Figuring out whether your agency is billing Medicare correctly and receiving accurate payments may seem impossible under complicated new PPS claims processes. Overcome your NRS billing process dilemma with these expert information provided by our expert in a home health conference.
Difference between the PEPs, the LUPA and the outlier
In LUPA, that's going to be a Low Utilization Payment Adjustment. And that's going to apply anytime an episode is billed with fewer than five total visits. And in that case, instead of getting the full episode payment, what you end up with is a per visit payment based on the discipline of service.
A Partial Episode Payment or a PEP, that's going to be anytime an episode is ended due to discharge or transfer and then a new episode is reopened within the original 60 days period that was started from the previous episode.
And in that situation, what would happen is that initial episode rather than getting the full 60 payment would get only a partial payment and that partial payment would be based on the last visit date. So if there were 30, rather if there was a visit, the last visit was performed on date 30 than you would get 30, 60th of that episode payment, as mentioned by our expert in a home health conference.
And then an outlier is by far the most complex but it is based on number of visits billed in a particular episode. And it is just a way to compensate for high cost episodes usually it's something like a wound care case where you may be doing daily or twice daily visits.
So what happens is every episode, there is a computation that is run to measure what is the outlier threshold compared to the outlier cost which is just rather an estimated cost of care. And if the cost is higher than that threshold, then 80% of that difference is paid on top of your regular episode payment.
So again, it's a fairly lengthy calculation but just to try to summarize, that is how that process works.
Non-Routine Supplies: HIPPS Codes
If an intimate alpha character, then the non-routine supplies have to be included. In whole changes, does it automatically change the HIPPS code if the non-routine supplies were not included?
That is something that you would need to ask of your software vendor because that is going to be unique to all the different vendors out there. But ultimately, it is the responsibility of the provider and whoever that might be within your organization as far as designated personnel to identify whether or not the non-routine supplies were simply just not remembered to put onto the claim or if there simply were no supplies provide.
And if your software is not going to help guide you through that process, then that would be something that you manually need to change your HIPPS code before you bill your final claim.
Home Health Training Tip: Some software systems are probably going to be implementing some edits where, you know, if supplies don’t pull on to the claim, they automatically change the HIPPS code.. You know, can you very if that is truly the case rather than just going ahead and automatically changing it to give you a chance to look into the episode and just make sure that the supplies were accurately reported.
So it is a question that definitely needs to be directed towards a software vendor. If you don’t have a software other than perhaps PCAs which is the free software that you can get from your RM, Medicare intermediary, then it is solely just going to be up to you to change that HIPPS code before it is billed.
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