Questions and Answers
Episodes
| Question Number | Question | Answer |
|---|---|---|
| 1 | If the certification period for a patient begins on April 1, 2012, and the episodic system takes effect May 1, will Medicaid billing be handled Fee for Service from April 1st thru the 30th and then a partial episode payment made for May 1st thru May 30th? Would partial episodic or LUPA payments be made for the shortened periods after 04/30/2012? | FFS billing and payments will continue as authorized and applicable through April 30, 2012. In order to transition to episodic coverage for existing patients, providers would initiate a Medicaid episode beginning on May 1st. Payment will be based on the most recent OASIS assessment (must be no more than 60 days prior to beginning of Medicaid episode). OASIS assessments will continue to be completed in accordance with Federal requirements. If the provider wishes to synchronize the Medicaid episodic dates with the existing assessment schedule, the agency should submit a claim for a partial episode ending May 30, then switch to full 60-day episodes if the patient remains under care. Payment for a partial episode will be pro-rated unless the patient is discharged to home, hospital or hospice, or is deceased. If total service cost is $500 or less, claim will be paid as a LUPA. |
| 2 | For cases already in a second or later episode/cert period prior to May 1st, will episodic payment begin with what is considered a Start of Care episode paid at a lower rate or a subsequent episode paid at a higher rate? | The rate to be used for Medicaid billing will be based on the most recent OASIS. If the most recent assessment was a "Recertification," the NYS Medicaid rate will be based on Recert., even if it is the first episode billed to Medicaid. |
| 3 | When a patient is receiving Medicare only benefits, but then requires Medicaid eligible services at a date subsequent to the start of home health care, how should episodes be kept in synch? (e.g. - On day 35 of a Medicare episode it is determined that patient no longer meets Medicare billing criteria, or begins to receive additional home health aide hours billable to Medicaid) How/When should the Medicaid episode be created if part of the services are to be billed to Medicaid and part continue to be billed to Medicare? Is one possibility to bill Medicaid-covered services for the above patient as fee for service until the next cert period and then synchronize episodes? How should the episode be created if all of the services shift from Medicare coverage to Medicaid? | The authorization to bill fee-for-service ends on May 1, 2012, except for children under 18 years of age. An initial Medicaid episode commences with the date of the first Medicaid eligible service. No Medicare covered services can be included in the Medicaid episodic claim. To synchronize subsequent episodes with the federally required OASIS assessment cycle, the initial Medicaid episode would be submitted with DOS covering the initial partial period (as claimed on UB-04, field 6 "Statement Covers Period From/Through") and a partial episodic payment would result. Example: Medicare episode is April 15 through June 13. Medicaid eligible services begin May 20. If the agency wishes to synchronize episodes, the initial Medicaid claim will be for May 20 through June 13 (partial episode). Subsequent Medicaid claim will be for June 14 through August 12 (full episode). |
| 4 | If a patient is receiving Medicaid only services and then becomes Medicare eligible, a new SOC OASIS is completed for the Medicare episode. How should providers keep episodes in synch? Should original Medicaid episode be ended and create a new one, resulting in a PEP to the Original? If not OASIS will be out of synch for the two payers. | A partial episode can be used for Medicaid to keep the Medicaid and Medicare episodes in synch. If all services become ineligible for Medicaid (i.e. Medicare covered), the Medicaid episode would end, and based on the dates of Medicaid service as claimed on the UB-04, a partial episode and corresponding partial payment would be determined. |
| 5 | If a patient is dually eligible and the CHHA is billing for both Medicare and Medicaid, there may not be a visit on the first day of the Medicaid episode for a SOC case, as the home health aide may not go into the home until a few days after the SOC. Will it be acceptable that the first visit falls after the Start of Care Date? | A Medicaid initial episode cannot begin until a Medicaid eligible service is provided. This is consistent with Medicare payment rules. For a second or later episode the subsequent episode begins on the day after the end date of the previous episode, provided the patient is receiving continuous care. There is an exception which applies only to May 1, 2012: If the patient was receiving Medicaid-eligible services in April 2012, and care continues into May 2012 without a discharge, the initial Medicaid episode can begin May 1 even if there is not a Medicaid-billable service provided on that date. |
| 6 | How will partial episodes be calculated? Episode start thru last visit, or first visit thru last visit? | The partial episode is based on the dates of service as claimed on UB-04, field 6: "Statement Covers Period From/Through". |
| 7 | If a patient is discharged after one or two episodes and readmitted at a later date, does the episode counter start back at 1? | There is no episode "counter." Under this example, a start of care assessment would need to be completed for this patient. |
| 8 | How will the final payment adjustment work based on length of stay? | If the dates reported in UB-04 field #6 ("Statement Covers Period") reflect 60 days or more, provider will receive payment for a full episode. For periods of less than 60 days, the payment amount will be pro-rated unless the patient was discharged to home, transferred to a hospital or hospice program, or is deceased. Beginning May 1, 2012, these exceptions will be determined by the Discharge Status reported by the provider (field 17 on the UB-04). This logic will not be available during the testing period (Jan. 4, 2012 through April 30, 2012) and all reported episodes of less than 60 days will be pro-rated. |
| 9 | If there is a concept of billing episodes, do all active patients on 5/1/2012 have their billing episodes start new on 5/1/2012 or would they convert to episodic payments at recert time? | FFS billing for patients 18 and older is not valid after April 30, 2012. For patients under continuous care in April and May, the first episode will start May 1. For a new patient in May, first episode will begin on the date of the first Medicaid eligible service. |
| 10 | What is the claim procedure when a CHHA discharges a patient to the home/community in less than 60 days, and then readmits the same patient before the end of the 60-day episode? | If the agency has already filed a Final Claim and then provides additional services within the 60-day period, an Adjusted Claim will be required. All services within 60 days of the original episode start date will be considered part of the same episode. |
| 11 | If a patient is hospitalized during the 60-day period do we discharge, and re-admit once the patient is discharged from the hospital, or do we handle this like Medicare, where the patient remains in "pending" until the 60-day episode runs out? | All CHHA services within the 60-day period should be billed as a single episode. If the agency has already filed a final claim reflecting less than 60 days, and then resumes care for the same patient, an adjusted final claim should be filed. |
| 12 | Explain what the statement from and thru dates reflect on the claim; would that reflect the billing cycle? | The from and through dates represent the beginning and end of the episode. If this is the first Medicaid episode, the from date coincides with the date of the first Medicaid eligible service. The through date is either the end of the 60-day period, or the last date services were rendered, if the episode is a partial. For subsequent episodes, the from date is the date immediately following the through date of the previous period. The through date is populated following the same rules as the initial episode. |
| 13 | If a patient receives Medicaid FFS and is under the age of 18, however has a birthdate within the next 60 days, how should the Episode be reported? If the patient turns 18 and only has 30 days within the episode, will an adjustment be required? | Services provided to a patient under age 18 must be billed on a fee-for-service basis (not episodic). Episodic billing for the patient will begin on his/her 18th birthday, provided that a Medicaid eligible service is provided on that day; otherwise, the episode will begin on the first day after the 18th birthday that a Medicaid eligible service is provided. If the episode begins on the patient's 18th birthday and ends 30 days later, it will be reimbursed as a partial episode, unless it meets one of the criteria for full episodic payment (e.g. discharge to home). |
| 14 | Should the patient be discharged from the Medicaid FFS program on the day before his/her 18th birthday? | There is no need to discharge the patient. Services must be billed FFS prior to the 18th birthday, with episodic billing starting at age 18. |
| 15 | Many of our customers have conveyed that they are on a 6 month certification cycle, rather than a 60 day cycle. Would these agencies be required to complete a certification assessment prior to or on May 1, 2012 in order to have a current 60 day certification to use for beginning the episodic cycles? | Federal CMS rules require completion of an OASIS assessment for home health patients no less frequently than every 60 days. |
