American Speech-Language-Hearing Association

Changes to Medicare Home Health Agency Claims

(April 22, 2014)

Effective July 1, 2014, Medicare Home Health Agency (HHA) Prospective Payment System (PPS) claims must include (a) a valid individual National Provider Identifier (NPI) and the name of the physician who certifies/re-certifies the patient's eligibility for home health services (certifying physician) and (b) the NPI and name of the physician who signs the patient's plan of care (attending physician).

Both physicians must be enrolled in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) as either a participating or non-participating provider. Physicians who have opted out of Medicare, but refer patients for Medicare services, must have completed an updated opt-out affidavit with Medicare.

In most instances, the certifying physician will be the same physician who signs the plan of care, in which case the HHA only reports the NPI and the name of the physician as the attending physician. However, physicians who attend to hospitalized patients, but do not follow them into the community, are considered certifying physicians and are subject to the ordering and referral enrollment requirements. On the electronic claim, these physicians are indicated in the "Other Provider" field.

Background

The Patient Protection and Affordable Care Act (ACA) included requirements for referring physicians (including physician assistants, clinical nurse specialists, and nurse practitioners) to be enrolled in Medicare. Currently, the enrollment edit only applies to the attending physician for the home health claim. The edits instituted on July 1, 2014, will check home health claim submissions to ensure that attending and certifying physicians have valid National Provider Identifiers (NPIs) and are of a specialty type eligible to order and refer the HHA items and services on the claims. Claims will be denied when this information is missing or invalid.

Resources

For more information regarding the physician referral requirements, refer to the CMS MLN Matters publication Certifying Physicians and the Phase 2 Ordering and Referring Denial Edits for Home Health Agencies (HHAs) [PDF].

For questions or additional information, please e-mail reimbursement@asha.org.


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