Remark code M95 indicates that the services billed have been subjected to a medical review or cost report audit under the Home Health Initiative. This means that the claim has been flagged for additional scrutiny to ensure compliance with specific regulatory requirements or to verify the accuracy of the cost reporting related to home health services provided.
Common causes of code M95 are typically related to discrepancies or issues identified during a medical review or cost report audit for home health services. These may include:
1. Inaccurate or incomplete documentation that fails to support the medical necessity of the home health services provided.
2. Billing errors, such as incorrect service dates, procedure codes, or billing for services not rendered.
3. Non-compliance with Medicare's home health coverage guidelines, such as providing services to patients who do not meet the homebound criteria.
4. Inconsistencies between the care provided and the care plan or physician's orders.
5. Failure to meet the face-to-face encounter requirements mandated for home health certification.
6. Cost report issues, such as improper allocation of costs, unallowable expenses, or discrepancies between reported costs and financial records.
7. Lack of proper authorization for services that require pre-approval before being rendered to the patient.
Addressing these issues promptly is crucial to ensure compliance and to avoid potential payment delays or denials.
Ways to mitigate code M95 include ensuring that all home health services billed are in strict compliance with the latest medical necessity guidelines and documentation requirements. Providers should conduct regular internal audits to verify that the services provided align with the patient's care plan and are accurately reflected in the cost reports. Staff should be trained on the specific criteria that home health services must meet to pass medical review and should maintain thorough and timely documentation to support the medical necessity of each service. Implementing a robust quality assurance program that reviews and validates the appropriateness of coding and billing practices can also help prevent this code from appearing on remittance advice. Additionally, staying updated on any changes in home health initiative policies and integrating those updates into the organization's procedures will reduce the risk of triggering code M95.
The steps to address code M95 involve conducting a thorough review of the patient's medical records to ensure that all services billed are accurately documented and medically necessary. It's essential to gather all relevant documentation that supports the home health services provided, including physician orders, care plans, progress notes, and any other clinical documentation that justifies the services.
Next, perform an internal audit of the cost report to ensure that all costs reported are allowable and properly allocated. If discrepancies are found, make the necessary adjustments and prepare a detailed explanation to support the legitimacy of the costs.
Prepare a comprehensive response to the medical review or audit request, including all requested documentation and a cover letter that summarizes the case and explains why the services were necessary and appropriately billed. Ensure that the response is organized and submitted within the specified timeframe.
If the review or audit results in a denial or adjustment, evaluate the findings and determine if there is a basis for an appeal. If so, file an appeal with the appropriate documentation and a clear argument for why the services should be covered.
Finally, review your home health agency's policies and procedures to identify any areas for improvement that could prevent similar issues in the future. Implement staff training or process changes as needed to ensure compliance with Home Health Initiative guidelines and reduce the risk of future audits or medical reviews.