Courtesy of the National Association for Home Care & Hospice

The Centers for Medicare & Medicaid Services (CMS) last month posted a new project, 01-031 Home Health Notification of Medical Review. This is a post-payment review of claims for Medicare home health services billed on dates of service from January 1, 2020, through December 31, 2020, for the following bill types:

• 032X Home Health Services Under A Plan of Treatment
• 034X Home Health Services Not Under A Plan of Treatment

Detailed specifics about the project are not posted, but the following background information and list of documentation required in response to a record request under the project are provided.

Background and Reason for Review

Under the Patient-Driven Grouping Model (PDGM), the national, standardized 30-day payment amount is adjusted to account for patient characteristics and other information; including the principal diagnosis, secondary diagnoses, and functional impairment level. The need for therapy services under PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits. Under the new PDGM, a possible drop in therapy utilization and/or the manipulation of other combinations of care to maximize payments could create potential vulnerabilities.

The Supplemental Medical Review Contractor (SMRC) will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance. Applicable waivers and flexibilities established during the Public Health Emergency will be utilized during claim review activities.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each Additional Documentation Request (ADR) to obtain the necessary documentation to perform the review. Documentation requested has been made specifically to assist the provider in collecting and submitting pertinent information to decrease provider burden.

1. Acute/post-acute care document to support home health eligibility
2. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
3. History and physical reports (include medical history and current list of medications)
4. Documentation of all face-to-face encounters and/or signed attestations from start of care
5. Copy of the physician’s or authorized non-physician provider’s order or referral for home health services if separate from plan of care
6. Signed consent form
7. Home health start of care assessment
8. All physician or authorized non-physician provider’s orders, including medications and any durable medical equipment prescribed for the beneficiary
9. Initial certification and all re-certifications from start of care
10. Homebound/not homebound status
11. OASIS documentation (certifications, recertifications, follow-ups, and significant change)
12. Copy of the current medication list
13. Signed and dated overall plan of care including, short- and long-term goals with any updates to the plan of care
14. Home health plan of care
15. Physical/occupational/speech therapy – Initial evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
16. Home health skilled nursing, home health aide, or rehabilitation therapy notes including initial evaluations, re-evaluations, progress notes, and actual therapy minute grids
17. Any other documentation supporting the beneficiary’s need for the home health services being provided
18. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Policy Article
19. If medical record documentation is submitted via esMD, beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
20. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
21. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created; include an example of how the electronic signature displays once signed by the physician
22. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)

As the SMRC, Noridian performs and/or provides support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. CMS directs the topic and time frames for the projects. Project review types include:

• Healthcare Fraud Prevention Partnership (HFPP) Support Review – Review based on fraud, waste, and abuse trends identified by the HFPP
• Program Integrity (PI) Support Review – Claim review focused on possible falsification or other evidence of alterations of medical record documentation including, but not limited to: obliterated sections; missing pages, inserted pages, white out; and excessive late entries; evidence that service billed for was actually provided and/or provided as billed; or, patterns and trends that may indicate potential fraud, waste, and abuse
• Provider Compliance Group (PCG) Review – Claim review based on evaluation of beneficiary’s information and supporting medical records to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements

More information is available on the Noridian SMRC website.