Edition: Home Health

July 2024

Stay informed with the latest updates and hot topics in the managed care industry with our July newsletter. We are dedicated to keeping all providers informed of the ever-changing and evolving landscape that is managed care.

Happy Fourth of July!

Wishing everyone a day filled with joy, reflection, and a renewed commitment to building a brighter future. Here's to liberty, creativity and the pursuit of excellence!

Home Health providers that service United Health Care plans need to watch their coding.  “Effective July 1, 2024, UHC will implement a new Home Health Services Policy, Professional. The change is in alignment with CMS , home health services billed in placed of service 12 will not be reimbursed if the dates of service overlap with an inpatient stay. The date span criteria will exclude the date of admission and discharge.”

For more information click here.

How efficient and accurate is your team on diagnosis and claims coding? We recently posted that the health plans are starting to decline claims based on improper coding.

Simply Healthcare is offering free coding webinars for providers. Find the educational webinars here.

This is an easy way to provide education to your team.

Improper Diagnosis Codes Causing Claim Denials


Who determines the patient’s diagnosis codes when a patient enters your facility under managed care? Which codes are being used to obtain the authorization and are they really appropriate? If it is admissions, are they trained for this? Are they collaborating with nursing or MDS for appropriate codes?

Health plans are cracking down on inappropriate diagnosis codes and denying claims as such. All too often, we see claims denying because the codes utilized are not correct.

Example: S72.92XA “Unspecified fracture of left femur, initial encounter for closed fracture” would be used by the hospital and would likely be the diagnosis on the referral. However, a SNF does not do initial encounters; SNFs provide after care. Z47.89  “Encounter for other orthopedic aftercare” would be one of the choices as a more appropriate code for a SNF. It is important to validate what codes your team is using, not only the admission diagnosis, but also for submission of the claim. This is another reason why Triple Check for managed care is just as important as it is for Medicare.


Some things to think about - does your team do Triple Checks? Was there pushback from the team to include managed care? 

Reminder Kepro, the Quality Improvement Organization (QIO) Kepro BFCC-QIO (keproqio.com) is rebranding as Acentra Health. Same services and websites for now. Forms will be need to updated from Kepro to Acentra Health by fall 2024, allowing the use of Kepro on NOMNC, IM and other QIO associated form for now. Find the FAQ here.

Sunshine Health is offering a variety of billing and coding webinars to providers. It appears that they will be discussing ICD 10 Coding issues on some of the webinars. Incorrect and duplicate coding is causing a lot claims rejections from multiple health plans. To learn more about the webinars offered by Sunshine, please visit Sunshine Health Offers Free Webinars to Improve CDI, Coding Skills | Sunshine Health

How does Substitution Apply to Home Health?

Substitution, what does is mean regarding Home Health and how does it apply?  Substitution is a term used when an agency wants to use a lower license type instead of a higher license.  An example would be utilizing a LPN for RN services or a PTA in place of the PT. While the service or treatment being performed can be done by the lower licensure, the question becomes whether it is allowable by the payer’s contract. Some health plans or TPAs will allow the substitution with a notification and service code change. Other plans do not require a different code at all because the HCPCS are generic.   Then there are plans that do not allow substitution because they do not allow lower licensure usage.

For plans that do allow for substitution, it is important that the treating physician agrees, the plan allows with codes to identify the licensure and that provider bills appropriately to reflect the change. Billing for a PT but utilizing a PTA would be a qualifier for claim denial if the plan had separate PTA HCPCS. Bottom line is everyone in the organization needs to be aware of what a contract does and does not allow regarding substitution. Communication between intake/authorization coordinator, the scheduler and the billing department are vital so that everyone is on the same page and aware of the contract requirements. This is an example of why doing regular billing verification meetings with your team is important to catch claim issues before they are submitted.

Upcoming Conferences

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Housekeeping Items

  • Verify benefits every 1st and 15th of the month as a best practice.
  • New employees, please let our liaisons know so we can setup training
  • Discharge Summaries should be sent to the health plans and patient's PCP upon discharge
  • Have you registered for our new portal? Register here!

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