Complete Story


The Pulse: February 2014

Featured News

Message from President Jeff Lycan
Jeff Lycan President/CEO


Opiates, Heroin & Hospice

 It seems the nightly news recently is filled with prescription drug diversion and abuse and its relationship with a mounting Heroin crisis. Right in the thick of the conversation at the state level is Opiate use and hospice, thus my title, Opiate, Heroin & Hospice.

As unlikely of an association that one would want to make of this, there it is, weaved into the conversation. Three main issues for hospice to be concerned with:

-        First, do we appreciate the potential harm that could come from the diversion of these opiate drugs into the hands of a curious or misguided individual?

-        Second, are our policies around managing the use and oversight of our opiate therapy as thorough as they could be?

-        Lastly, how successful are we at removing the risk of those potential lethal drugs from the home when they are no longer needed by destroying them appropriately?

Wednesday, the Hospice Opiate bill (HB 366), passed the House and will now go to the Senate for hearings. The bill was thoroughly, yet quickly, vetted in a subcommittee prior to coming back to the House for discussion and vote. With the help of MCA’s Public Policy committee and the effort of several members to reach out to specific Health and Aging Representatives, we have been able to shift this bill from an over-burdensome and confusing set of requirements to one now described as a best practice bill. MCA is reasonably pleased with the current version of the bill. Nevertheless, the association will continue to work for the “best” bill possible as it moves through the Senate.

At the hearing one of the legislators asked “What brought on the need for this bill, the move to tightly control these drugs for patients in hospice? This is such an emotional and delicate time, we certainly don’t want to create additional hardships on caring for our loved ones at death.” Representative Sprague, as part of his testimony, read testimony submitted from a mother whose son died from a “single” opiate dose. That opiate came from medications that were “put away” in the closet of a grieving spouse following the death of his wife. That loved one was a hospice patient who had been taking Vicodin and Methadone at the end of life. The grandfather was storing memories.

One Representative described the hospice environment “ripe for diversion”, particularly following the death of the individual, if these drugs are left in the home. Unfortunately, over the last eight weeks there were a number of stories that Representatives spoke about that highlighted opiates left in the home following the death of a patient. As an industry we must have a zero tolerance for diversion or abuse of opiates that are ordered for our patients. A patient’s home is a sensitive area to exert control however, the need to protect and to find that balance between the patient’s home and interventions from outside care givers is critical and something we do every day. You know that! But just as diligently as you approach the patient and family around creating an environment that protects them and provides a safe place to die, we need to elevate the safety of the patient and family by incorporating actions and procedures that provide for safe management of opiates and destruction of those meds when they are no longer needed.

For most of our members MCA believes this will require some shifting and updating of policies but overall will not create additional burdens as much as emulating best practice. Working with our Public Policy Committee, MCA is creating a number of tools to help members implement the changes. We are also developing a public information tool that providers can use for patients and families describing the industries responsibilities towards opiate management.

What’s next, the legislation moves to the Senate where hearings and work with the Senate moves forward. It is expected that the passing of a bill would occur by May and then the Ohio Department of Health needs time to develop rules. In all likelihood we wouldn’t see the effect of these changes till the third quarter of the year at the earliest.


Current State Legislation & Statehouse News

Opiate Bills

HB332:Establishes standards and procedures for licensed health professionals when prescribing opioids to patients under 50 years old with chronic pain. Requires that professional disciplinary action be taken against a health professional who fails to comply with the standards and procedures.

MCA position:Currently, the language in this bill is mismatched to language found elsewhere in the ORC which exempts patients with a terminal condition. There have been several Interested Party meetings on this bill over the last month. A substitute bill was announced during the Opiate subcommittee hearing on 02/04/14. We have not seen that language yet. However, during testimony on the February 4, MCA expressed support for language similar to exemption language in HB 341 (below).

HB 341: Prohibits certain controlled substances from being prescribed, dispensed, or furnished without review of the patient information in the State Board of Pharmacy's Ohio Automated Rx Reporting System. The bill authorizes disciplinary action against health care professionals who fail to request or review patient information before prescribing, dispensing, or furnishing certain controlled substances.

MCA position: Currently a substitute bill has an exemption for “hospice patients in a hospice care setting” from this requirement. MCA testified in support of this language on 02/04/14 and also offered a friendly addition, to have “patients with a terminal condition” included with the sentence identifying hospice patients. Testimony also sought to reduce confusion by seeking common exemption language between 341 and 332 to not allow those with a terminal condition be burdened with the additional requirements sought in these two bills.

HB 378:Prohibits a physician from prescribing or personally furnishing certain medications to treat dependence on or addiction to opioids unless the physician has been certified by the medical director of the Department of Mental Health and Addiction Services. Prohibits a physician from prescribing or personally furnishing the medications to a patient who is not actively participating in appropriate behavioral counseling or treatment.

MCA position:MCA's principle concern is that hospice and palliative physicians be allowed to continue prescribing this class of medications for treating pain and other symptoms at end of life. The other issue is treating someone that is addicted at end of life and working for a smooth transition from one provider to another without the hospice or palliative physician needing to have completed the certification. Our primary concern is to avoid unintended consequences. MCA testified regarding these concerns and requested an exemption similar to the request in HB 332 and HB 341.


HB 126 – Signed by the Governor in December 2013

HB 126 makes a few changes to Ohio’s Durable Power of Attorney for Health Care (DPOAHC) laws which permits a DPOAHC to authorize the attorney in fact, at execution of the document and regardless of whether the principal has lost capacity, to make health care decisions and obtain information concerning the principal's health. It also includes an alternate attorney in fact in the list of individuals who are ineligible to be witnesses to a DPOAHC; authorizes a principal in a DPOAHC to nominate a guardian of the principal's person, estate, or both; modifies the Uniform Power of Attorney Act by providing that the principal's nomination of a guardian of the principal's person, estate, or both or of the person, the estate, or both of one or more of the principal's minor children or incompetent adult children is revoked by the principal's subsequent nomination of a guardian of the principal's person, estate, or both or of the person, the estate, or both of one or more of the principal's minor children or incompetent adult children.

MCA is working with the Ohio State Bar Association on revisions to the current forms and we expect to see those changes in print sometime in the second quarter of the year. This will require MCA to print a new edition of the Choices brochure during that same time frame as well.



In a public call there was an expectation that MITS could be delayed for hospices but no notice has been issued to support that. Karen Jennings retirement creates additional complications for providers to get resolution. MCA has attempted to directly communicate to the Ohio Department of Medicaid (ODM) since Ms. Jennings left, but like many of our providers, no response has been returned.

On Monday, February 10th, MCA sent a letter to the Office of Health Transformation describing the many issues hospices are encountering with MITS. We will keep you informed as things continue to unfold with MITS in this 11th hour.


5 Year Hospice Licensure Rule Review

The Hospice Rules are out for review and public comment. MCA is currently reviewing the rules and encourages providers to send comments to us by March 4th. The Public Policy Committee will be reviewing the rules and will hold a conference call on February 27th to begin forming our response to the rules. Several notes of interest: Ohio Department of Health is pulling out guidelines into a separate document (Interpreted Guidelines) and ODH is also reformatting the policies so many changes are in fact created by shifting rules. Please send any comments to MCA by March 4th to If you have any questions please don’t hesitate to contact Jeff at the email above or call 614-545-9016. To access the Rules, click HERE.


Federal News

Change Request 8358: Are YOU Ready?

On January 31, 2014, CMS issued a revision to Change Request (CR) 8358 to provide clarifying information and examples in the policy section of the change request and to make technical corrections to the manual text. All other information remains the same. The effective date of this change request remains April 1, 2014.

MCA, as well as others in the industry, are concerned that this CR is burdensome for providers especially the requirement to include non-injectable and injectable prescription medication on a line-item basis per fill, based on the amount dispensed by the pharmacy and to include the infusion pumps on a line-item basis for each medication fill and refill on the claims.

MCA wants to advocate on your behalf regarding these new non-compensated burdens and would appreciate it if you would take just a few minutes to answer a few questions related to how prepared your organization is to be in compliance with these new requirements. Click here to access the CR 8358 survey!


MedPAC Finalizes Hospice Payment Recommendations for FY2015

As noted previously in the NAHC Report, the Medicare Payment Advisory Commission (MedPAC) met on January 16 and 17 to finalize the recommendations which will be included in its March 2014 Report to Congress. MedPAC affirmed its support for the hospice recommendations discussed at its December 2013 meeting, with one significant change – in December MedPAC supported inclusion of hospice care under the Medicare Advantage (MA) benefit package beginning in 2017.  The final recommendation, however, has this change take place in 2016 instead.  The acceleration of the effective date was driven by interest on the part of several MedPAC commissioners to see this change take place sooner rather than later.

Following are the hospice recommendations that will be included in the March report:
1.  Congress should eliminate the update to the hospice payment rates for fiscal year 2015.
2. Congress should include the Medicare hospice benefit in the Medicare Advantage benefits package beginning 2016.

The transcript for the January meeting, as well as the presentation slides related to hospice payment and Medicare Advantage are available online here:

Hospice payment presentation
Medicare Advantage presentation

As part of the MA presentation on hospice, MedPAC staff provided some additional detail related to how they would see the recommendation being implemented.  MedPAC expects that the hospice benefit in its entirety (as required under current law) would be covered, so plans could not pick and choose which services would be provided. 

Preauthorization could be part of how the plan approaches hospice coverage, but MedPAC believes that preauthorization for hospice services, given the scope and use of the benefit, would likely be too cumbersome for plans to implement.  MedPAC also noted that plans would have the latitude to charge beneficiary cost sharing for hospice. (NAHC Report January 29, 2014)


Bipartisan Letter Seeking Postponement and Re-evaluation of Home Health Rebasing Rule Sent to House Leadership

Last week, Representatives Ralph Hall (R-TX), Tom Price (R-GA), David McKinley (R-WV) and Doris Matsui (D-CA) sent a letter to House Speaker John Boehner (R-OH) and House Minority Leader Nancy Pelosi (D-CA) urging congressional action to postpone CMS’ Final Rule on home health rebasing and require that CMS re-evaluate the rule.

Citing previous Dear Colleague letters from last summer in both the House and the Senate, as well as appeals from other stakeholders highlighting the widespread opposition to CMS’ rebasing rule, the letter states that, “urgent action is needed.”

The letter strongly reinforces the points that NAHC has been stressing since the beginning of the rebasing debate, namely that:

“If this rule is not postponed and appropriately evaluated, according to CMS projections of almost half of the home health industry will be paid less than their costs. Current industry data shows that as many as 73% of home health agencies across the country could be out of business when the rule is fully implemented…

The Final Rule…clearly does not take into consideration the appeals made by the U.S. Congress and interested stakeholders. The Final Rule unnecessarily rebases payment rates at the maximum cut permitted under the Affordable Care Act: a cut of -3.5% per year over each of the next 4 years, totaling an unprecedented cut to Medicare home health funding of 14% by 2017…

Urgent action is needed as the Final Rule took effect January 1, 2014.

Home health plays an essential role in our health care system by serving the Medicare population with skilled nursing and rehabilitation services in the least costly setting – the home, and it is imperative that we protect access to care through informed and reasonable rulemaking.”

The letter included legislative language that would require a postponement and re-evaluation of the rule.  NAHC and its state affiliate, the Texas Association for Home Care & Hospice, are working with the authors of the letter to seek opportunities to offer this provision as an amendment to pending legislation to fix the flawed Medicare physician payment formula known as “SGR.”

During an update to MCA on February 11, NAHC reports that the resolution regarding the SGR fix is “changing by the hour. Everything, from getting rid of the SGR to another short-term patch is on the table for discussion at this point.” While the Finance Committee has been reviewing a list of possible cuts, none have been scored at this time, so they are still just discussion points. (February 5, 2014 NAHC Report)


National Council on Medicaid Home Care Reports on Ways and Means Employer Mandate Hearing

On January 28, 2014, only hours before President Obama was scheduled to deliver his State of the Union address, the House Ways and Means Committee held a hearing on the employer mandate included in the Affordable Care Act (ACA). Michelle Martin, Policy Director for the National Council on Medicaid Home Care, a NAHC affiliate, attended the hearing.

The hearing was well attended by the members of the Ways and Means Committee and focused on the 30-hour rule included in the ACA. The members heard testimony from five witnesses (written testimony of the witnesses can be found here):

  • Lanhee J. Chen, Research Fellow, Hoover Institution
  • Peter Anastos, Owner, Maine Course Hospitality Group
  • Neil Trautwein, Vice President, National Retail Federation
  • Thomas J. Snyder, President, Ivy Tech Community College
  • Helen Levy, Research Associate Professor, Institute for Social Research

Following the testimony of each of the witnesses, all of the committee members in attendance were allowed five minutes for question and answer. The content of the hearing focused on the “Save American Workers Act” (HR 2575), a bill offered by Congressman Todd Young (R-IN) in June of 2013. The bill seeks to redefine “full-time employee” as a person who works 40 hours per week, instead of 30 hours per week as defined in the language of the ACA, for purposes of the employer mandate. A similar bill, “Forty Hours Is Full Time Act of 2013,” was offered by Senator Susan Collins (R-ME) in June of 2013 and has bipartisan support in the Senate.

During the hearing the Republican members of Congress repeatedly expressed support for redefining “full-time employee,” while the Democrats maintained that moving the threshold from 30 hours to 40 hours would be a greater incentive for employers to cut employees’ hours. For a discussion, please see the testimony of Helen Levy here.

Several of the Democrats concentrated their comments and questions on broader issues such as the best ways to fix the ACA and corporations’ responsibility to employees, which created the feeling that those members may not disagree with the change in definition, but feel that there are bigger issues to focus on.

On February 4, 2013, the Ways and Means Committee voted to move Congressman Todd Young’s bill forward by a party-line vote of 23-14. No Democrats voted in favor of advancing the bill.

NAHC and the National Council on Medicaid Home Care recognize the relief that home care and hospice providers would experience if the ACA’s definition of “full-time employee” were changed to 40 hours per week in advance of the implementation of the employer mandate.

NAHC applauds the efforts of Congressman Todd Young and Senator Susan Collins to provide relief to hundreds of employers and thousands of employees throughout our nation. We hope that members of Congress will see the need to continue to work together to pass this important legislation and “fix” the parts of the ACA that have proven unworkable.  Until the vote by the Ways and Means Committee, Republicans have staunchly refused any action related to improving the ACA, instead opting strictly for repeal of the full law.  


National Hospice News

Study Finds Hospice Workers Less Likely to Leave Jobs

A recently released study published in Home Health Care Services Quarterly reveals that hospice workers fare better in staying with their jobs, on average, than other home health workers. Researchers have delved into a database that links the 2007 National Home Health Aide Survey with the 2007 National Home Health Agency Survey, allowing them to examine how home health workers differ according to a variety of factors, including: Socio-demographics; compensation; benefits; satisfaction; and retention. The report suggests several possible explanations for the discrepancies between hospice and other home health workers’ longevity on the job, including categorization of home health workers and possibly differing pay and benefits.

Researchers remark on the fact that “most research to date has examined home health workers as a group, but has not made distinctions between worker categories.” They describe several categories that could be independently assessed. Some workers are home health aides and certified nursing assistants (HHA/CNA), who are “employed by certified home health agencies and work under the supervision of a registered nurse.” Other workers are hospice aides, who provide care to those in the final stages of life. Home care aides or personal care attendants are the third type of workers who “are hired by an agency to assist clients with activities of daily living.” The paper suggests that not understanding how these types of workers differ “makes it difficult to assess the extent to which public policies and private sector attempts to strengthen the home health workforce... are likely to succeed.”

The authors of the study also suggest that differences in pay and benefits might play a role in the greater job stability of hospice workers. In 2007, the average hospice worker earned about 80 cents more per hour than the average for all home health workers ($12.40 versus $11.60). Hospice aides also received better benefits on average than workers in other health fields. For example, almost all hospice aides had access to employer-sponsored health insurance, while only three quarters of home care aides and HHAs/CNAs did. More than 90% of hospice aides received travel reimbursement, while only 67.9% of HHAs/CNAs, and 52.4% of home care aides did.

Despite the discrepancies in stability and benefits, the authors report that job satisfaction is high across all types of home health workers. “Nearly half of all workers indicated that they were ‘extremely satisfied’ with their job. One half of all workers also said they were ‘extremely satisfied’ that they were learning new skills.” Nevertheless, almost 1 in 5 workers indicated that they are looking for another job. Almost half of home health aides anticipated leaving their jobs in the next year, compared to only one-third of HHAs/CNAs and one-fifth of hospice aides. (LeadingAge, 1/27) Read more....


New Study Says Seniors Rely on Family Members to Make Critical Medical Decisions

When the time comes for making critical medical decisions while in the hospital, a new study says older people often rely on family members or other surrogates to make those calls.Research published in JAMA Internal Medicine finds that about half of older patients needed help making decisions within two days of being admitted to a hospital setting. (JAMA, 1/2014) Read more....
(Reuters, 1/21) Read more....


Study Reveals Ethical Issues at the End of Life Are More Than Just Medical

Ethical issues at the end of life are not primarily medical or scientific. Rather, states a study published in The Journal of Hospice and Palliative Nursing, the primary issues are social, legal, religious and cultural.Because of this, it is crucial that nurses respect the cultures they are working within, while at the same time “negotiating between ethical systems to meet the goals of the patient.” (Journal of Hospice and Palliative Nursing, 2/2014) Read more....


Importance of Embracing Palliative Care in Children

NPR in Vermont highlights the importance of embracing palliative care for children suffering from chronic illnesses.“There is a national effort underway to get more health care providers to see the value of and recommend palliative care treatments for patients with serious illnesses, and that includes children.” (VPR, 1/27) Learn more....



National Home Care News

MedPAC: Tie Payments to Re-hospitalizations

Medicare payments would be reduced for agencies that exceed a patient re-hospitalization limit under a recommendation the Medicare Payment Advisory Commission (MedPAC) will include in its March report to Congress.The proposal would apply only to re-hospitalizations of beneficiaries after they were admitted for home health within 30 days of hospital discharge. It calls for a hospital readmission threshold equal to the average rate of the 40% of agencies scoring best for re-admissions. However the threshold wouldn’t apply to readmissions until the year after the threshold was established, giving high re-admission agencies the opportunity to improve their performance. Prior to the commission’s unanimous vote in favor of the recommendation, MedPAC staffer Evan Christman noted that the payment reduction penalty could take several forms, but at a minimum should be equal to the amount Medicare paid for the home health services provided during episodes that resulted in excess re-admissions.

The quarter of agencies with 58% of the re-admissions would have been harder hit with penalties than all the remaining agencies, which accounted for only 26% of hospital re-admissions, MedPAC said. In the four highest re-admission states — Texas, Louisiana, Oklahoma and Mississippi — three quarters of the agencies would have exceeded the threshold MedPAC used for its estimates.

In the MedPAC presentation, re-admissions that aren’t due to shortcomings in an agency’s care wouldn’t be penalized. However, the presentation doesn’t make clear how such re-admissions would be defined.

Moreover, the payment penalties for agencies with larger numbers of low-income patients that experience higher re-admission rates could be made fairer by basing them on a comparison with agencies that have similar caseloads, Christman explained.
(HH Line)

Savings – The Potential of Medicare ACOs

There seems to be a “strong start” to programs to establish Accountable Care Organizations (ACOs) and “bundled payment” contracts in which doctors and hospitals coordinate to deliver more efficient care.

A top Centers for Medicare and Medicaid Services official said the preliminary savings figures of about $400 million in the first year were so strong they show that ACOs are an excellent long-term strategy for controlling spending in Medicare.

Medicare began contracting with ACO’s two years ago. Jon Blum, the top deputy administrator to Centers for Medicare and Medicaid Services, tells of the promise shown by ACOs.

A total of 5.3 million Medicare beneficiaries, or about 12 to 13 percent of all of its enrollees, now receive care under ACO arrangements, said Blum.  “This number is far higher than what we had guessed would happen three years into the program,” he said in a press call.

Results from the first year show that more than half of the initial group spent less on care than they had projected. 29 of the 114 ACOs that were in the first group that contracted with Medicare in the shared savings program were able to deliver large enough reductions to be able to share in the savings with the federal government. Collectively, those 29 ACOs are getting $126 million as a result.  They “demonstrated that their care models have produced greater Medicare savings than the underlying dramatic low trend rate” for Medicare spending, Blum said.

Another 23 pioneer ACOs get to keep $147 million of the savings they have produced for Medicare.

Under the ACO program, savings are divided between the provider organizations and the U.S. Treasury. The Medicare trust fund has been able to keep $128 million in savings thanks to the ACOs, Blum said.  The cumulative savings for both the providers and the government is $401 million.

Blum says ACOs that delivered savings did so by using medical imaging more wisely, reducing unnecessary visits to the emergency room, and doing a better job of preventing hospital re-admissions, for example.

Blum was asked what potential ACOs have for eventually generating far higher level of savings than the figures announced Thursday.  He replied that they are only one part of the strategy.

“One thing I think [we] have seen in the last four years is unprecedented slowdown in total Medicare cost on a per capita basis,” he said. There are “many things driving that result—new care models, new payment models, more vigilance on fraud and abuse, and putting in place a menu of different tools and programs,” he added.

Blum suggested that many more beneficiaries will fall under ACO arrangements in the future.  “We are adding about a hundred new ACOs each year.” Blum said if “these growth trends continue, then it’s going to be a continued phenomenal story for the Medicare program.”

 “It means we’ll be able to move forward without hesitating” on use of the ACO model. “Medicare getting out front and doing this on a fairly large scale has been very important. It’s so important for long term success for there to be consistency across the payers in any area so that the providers have similar incentives for most of their patients.”  “I think it’s time to start talking about evolving the model,”

The next step is to get beneficiaries more directly involved with ACOs so the entities might better direct patients to providers, he said. Right now, beneficiaries are assigned to ACOs but do not have to actually enroll in them and aren’t steered in any way in where they have to go for care.

Getting beneficiaries more directly involved will be a heavy lift, he said. “It seems as though both parties in Congress don’t want to ask beneficiaries to do anything.”

McClellan said it’s also important to watch innovation among Medicare Advantage programs in assessing potentially promising changes in Medicare. “There are a lot of Medicare Advantage plans that are doing things like the Medicare shared savings program in terms of changing payments to providers in a way that supports better care,” he said. “In many cases, they are going further.” (CQ HealthBeat)


CMS Develops New Billing Codes for Chronic Care Management Services

The 2014 final rule for the Medicare physician fee schedule included the addition of a new payment code for chronic care management to begin in 2015. The new code will allow reimbursement for non-face to face time physicians spend managing patients with multiple chronic conditions that are not reimbursed under the current Evaluation and Management codes physicians’ bill for office visits. These codes are in addition to the recently added Transition Care Management codes (TCM 99495-99496), which also reimburses physicians for non-face to face time association with transitioning patients to the community.

There will be only one code for chronic care management services rather than two separate codes, and the time frame for providing the service will be 20 minutes per 30 days. The new code will read as follows: “Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days”

The final rule sets the scope for chronic care management services to include:

  • 24-hour-a-day, 7-day- a-week access to address a patient’s acute chronic care needs.
  • Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
  • Care management for chronic conditions including systematic assessment and development of a patient centered plan of care.
  • Management of care transitions within health care.
  • Coordination with home and community based clinical service providers.
  • Enhanced opportunities for a patient to communicate with the provider through telephone and secure messaging, internet or other asynchronous non face-to-face consultation methods.

CMS Announces Second Wave of Moratoria 

Thursday, January 30 the Centers for Medicare and Medicaid Services (CMS) announced the second wave of moratoria on the enrollment of home health agencies in four metropolitan areas, to take effect January 31, 2014. The areas affected are Fort Lauderdale, Fla.; Detroit, Mich.; Dallas, Texas; and Houston, Texas. CMS also announced it is extending for six-months the current enrollment moratoria of home health agencies in Chicago and Miami.

According to CMS, "existing providers and suppliers can continue to deliver and bill for services, but no new provider and supplier applications will be approved in these areas." Additionally, the six-month extension of the moratoria in these areas and the imposition of new moratoria in the additional counties will appear in the February 4, 2014 Federal Register and can be downloaded.

Agencies in the process of obtaining a Medicare provider number should contact their Medicare Administrative Contractor (MAC). CHAP will be reaching out to providers in the affected areas who are in the process of initial accreditation in the coming weeks. CHAP will continue to monitor the status of the moratorium and provide updates as they are made available. 

Below is previous communication CHAP issued regarding the July moratoria, which may help to answer questions you have.

CHAP Update on CMS Moratorium - August 28, 2013

CMS and Palmetto Related News

Strange Home Care Denial Noted – 5CHHB

Some Home Health agencies in other states have reported an unusual denial for long stay patients involving billing code 5CHHB. Upon investigation nothing could be found regarding any documentation for the denial code other than “CMS edit to deny beneficiary claims submitted with referring provider”.  After calling Medicare it was learned that there is no information currently regarding this denial code and no information will be released until JULY.  CMS indicated that this is an active denial code as of January 2014 and they have received several calls during the past week regarding the code.  CMS indicated that providers who receive this denial should do a first level appeal and detail why the patient used a particular physician along with all documentation of a normal ADR.  CMS does not plan to issue a letter to go along with the appeal.  The CMS representative did say that apparently, at one time, the physician or the patient made a complaint against the other.


Claim Status Category and Claim Status Codes Update 

This article is based on Change Request (CR) 8582 which informs Medicare contractors about the changes to Claim Status Category Codes and Claim Status Codes.  Make sure that your billing personnel are aware of these changes. Read more….

Latest OASIS Q & A’s

The most recent list of OASIS Q & A’s is now available from CMS. Click here to access the January edition.


The Comprehensive Error Rate Testing (CERT) Program is a federally mandated program set in place to monitor and improve accuracy of Medicare payments. This program created a way for the Centers for Medicare & Medicaid Services (CMS) to look at the Paid Claim Error Rate and provider compliance for Palmetto GBA. For more information on the CERT program and how to respond to CERT requests, click here.

Are You Answering OASIS M1200 Correctly?

CMS addressed this topic in its January 2014 OASIS Q&A, released Jan. 22, on question No. 4.  The questioner asks the federal Medicare agency whether a clinician should assess a patient’s ability to read a prescription label using both corrective lenses and an adaptive reader.

Neither an adaptive reader nor a magnifying lens is considered a corrective lens when assessing a patient’s vision abilities for M1200, CMS says. Clinicians should report in M1200 what the patient is able to see with a corrective lens.  According to the CMS OASIS Guidance Manual, a patient’s “usual status” is considered what is true more than 50% of the assessment time frame. So if a patient wears reading glasses, the clinician will need to make a judgment about whether the patient them more than half of the time, in which case the vision should be considered impaired and an answer of “1” is appropriate.  The OASIS item also impacts an agency’s risk adjustment. (HH Line)

PGBA Reviews Three HIPPS Codes with 20 or More Therapy Visits

Palmetto recently announced plans to review more than 1,000 claims involving three HIPPS codes. The codes have episodes with at least 20 therapy visits, and each code pays about $6,000 per episode, with amounts varying depending upon location, says Aaron Little, senior managing consultant at BKD Health Care Group in Springfield, MO.  

The MAC is “conducting these probes to validate if errors exist in our jurisdiction,” states a Palmetto spokesman.  “These reviews may take several months as we issue the Additional Documentation Requests (ADRs), receive the records and review the claims,” the spokesman says.

Depending on the code, affected patients will have moderate to high clinical and functional severity scores on the OASIS; 5CHK has the highest score possible; an episode with 5CHK has a case-mix weight of 2.2292.

Percentage of episodes and average visits by HIPPS code

Palmetto GBA is performing its latest medical review edits on cases involving HIPPS codes 5CHK*, 5CGK* and 5BHK* (last digit variable). These codes involve episodes with 20 or more therapy visits. Compare your agency’s visit numbers for these cases against other agencies nationwide. The data below are based on 1.5 million episodes provided by more than 2,000 agencies in 2013.

HIPPS code

% of episodes by code












































Source: OCS HomeCare, Seattle