4 Common Reasons for HIT Claim Denials

Billing for Medicare’s new Home Infusion Therapy (HIT) benefit is becoming easier for providers who regularly submit claims, but SimiTree’s revenue cycle experts say a few aspects continue to confuse agencies providing services under the benefit.

“The Home Infusion Therapy Benefit is still a relatively new benefit, and there are a few tricky parts that just seem to consistently cause confusion,” said Lynn Labarta, SimiTree’s VP of Post-Acute Revenue Cycle Management.

Effective since Jan. 1, 2021, the new benefit allows home health and several other types of providers to create a new service line around the provision of certain types of home infusion drugs.

HIT covers professional services such as skilled nursing, patient monitoring and patient education – services not otherwise covered under the Durable Medical Equipment (DME) benefit.

“Much of the confusion we see is around understanding what is and what isn’t covered,” Labarta said. “HIT only covers services that are not already covered by DME.”

Providers also have questions about the accreditation required to provide services under the HIT benefit, Labarta said.

“If your agency is already accredited by CHAP or ACHC or another accrediting organization, you are not automatically eligible,” she said. “A separate accreditation will be required for HIT.”

The revenue cycle experts at SimiTree work with agencies to explain accreditation requirements, services covered and other considerations. A consultation can help home health providers determine whether it is feasible to pursue a new line of service under the HIT benefit, Labarta said.

Top reasons for denial

Since its implementation, four common problems have emerged as the top reasons for denials and billing confusion surrounding HIT, Labarta said. Some are simple fixes, allowing claims to be resubmitted after a tweak, and others require more work.

The four top reasons for denials are:

1. Enrollment issues. Claims are often rejected for lack of a specialty code of D6 effective for claim lines for HIT services. This is usually a CMS 855B form issue, Labarta said, with providers having failed to properly identify themselves on the form. A Type of Supplier checklist requires providers to select one box from a list of many. The correct answer for proper HIT enrollment is Other, Labarta said. Providers will also need to specify Home Infusion Therapy in the space provided next to Other.

When this enrollment issue is the problem with the claim, billers may see Claim Adjustment Reason Codes (CARCs) or Remittance Advice Remarks Codes (RARCs) such as:

• CARC 16. Claim lacks information or has submission errors.

• RARC N256. Missing, incomplete, or invalid billing provider or supplier name.

Remedy:

Labarta said the remedy is to reach out to regional Medicare enrollment and request to correct the enrollment issue.

2. No corresponding DME claim. Although providers billing for professional services under the HIT benefit do not have to be DME suppliers themselves, there must be a corresponding DME claim from the pharmacy or other DME supplier for the drugs which were infused in the home. Otherwise, Medicare will not approve the HIT claim.

When a HIT claim does not correspond to a DME claim with one of the allowable drug J codes, the Medicare Administrative Contractor (MAC) will recycle the claim up to three times during a 15-day period. If the corresponding DME claim doesn’t show up in the system during that timeframe, the HIT claim will be rejected.

When the lack of a corresponding DME claim is the problem, billers may see these types of messages from the MAC:

• CARC 16. Claim lacks information or has submission errors.

• RARC N657. Bill with appropriate code for services.

Remedy:

Labarta said the remedy is consistent communication between the home health agency and the DME supplier.

3. Multiple G codes. Drugs infused under the HIT benefit are classified by Medicare into one of three different categories, depending on complexity, and each category is paid at a different rate. Although some patients may receive multiple types of drugs from different categories, Medicare will only pay for one G code listed per line item on the date of service. Medicare allows only the highest paying category to be billed.

If more than one G code line item is billed for the same day, it will be denied. Billers will see these types of messages from the MAC:

• CARC 97. Benefit for this service included in payment or allowance for another service.

• RARC N111. Service has been previously billed.

Remedy:

Labarta said the remedy is to correct the G code, making sure it reflects the highest paying category, and resubmit the claim.

4. Duplicate billing issue. Medicare pays different rates for initial and subsequent home infusion services. A claim billed at the initial service rate requires that no infusion was provided to the patient for at least 60 days prior to the service being reported. Otherwise, the rate for the subsequent infusion will apply.

If the G code indicates that the home healthy provider is billing for an initial service and the Medicare system indicates the patient received home infusion within the past 60 days, the claim will be rejected.

When this is the problem with the claim, billers will see these messages from the MAC:

• CARC 96. Service not covered.

• RARC 640. Service exceeds the frequency allowed within the timeframe.

Remedy:

Labarta said the remedy is to change the G code and resubmit.

SimiTree can help

Does your home health or hospice agency have a backlog of unpaid claims with missing or improper documentation? Are your claims frequently denied?

The billing and collections experts at SimiTree have the industry expertise and training to make quick work of Accounts Receivable – and our proprietary collections tool will quickly identify the upstream revenue cycle obstacles slowing down the claims process, so that you can take corrective action to get paid faster.

We become a seamless extension of your office, working alongside your team to provide the training and services needed to make certain your agency is fully reimbursed in a timely manner for the care and services delivered.

Use the form below to reach out to us today and let’s get started helping your agency become more profitable.