Billing and coding for home health and hospice is only becoming more complicated. As we move forward into a new year with new challenges, it will be critical for providers across the board to establish strong best practices to optimize reimbursement, increase accuracy, and avoid audits.As you get ready for 2020 and build out your best practices, here are our top suggestions to consider for implementation this coming year.
Assign Ownership for Updates to Regulations and Coding Standards
The world of billing and coding is constantly changing, mostly because of annual updates to laws, regulations, and code sets.
For example, the Patient-Driven Groupings Model (PDGM), the biggest change to Medicare’s home health payment methodology since PPS, is set to have a huge impact on home health reimbursement, and it kicks in this year. At the same time, the ICD-10 2020 code set went into effect on October 1, 2019. Sorting out how these will impact your workflows, training, and reimbursement shouldn’t be left to chance. An individual or team should have responsibility for staying ahead of these changes and taking advantage of preparation periods.
If you need help getting ready for PDGM, this post might help.
Aim for Excellence in Accuracy
In 2020, accuracy will matter more than ever. Of course, the basics such as proper documentation of name, date of birth, and Medicare number will still be important, but as PDGM takes effect, accuracy now has a higher price.
Your reimbursement is no longer directly tied to the number of therapy visits as PDGM essentially drops the therapy factor altogether. PDGM presents new accuracy-based challenges such as:
- The validity of the selected primary code
- Selection of the code describing the highest level of specificity of the principal reason the patient is receiving home health services
- Documentation of medical necessity and outcome and assessment information set (OASIS) assessment
While these elements were effective under HH PPS, under PDGM, they impact payment calculation.
Prioritize Payer Relations
Each payer, Medicare and Medicaid included, have their own specific sets of rules and constantly evolving guidelines. While you may have been dealing with the same payers for years, new payers and even changes to existing payers can present challenges and create unnecessary risk in reimbursement.
If someone in your organization isn’t already responsible for keeping billing practices in line with payer expectations, consider creating an oversight role or giving the duty to a team member with a strong track record of understanding payer nuances.
Track Your Results
2020 presents a lot of changes so it will be critical to stay on top of how you’re being impacted and how any changes you’re making translate to results. Make sure you’re staying on top of your key performance indicators (KPIs) and reviewing them to ensure your efforts are headed in the right direction. Consider measurements including:
- Days in receivables outstanding
- Denial rate
- Claim resolve rate
Additionally, don’t rule out the idea of custom KPIs to evaluate how well your billing and coding practices are aligning with any changes you’re making to adjust to PDGM or ICD-10 2020.
Get Back to Basics
With all these new concerns to keep top of mind, it might be easy to let some of the foundational elements of proper billing and coding go. This is something you don’t want to let happen.
Make sure you’re properly documenting supplies, are clearly addressing challenging questions like overlapping dates of services, and are taking care of error-prone elements like admission dates. For example, according to CMS,
“On the first RAP in an admission, this date should match the statement covers ‘from’ date in FL 6. On RAPs for subsequent episodes of continuous care, this date should remain constant, showing the actual date the beneficiary was admitted to home health care. The date on RAPs for subsequent episode should, therefore, match the date submitted on the first RAP in the admission.” 
Assess Your Support Options
Don’t take on a year like 2020 on your own. Now is the perfect time to reassess your needs and consider options such as partnering with a specialized outsourcing solutions provider, and reevaluate whether your billing and coding technology solutions are fitting your needs.
If you’re considering working with a vendor, look for experienced professionals, but only after outlining the results you expect and the pain points you’re trying to address as you navigate this year. Have a list of questions prepared to understand how potential technology and outsourcing partners will address PGDM, ICD-10, and any other specific challenges you have.
We love to have this conversation with our partners and encourage everyone to talk with us about our perspective on outsourcing and the future challenges of home health billing and home health coding. If you’re considering outsourcing your medical billing, we’d love to talk and answer any questions you have.
 U.S. Centers for Medicare & Medicaid Services, “CMS Manual System,” 16 January 2004. Available: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R61CP.pdf.