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PPS Reform: Analysis and Guidance

Here’s What to Do When the Need for Therapy Increases

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Beacon Health Briefing
Mequon, Wisconsin - November 5, 2008

Common scenario: The patient was admitted to BHC Homecare after a short stay in a rehabilitation facility following a total knee replacement. His plan of care had orders for six physical therapy and three occupational therapy visits. Three weeks later, the physician ordered six more physical therapy visits.

Homecare providers are confused about how to handle an increase in therapy services. Third parties, such as intermediaries, often compound that confusion by issuing incorrect guidance. Consider this question.

If there is a change in therapy during the episode, how should we handle the Health Insurance Prospective Payment System (HIPPS) code on the claim? We have had several claims for increased therapy rejected because the HIPPS code on the request for anticipated payment (RAP) did not match the one on the claim. Someone in our agency changed the code. However, I heard that when therapy increases, we only have to report the visits on the claim. We do not have to call back the RAP or change any codes. When I called Medicare for clarification, I was told that the codes on the RAP and claim must match AND we should change the one on the RAP to match the claim. Now I am totally confused.

There are three fundamentals that apply to an increase in therapy or any service.

• The first four positions on the HIPPS code on RAP must match the one on the claim or the claim will be rejected.
  
  
• With elimination of the significant change in condition (SCIC) adjustment, there is no mechanism to change the HIPPS code during the episode.
  
  
• Even though the SCIC adjustment is gone, the requirement to update the comprehensive assessment for a major improvement or deterioration in health status and transmit the data remain.

This clinician is correct in her understanding of how to handle an increase in therapy. The agency does not have to cancel and resubmit the RAP or change the HIPPS code. However, if the increase was due to a major change in condition, the clinician will need to update the assessment with OASIS and the agency must transmit the data. Finally, the claim must note all therapy visits. The system will pay based on that number, not on the HIPPS code reported. In the scenario, the HIPPS code would reflect nine therapy visits but the claim would report 15, the basis of the episode payment.

We can understand homecare providers being confused about how to handle many of the changes in the revised PPS. What we don't understand is the frequency with which Beacon Institute™ members are reporting incorrect guidance given to them by intermediaries. This intermediary said to change the code on the RAP to match the claim, which is the wrong thing to do. CMS Publication 100-4, Chapter 10, §40.2, says, “claims must report a 0023 revenue code line (the line with the HIPPS code) matching the one submitted on the RAP. If this matching 0023 revenue code line is not found on the claim, Medicare claims processing system will reject the claim.”

© 2008 Beacon Resource Group, Inc. All Rights Reserved.

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