Service Specific Post-Payment Audits of Home Health PDGM Bills

Table of Contents

• Service Specific Post-Payment Audits of Home Health PDGM Bills
• Overview
  • Documentation Requirements
• Related Content

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Service Specific Post-Payment Audits of Home Health PDGM Bills

Please note: TPE reviews continue to be on hold due to the public health emergency related to COVID-19. However, the National Government Services Medical Review Department will be performing service specific post-payment reviews for claims submitted to Medicare Part A.

Edit Reason Code: 5WGMP/5CGMP
Bill Type = 329
Dates of Service: 1/1/2020 thru 2/29/2020

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Overview

When a claim is randomly selected for review, the provider will receive an ADR letter. We must receive the medical records necessary to support the billed services within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in denial of the billed service. All documentation must be legible and authenticated by an acceptable handwritten or electronic signature. We will issue results upon completion of the post-payment review and offer education as needed.

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Documentation Requirements

1. Actual clinical note (discharge summary, progress note, plan of care, etc.) for the face-to-face encounter
2. Initial (start of care) certification by one certifying physician and the initial plan of care regardless of dates of service billed
3. Recertification, also by one physician and plan of care to cover this period billed if subsequent date of service
4. Home health agency generated documentation, including, but not limited to the initial nursing, therapy and OASIS assessments
5. If a patient’s sole skilled service need is for skilled oversight of unskilled services, submit the physician’s brief narrative documentation describing the clinical justification of the need for service. This statement can be part of the certification or recertification or as a signed addendum.
6. All signed physician's orders
7. Home health discipline notes for all services billed and flowsheets supporting coverage of visits
8. Initial therapy (PT/OT, SLP) evaluation regardless of dates of service billed
9. Therapy documentation, including assessment/re-assessments; re-evaluations
10. If there is an ABN on file, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

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Related Content

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Home Health Services
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Home Health Billing

Posted 9/1/2020