Note: A new validation code will be required. A patient control number (UB04 form locator 03a) or medical record number (UB04 form locator 03b) from a claim for a traditional Medicare FFS beneficiary with a claim “from” or “through” date between October 1 – December 31, 2018, will be required.
  3. Visit the PEPPER Resources Portal.
  4. Complete all the fields.
  5. Download your PEPPER.

The HHA PEPPER will be available to download for approximately two years. A webinar to review the new PEPPER is scheduled for Thursday, July 18, at 3 p.m. EDT. For more information visit the HHA Training and Resources page.


PEPPER is an educational tool that summarizes provider-specific data statistics for Medicare services that may be at risk for improper payments. Providers can use the data to support internal auditing and monitoring activities.Visit the HHA Training and Resources page at to access updated resources for using PEPPER, including recorded web-based training sessions, a sample PEPPER and the HHA PEPPER User’s Guide. PEPPER is developed under contract with the Centers for Medicare & Medicaid Services (CMS) by RELI Group, along with its partners TMF Health Quality Institute and CGS.

Do you have questions or comments about PEPPER or need help obtaining your report? Visit our Help Desk to request assistance with PEPPER. Provide your feedback or suggestions regarding PEPPER through our feedback form.

July 2019, Quarterly Release Temporary Hold

Each quarter, the Fiscal Intermediary Shared System (FISS) is updated to include new logic for claims processing, pricing, etc.

When the release is installed, Palmetto GBA places a temporary “hold” to ensure the release is installed properly. During this time, claims with dates on service of July 1, 2019, or later will be held in the status/location listed below and may be released before or on July 18, 2019, to continue processing.

  Reason Code  Location Status  Status Description
 36452  SMHOSP Hospice
 37230  SMHOME Home Health Prospective Payment System (PPS) Claims
 WW999  SMFISS Holds All Claims

This process does not apply to home health requests for accelerated payments (RAPs) or hospice notices of election (NOEs).

Providers should be reminded that Medicare claims processed by the 30th day from claim receipt are considered timely. Beginning on the 31st day from receipt, interest will be applied to claims that have not been processed.

What Physicians should know about Value-Based Payment Models

Payment models have undergone numerous and frustrating changes over the past few years, and the implementation of the value-based reimbursement model is no exception. Physicians submitting claims to Medicare have likely experienced the changes relating to this payment model.

Value-based reimbursements are/were intended to compensate providers based on performance and guidelines focused on improving patient health rather than a wide range of services provided and rendered at your practice. Changes will continue to occur throughout 2019 and have an influence on a wide range of healthcare specialties.

During its rollout, value-based reimbursement payment models were based on several criteria – among those professionals affected by the merit-based incentive payment system (MIPS) such as physician assistants, physicians, and nursing professionals. This year, we have seen clinicians and rehabilitation therapists and specialists become eligible for MIPS participation as well.

The downside?

Use of incorrect modifiers, ensuring accurate patient information and reducing duplicate billing continues to challenge many practices utilizing in-house billers. Busy physician staff don’t always have the time to navigate confusing and ever-changing insurance regulations. They can’t spend valuable time attempting communication with insurance representatives, or correcting claims denials, or time spent resubmitting claims in order to collect on an outstanding patient balance.

Reporting accuracy a must for today’s physicians

As of 2018, the Quality Payment Program (QPP) Final Rule is in place. Methods for reporting on MIPS determines not only if you and your practice measure up to the quality goals, but the revenue goals you’re seeking. Numerous options are available for reporting, including but not limited to:

  • MIPS registries
  • Qualified clinical data registries
  • Claims-based submissions
  • EHR submissions
  • New CMS portals for reporting advanced care information/improvement activities

Some healthcare professionals are still excluded from participation in MIPS, such as:

  • a clinician who has enrolled for their first year in Medicare Part B;
  • smaller practices with Medicare bill charges of less than $90,000 annually;
  • those who have less than 200 Medicare Part B beneficiaries;
  • Professionals who participates in other advance payment models if they collect more than 25% of their Medicare payments through such models.

Recently, HHS launched their new Primary Care Initiative, with a goal of enabling physicians to spend more time with their patients and less time dealing with administration issues. The initiative includes five value-based payment models as listed above. Is your billing staff aware of these exclusions and other rules for submitting claims under the value-based payment model?

Precision Medical Billing takes care of claims submissions processes. By 2021, it’s expected that physicians outsourcing medical billing will reach nearly $17 billion, primarily because of the confusion caused by ever-changing healthcare regulations, increased risk management, and compliance issues that often leave a practices in-house billing staff reeling. Contact us today and ask how we can help you with your billing practices.

CMS Announces Further Changes to Support Hospice Eligibility Inquiries in HETS

Over recent years the Centers for Medicare & Medicaid Services (CMS) has sought to streamline hospice beneficiary eligibility inquiries and establish the HIPAA Eligibility Transaction System (HETS) as the single source for this data. This effort was delayed due in part to the availability of insufficient information in the HETS system regarding hospice benefit period utilization. On March 27, 2019, the MCARE system issued a notice indicating that changes had been made to the HETS system and that, beginning in fall of 2019, CMS will terminate access to Common Working File (CWF) eligibility queries for entities that already use HETS for that purpose.

As referenced previously, the National Association for Home Care & Hospice (NAHC) sought additional information from CMS, as concerns remained that HETS eligibility queries might not provide sufficient information to allow hospices to determine whether a patient being taken onto service required a face-to-face encounter.  In a response, CMS’ MCARE Help Desk indicated that CMS “plans to make a change in the upcoming HETS R2019Q300 release to remove the Hospice Occurrence Count and instead return all available CWF Hospice Occurrences and/or Notices of Election on the 271 response.”

More recently, as part of Change Request 11277/Transmittal 2285, CMS formally announced instructions designed to address hospice eligibility and face-to-face encounter eligibility data needs in HETS by ensuring that all hospice benefit periods (regardless of age) are submitted to HETS and by populating HETS with separate record of Hospice Election Period data and Hospice Benefit Period data.  These changes are scheduled to become effective on October 1, 2019 (with an implementation date of October 7, 2019).  MCARE has not yet announced a specific date on which CMS will eliminate access to CWF queries for those providers who conduct eligibility queries in HETS but NAHC will be monitoring for announcement of this change and provide updates via NAHC Report as they are available.


CMS Releases Additional Instructions for Claims under PDGM

The Centers for Medicare & Medicaid Services (CMS) has released a second set of revisions to Chapter 10 of the Medicare Claims Processing Manual providing instructions to home health agencies for claims submission under PDGM. CMS Transmittal 4294/Change Request (CR) 11272, Home Health (HH) Patient-Driven Groupings Model (PDGM) – Additional Manual Instructions, provides some clarity over the first set of revisions via CR 11081. (See NAHC Report article here.)

NAHC reached out to CMS with questions that remained after the release of CR 11081. These questions, along with additional revisions to the Claims Processing Manual, have been addressed with the changes outlined in CR 11272. Specifically, the following is clarified:

  • The percentage payment for the RAP under PDGM is based on the HIPPS code as submitted. It was previously unclear how the Medicare systems would be able to identify the correct HIPPS code at the time the RAP is submitted since the OASIS does not need to be submitted prior to the RAP. This will remain the case under PDGM. Upon receipt of the corresponding claim, grouping to determine the HIPPS code used for final payment will occur in Medicare systems. This HIPPS code is used to match the claim to the corresponding RAP that was previously paid. After this match is completed, grouping to determine the HIPPS code used for final payment of the period of care will occur in Medicare systems. At that time, the submitted HIPPS code on the claim will be replaced with the system-calculated code.
  • For claim “From” dates on or after January 1, 2020, the ICD code and principle diagnosis used for payment grouping will be claim coding rather than the OASIS item. As a result, the claim and OASIS diagnosis codes will no longer be expected to match in all cases. Typically, the codes will match between the first claim in an admission and the start of care (Reason for Assessment –RFA 01) assessment and claims corresponding to recertification (RFA 04) assessments. Second 30-day claims in any 60-day period will not necessarily match the OASIS assessment. When diagnosis codes change between one 30-day claim and the next, there is no absolute requirement for the HHA to complete an ‘other follow-up’ (RFA 05) assessment to ensure that diagnosis coding on the claim matches to the assessment. However, the HHA would be required to complete an ‘other follow-up’ (RFA 05) assessment when such a change would be considered a major decline or improvement in the patient’s health status
  • For claim “From” dates before January 1, 2020, the other diagnoses and ICD codes reported on the claim must match the additional diagnoses reported on the OASIS, form item M1022 (Other Diagnoses). For claim “From” dates on or after January 1, 2020, claim and OASIS diagnosis codes may vary as described under Principal Diagnosis.
  • In CR 11081 there was a section titled “SCIC” without any additional information. This has been removed from the Claims Processing Manual, but NAHC fully expects that CMS will insert this section in future CRs.

Additional revisions include technical instructions describing systems handling of the claims as well as one that holds HHAs responsible for submitting claims with required visit charge information. All services must be billed on one claim for the entire episode/period. The A/B MAC (HHH) will return to the provider TOB 0329 when submitted without any visit charges.

CMS has indicated it will continue to release instructions for billing under PDGM. Stay tuned to NAHC Report for further information.

Source: NAHC

Renewal of the HHCCN

The Office of Management and Budget (OMB) has approved the Home Health Change of Care (HHCCN) Form, CMS-10280.  Effective July 1, 2019, all Home Health Agencies (HHA) will be required to use the renewed form with the expiration date of 4/30/2022 on the bottom.  Please note that HHAs may continue to use the old form up until July 1, 2019 but we encourage HHAs to begin transitioning to the renewed form.

There have been no changes made to the form.  HHAs may find the form and the form instructions in the download section of the website at:


Information About Home Health Ordering/Referring/Attending Physician Adjustments

From October 1, 2018, through April 22, 2019, the home health ordering/referring/attending physician reason code 32072 was not editing correctly. This allowed claims containing a terminated attending physician to incorrectly pay. These claims should have denied.

In the beginning of May, a Fiscal Intermediary Shared System (FISS) utility was initiated to adjust claims that should have originally denied with reason code 32072. The utility captured some claims that it should not have, but the adjustments did process properly. This will cause unnecessary adjustment activity on remittance advices. However, there is no impact of incorrect payments. This may continue until all of the adjustments finalize. We apologize for any inconvenience this may cause.

The adjustments (32I type of bill) fall into three categories:

  1. Adjusted in error — the attending physician is active in the Provider Enrollment, Chain, and Ownership System (PECOS) at the start of care. No payment change between the original claim and the adjustment. However, these will show adjusted on remittance advices.
  2. Adjusted correctly — the attending physician was inactive in PECOS at the start of care. The adjustment is denying with reason code 32072 and payment is being recouped correctly. For more information on ordering/referring/attending denials, please visit the Ordering/Referring/Attending Physician Claim Denials article.
  3. Pending claims — these are editing with other reason codes and are being suspended.  Palmetto GBA is identifying and deactivating these claims. These claims will be adjusted in June.

Source: Palmetto GBA

Billing Process Tips that Increase Revenue

Treating patients is your job. So too is getting paid. Unless you belong to a large medical group, chances are that your staff is taking care of billing for you. Small practices are especially at risk of delayed payments for a variety of reasons.

Approximately 83% of physician practices with fewer than five practitioner states slow payments by high-deductible plan patients as one of their biggest reimbursement challenges.[1] The next obstacle for small and independent practices is inadequate and timely communication with patients in regard to payment accountability.

Even more alarming, patient failure to pay medical bills is on the rise. In 2014, nearly 49% of patients failed to finalize medical bill obligations. In 2015 that number rose to 53% and in 2016 that rose to 68%. By 2020, estimates of patient failure to completely pay off medical bills is expected to reach a whopping 95%.[2]

Tips to increase revenue and get you paid

Additionally, it’s no secret that a chunk of physician revenue falls through the cracks due to mistakes and loopholes in billing processes. Why?

The majority of denials are due to lack of knowledge of up-to-date billing guidelines of the Centers for Medicare and Medicaid Cervices (CMS).

Tip #1: Staff responsible for billing processes must be knowledgeable and familiar with claims submissions processes outlined by CMS and other third-party payers.

Unfortunately, if that staff member isn’t appropriately trained and credentialed, mistakes, delays, and poor revenue cycle management often result. Turning over your billing processes to a professional medical billing company reduces the risk of mistakes that delay or deny payments.

Failure to promptly follow up with additional requests for information or denials results in missed payments or denials.

Tip #2: File on time, verify accuracy of information on the claim, and ensure eligibility before claims are submitted.

These are just a few important aspects of accurate and professional billing practices. Professional billers are aware of time limitations for claims submissions and follow up on accounts receivable (AR) on a regular and timely basis.

Tip #3: Timely responses to denials are essential for payment.

Approximately 4% of claims are denied in spite of correct coding. However, when timely follow-ups to requests for additional information or correction of mistakes aren’t addressed promptly, that percentage can rise to 25%.

Don’t take chances with your revenue. Contact Precision Medical Billing to learn more about our services and resources so you can spend your valuable time taking care of your patients.


[2] Ibid.