Remark code N116 is an alert indicating that the current payment is conditional, as the service was provided in the patient's home and there is a possibility that the patient is also receiving care under a home health episode. Under consolidated billing rules, certain therapy services and supplies should be included in the payment to the home health agency (HHA). If it is later determined that the patient was indeed under an HHA episode of care at the time of this service, the payment made to the provider will be subject to recoupment. Providers should be aware of the patient's care status with HHAs to avoid future payment recovery issues.
Common causes of code N116 are:
1. The healthcare provider billed for services or supplies that should be included in a Home Health Agency's (HHA) consolidated billing because the patient is currently in a home health episode of care.
2. The claim was submitted without verifying whether the patient is receiving home health services under an HHA episode of care, which may overlap with the billed services.
3. The provider may not have coordinated with the HHA to determine responsibility for billing certain therapy services or supplies.
4. There may be a lack of communication between the billing department and the clinical team regarding the patient's current care status under a home health episode.
5. The claim was processed and paid conditionally due to the possibility of an existing home health episode of care, but the payment is subject to recoupment if the patient is confirmed to be under HHA care.
6. Insufficient documentation or incorrect coding may have led to the conditional payment, with the payer needing additional information to determine the appropriateness of the charges in relation to the home health services being provided.
Ways to mitigate code N116 include implementing a thorough verification process for each patient's current care situation before providing services. This process should involve checking the patient's eligibility and benefits to confirm whether they are currently under a home health episode of care. Establish clear communication channels with local Home Health Agencies (HHAs) to ascertain if a patient is receiving home health services that would fall under consolidated billing. Additionally, maintain accurate and up-to-date patient records, including any home health episodes, to ensure that services provided are not subject to recoupment due to overlap with HHA care. It's also advisable to educate your billing staff about the specifics of consolidated billing requirements to prevent this issue from arising.
The steps to address code N116 involve verifying the patient's home health care status. First, contact the patient's home health agency (HHA) to confirm whether the patient is currently under a home health episode of care. If the patient is under such care, determine if the services provided are subject to consolidated billing under the HHA's payment. If they are, coordinate with the HHA to ensure that billing and payment are processed correctly to avoid future recoupment.
If the patient is not under a home health episode of care, or if the services provided are not subject to consolidated billing, document this information thoroughly. Keep detailed records of the communication with the HHA and any other evidence that supports the claim that the services should not be included in the HHA's consolidated billing.
In the case that the payment is recouped, you will need to submit a corrected claim with the appropriate documentation to justify the standalone billing of the services provided. Ensure that all claims are accurate and complete to prevent further issues with payment. Regularly review your billing processes to ensure compliance with home health billing requirements and to minimize the risk of receiving similar conditional payments in the future.