4/21/2017 CASE MANAGEMENT IN HOME CARE: ADVOCACY AND ACCURACY CONNECTIONS THAT MATTER. Regional Education Consultant

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1 CASE MANAGEMENT IN HOME CARE: ADVOCACY AND ACCURACY CONNECTIONS THAT MATTER Jennifer Collins, RN, BSN, HCS-D, COS-C Regional Education Consultant 3 1

2 LEARNING OUTCOMES: 1. Identify the top denial reasons for payment in current home care landscape. 2. List the critical items needed to support reasonable and medically necessary care. 3. Define the weak areas and education needs of your staff. 4 ADVOCATE: THE ROLE OF THE CASE MANAGER What is the Ultimate Goal? Vision of CMS is to provide the right care for every patient every time 5 ADVOCATE: THE ROLE OF THE CASE MANAGER The Case Manager must connect regulatory compliance with high quality patient care and ensure evidence of both are in the patient chart. 6 2

3 ADVOCATE: THE ROLE OF THE CASE MANAGER The right person: Detail oriented, precise Analytical Rule Follower Right the first time mentality Owner vs Renter Critical thinking role vs data entry role 7 ADVOCATE: THE ROLE OF THE CASE MANAGER Education: Start with rules, regs, and documentation requirements Always ask why? Must be a priority Must be consistent Must be challenging 8 ADVOCATE: THE ROLE OF THE CASE MANAGER Steps for success Provide resources, web links, reference tools Clinical note templates Audit tools / checklists Clearly communicate expectations 9 3

4 ADR: Additional Documentation Request 10 ADRS Additional Documentation Request Who may send an ADR?: MACs CERT Recovery Auditors ZPICs Audit entity will specify documentation to be sent OASIS Plan of care with required pertinent information Visit notes from specified time period Face to Face document 11 ADRS: MEDICARE PROGRAM INTEGRITY MANUAL Chapter 3: Verifying Potential Errors and Taking Corrective Actions Stated goals MACs analyze claims for compliance Corrective action when non-compliant Correct behavior Prevent future inappropriate billing Only looking for violations or errors that affect Medicare payment amount BUT agency can be referred to CMS for issues not affecting payment 12 4

5 ADRS: DATA MINING Software examines claims data for patterns Type of profiling practice Combination of data from various sources Primary source: CMS National Claims History (NCH) 13 ADRS: SELECTION OF PROVIDERS Identified questionable billing practices per data analysis: Non-covered services Incorrect coding Incorrect billed services Alerts from MACs, QIOs, CERT, Recovery Auditors, OIG/GAO Complaints 14 ADRS: POSSIBLE TARGET AREAS High volume of services High cost LOS (Length of Stay) Dramatic change in frequency of use High risk of problem-prone areas RA, CERT, OIG, GAO data demonstrating vulnerability 15 5

6 ADRS: AUDIT TYPES CERT: Comprehensive Error Rate Testing Established by CMS Random claim selection, request charts from providers that billed for service Paid claims error rate: percentage of dollars paid incorrectly 2016 Home Health highest CERT error: Insufficient documentation - medical documentation submitted was inadequate 16 ADRS: AUDIT TYPES MR ADR: Medical Review Additional Documentation Request Pre-payment review Directed toward areas where data analyses indicate questionable billing patterns. 17 ADRS: AUDIT TYPES RAC: Recovery Auditors Identify and correct Medicare improper payments (post payment review) ZPIC: Zone Program Integrity Contractors Identify cases of suspected fraud, investigate them, and take action to ensure any inappropriate Medicare payments are recouped Home Health Probe and Educate Medical Review Ensure Home Health Agencies understand the policy at CFR (a)(1) and offer provider-specific education as necessary 18 6

7 ADRS: AUDIT TYPES PCRD: Pre-Claim Review Demonstration CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits. Additionally, CMS is testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care ADRS: BILLING PROBLEMS IDENTIFIED Repeated severe infractions MAC s discretion to initiate progressively more severe administrative action Example: 100% prepayment review of claims Minor or isolated inappropriate billing Provider notification, or Feedback with re-evaluation after notification 20 ADRS: IMPROPER PAYMENT Over- or under-payments Homebound status Face-to-Face Encounter documentation Ineligible recipient Ineligible service Duplicate payment Services not received Incorrect amount 21 7

8 ADRS: DOCUMENTATION RECOMMENDATIONS Agency records Progress notes Test reports Physician evaluations Hospital records Phone messages Conferences or other communication notes Any documentation maintained by the provider Anything that supports medical necessity and reasonable/necessary services 22 RED FLAGS IN ADR PROCESS Identical or nearly identical documentation Evidence of alterations Patterns and trends which may indicate potential fraud Missing signature from an order 23 CGS: ADR DENIAL REASON #1 Skilled nursing services were not medically necessary (66%) This claim was fully or partially denied because the clinical documentation submitted for review did not support the medical necessity of the skilled nursing services billed. 24 8

9 #1: SN MEDICAL NECESSITY NOT SUPPORTED Medicare Benefit Policy Manual: Chapter 7 Review language in and General Principles Governing Reasonable and Necessary 25 #1: SN MEDICAL NECESSITY NOT SUPPORTED Reviewer looking for services medically reasonable and necessary to: Treatment of injury; illness; disease/condition Must be: Safe and effective Not experimental or investigational Frequency and duration of services appropriate to treatment of disease or illness Appropriate to patient s needs/condition Furnished by qualified personnel Meets but does not exceed patient s need 26 #1: SN MEDICAL NECESSITY NOT SUPPORTED Justifiable reason for agency to provide care Why home care? Plan of care Meets standard and acceptable medical practice standards codes Medications: new/changed Diagnoses and patient condition support level of care Service consistent with the nature and severity of the illness or injury 27 9

10 #1: SN MEDICAL NECESSITY NOT SUPPORTED Primary Diagnosis Main reason for home health care services Documentation supporting next five diagnoses & case-mix OASIS questions Documentation supporting the focus of care Therapy need Support of established plan of care 28 #1: SN MEDICAL NECESSITY NOT SUPPORTED Caregiver status: Able, willing, available? Can care be taught to caregiver? Revolving door of caregivers? Barriers to provision of care, teaching/training, etc..? 29 #1: SN MEDICAL NECESSITY NOT SUPPORTED Skilled Nursing Care: Reasonable and Necessary Services which, by its nature, require the skills of a nurse to be provided safely and effectively continues to be a skilled service even if it is taught to the patient, the patient s family, or other caregivers. If patient needs the skilled nursing care and there is no one trained, able and willing to provide it, skilled nursing services would be reasonable and necessary

11 #1: SN MEDICAL NECESSITY NOT SUPPORTED Example: A patient was discharged from the hospital with an open draining wound that requires irrigation, packing, and dressing twice each day; Agency has taught the family to perform the dressing changes Agency continues to see the patient for the wound care that is needed during the time that the family is not available and willing to provide the dressing changes. 31 #1: SN MEDICAL NECESSITY NOT SUPPORTED Overall medical condition Valid factor in deciding whether skilled services are needed Supportive documentation Diagnosis Never the sole factor in deciding that a needed service is either skilled or not skilled Evident from F2F denials 32 #1: SN MEDICAL NECESSITY NOT SUPPORTED Skilled Nursing: Observation and Assessment Teaching and Training Management and Evaluation Skilled Care Care of Diabetic Patients Psychiatric Nursing See pages of handouts for descriptions and documentation needs of each 33 11

12 #1: SN MEDICAL NECESSITY NOT SUPPORTED SN Documentation Issues Incomplete Inconsistent No skill documented Lack of coordination of care Care incongruent with issues identified Illegible Clinician didn t proofread before submission Not according to POC 34 #1: SN MEDICAL NECESSITY NOT SUPPORTED Actual excerpt from SN note: SKILL PERFORMED THIS VISIT: SN assessment, Pt with recent hospitalization for DVT exacerbation of axillary vein of both upper extremity, proximal left lower limb; new medication: lovenox bid; Pt able to self administer since has had this medication at home previously; chronic pain in left leg with edema tight, pitting and red. 35 #1: SN MEDICAL NECESSITY NOT SUPPORTED Actual SN note: ROC visit completed today s/p hospital stay for pneumonia and fall. Pt was taken to ABC hospital after fall and dx with pneumonia and irregular heart beat. Pt was treated and then sent home on PO abx for pneumonia. PT to eval today for weakness and unsteady gait. Pt has appt with PCP Dr XYZ tomorrow am. SN to continue to monitor respiratory status and home safety. Dtr and paid cg present for visit

13 #1: SN MEDICAL NECESSITY NOT SUPPORTED: CONNECT The Role of the Case Manager Review clinical notes for medical necessity and homebound status Ensure qualifying (billable) skill provided AND documented every visit prior to claim submission Accurate G-code applied Lead case conference to verify ongoing need, ensure appropriate recertification, discharge, and communication with physician. 37 CGS: ADR DENIAL REASON #2 Requested documentation not received/received untimely (13%) Medical records were not received in response to an Additional Documentation Request (ADR) in the required time frame; therefore, the auditors were unable to determine medical necessity. 38 #2: REQUESTED RECORDS NOT SUBMITTED Prevention Strategies: Monitor claim status on Direct Data Entry (DDE) Aim to submit medical records within 30 days of the ADR date. Submit all claim information at one time 39 13

14 #2: REQUESTED RECORDS NOT SUBMITTED Prevention Strategies: Attach a copy of the ADR request to each individual claim If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost. 40 #2: REQUESTED RECORDS NOT SUBMITTED Prevention Strategies: Do not mail packages C.O.D.; the MAC cannot accept them Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department. 41 #2: REQUESTED RECORDS NOT SUBMITTED Agency response times from date of request: MAC 45 days (auto denial after 45th day) CERT 75 days Recovery Auditors 45 days ZPIC 45 days (auto denial after 45th day) 42 14

15 #2: REQUESTED RECORDS NOT SUBMITTED: CONNECT The Role of the Case Manager Proactive chart review Clean billing Faster turn around (submission) Tracking method once notified of ADR Deadline driven and own the outcome 43 CGS: ADR DENIAL REASON #3 The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist (7%) Medicare Benefit Policy Manual, Pub100.02, Ch. 7, #3: THERAPY MEDICAL NECESSITY NOT SUPPORTED For therapy services to be covered, one of the following three conditions must be met: The skills of a therapist are needed to: 1. Restore patient function 2. Establish or design a maintenance program 3. Perform maintenance therapy 45 15

16 #3: THERAPY MEDICAL NECESSITY NOT SUPPORTED Prevention Strategies: Reassessment by a qualified therapist for each discipline completed at least every 30 days. Verify an adequate number of billable therapy visits performed to meet threshold 46 #3: THERAPY MEDICAL NECESSITY NOT SUPPORTED Prevention Strategies: SOAP Note documentation format: S: Subjective Data O: Objective Data A: Analysis Most critical P: Plan See pages of handouts for examples of each 47 #3: THERAPY MEDICAL NECESSITY NOT SUPPORTED Documentation example: OT Reassessment: Pt reported she was fatigued and that her neck felt tired. She reported she had experienced an episode of bowel incontinence this morning. Pt's O2 sats were 79% on room air, but improved to 97% when she was cued to use deep breathing strategies to maximize her oxygen level. Pt's sats remained 97-98% for remainder of OT session. Therapist notified pt's HH nurse of pt's initial low O2 sats. Pt required Supervision to don LB clothing today, using RW for balance as needed to stand and don/doff pants from hips. She did not want to address shower transfers due to fatigue, but she did agree to complete ther ex. In sitting, pt completed activity tolerance retraining exercises of UE Restorator 7 mins with min to min/mod resistance. She completed sit to stands from her recliner to her 4wrw with MOD I. Pt has progressed from requiring SBA to Supervision with toileting, from SBA to Supervision with LB dressing, from SBA to MOD I with toilet transfers, and from Min A to SBA with shower transfers. Continue progressing pt with strength, activity tolerance, and dynamic standing balance to maximize her safety and independence with all ADLs and ADL transfers

17 #3: THERAPY MEDICAL NECESSITY NOT SUPPORTED: CONNECT The Role of the Case Manager IDT Coordinator: Case conference with 30 day reassessment deadlines, Recertification and Resumption of Care needs Ensure orders and goals on POC Minimize adjustments with accuracy on M2200 in coordination with OASIS Nurse Audit for Medical Necessity / HB in clinical notes 49 CGS: ADR DENIAL REASON #4 Medical necessity not supported as the OASIS was not submitted to the repository and/or not submitted prior to billing the final claim (3%) 42 CFR Condition of participation: Reporting OASIS information. 50 #4: OASIS NON-SUBMISSION 42 CFR (e) submission of an OASIS for all home health (HH) episodes of care is a condition of payment 42 CFR484.20(a) Reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary 51 17

18 #4: OASIS NON-SUBMISSION EFFECTIVE 4/3/17: If your OASIS assessment in not found in the State system when you submit your final claim AND the receipt date is more than 30 days after the assessment completion date (M0090), the Medicare system will automatically deny the home health claim. Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE17009.pdf 52 #4: OASIS NON-SUBMISSION: CONNECT The Role of the Case Manager Process step in RAP billing to finalize, release, or submit OASIS Review OASIS submission reports weekly as a double check Payer Source: review Medicare on-line verifications Case Conference: discuss payer changes 53 CGS: ADR DENIAL REASON #5 No documentation of services rendered (3%) Services listed on UB-04 are not (adequately) documented in records submitted

19 #5: NO DOCUMENTATION OF SERVICES RENDERED: CONNECT The Role of the Case Manager Billing Audit: HCPCS codes consistent with documentation Data entry error ADR submission checklist UB-04 compared to requested records ready to submit Case Conference: Review POC, skills ordered : ADR DENIAL REASONS 56 CGS DENIALS 1 ST QTR 2017 #1: SN services were not medically necessary (23%) #2: The physician certification was invalid since the required face to face encounter was missing/incomplete/untimely. (20%)*** #3: Requested documentation not received / received untimely. (18%) #4: The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist. (8%) #5: The initial certification was missing/incomplete/invalid, therefore the recertification episode is denied. (6%)*** ***Posted to CGS website 04/21/17*** 57 19

20 PRE-CLAIM REVIEW EDUCATION: PGBA Face to Face Encounter & Homebound Documentation 58 Prevention Strategies: Obtain copy of F2F encounter note with referral Examine for essential elements Consider sending supporting documentation to physician for signature/date Ensure certifying physician signs/dates F2F and supporting documentation (as applicable) Send actual visit note titled F2F Encounter with ADR 59 Time frame: Documentation of actual F2F encounter within 90 days prior to- or 30 days after HH SOC (signed/dated) May be in form of progress note, discharge summary, office visit note, clinical note, etc. Must be complete prior to EOE billing 60 20

21 Who may perform: Certifying physician (MD, DO, or DPM) Acute or post-acute physician Nurse practitioner** or clinical nurse specialist** Certified nurse midwife** or physician assistant** **must be working in collaboration with or under supervision of physician** 61 Signature & date: Required by certifying physician Must be prior to date final claim was submitted 62 Contents of F2F: Primary reason for encounter r/t reason for HH Date of encounter within required timeframe Need for intermittent skilled services (SN, PT, and/or SLP) Confined to home POC established and periodically reviewed by a physician Under the care of a physician 63 21

22 Homebound Status Eligibility under Medicare Parts A & B Physician must certify patient is confined to home Must meet two criteria to be considered homebound 64 Criteria-One: The patient must either: Need supportive devices; use of special transportation; or assist of another person to leave home OR Condition such that leaving his/her home is medically contraindicated 65 Criteria-Two: There must exist a normal inability to leave home AND Leaving home must require a considerable and taxing effort

23 Patient may leave home if: Absences are infrequent, or For periods of relatively short duration, or Are attributable to need to receive health care treatment Adult Day Care Outpatient kidney dialysis Outpatient chemotherapy or radiation therapy 67 Attendance of a religious service Deemed infrequent or short duration CMS expects most absences from home are to receive health care treatment Occasional absences for non-medical reasons 68 Per CMS: The aged person who does not often travel from home because of feebleness and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless they meet the homebound criteria 69 23

24 May be homebound for a psychiatric problem (without physical limitations) if the illness is manifested in part by: a refusal to leave home, or of such a nature that it would not be considered safe to leave home unattended CMS does not provide specific guidance on driving 70 HB Documentation: Use the homebound criteria 1 and 2 Measurable terms Example: Patient unsafe to ascend / descend stairs without assistance of two people; lives in mobile home with 3 steep stairs to gravel driveway Versus: Patient requires assistance for stairs 71 HB Documentation: Four questions to answer in documentation in order to effectively communicate the clinical rationale for determining if an individual is homebound and in need of skilled services: 1. What is the structural impairment of the patient? 2. What is the functional impairment of the patient? 3. What is the activity limitation of the patient? 4. How do the skills of a nurse or therapists address the specific limitations identified when answering the first three questions? 72 24

25 HB: What is ICF? ICD-10 International Classification of Diseases, diagnosis of diseases and disorders, and other health conditions ICF International Classification of Functioning, disability and health, and human functioning and disability are described as a dynamic interaction between various health conditions and environmental and personal factors ICD and ICF are complementary to each other. 73 HB: What is ICF? Moves the concept of disability away from being a consequence of disease to a recognition of the interaction of health and functioning and environmental and personal factors Describes an interaction of physical, social, and environmental factors with an individual s health conditions that produces outcomes of interest for physical therapists. Recognizes the role of the environment in determining an individual s ability to participate in society. 74 HB: ICF - Functional Impairments Documentation should address these areas: Acute vs. Chronic Illness or Injury Change from baseline HB: ICF - Structural Impairments Documentation should address: Structures of the body that influence function 75 25

26 HB: ICF - Activity Limitations What activities can the patient not do? The activity limitations must be ties to the system function. Able to ambulate only short distances (20 ft. or less) Cannot transfer from bed to chair Cannot dress oneself Cannot feed oneself 76 HB Documentation: ICF Elaborate on CMS homebound language to describe your individual patient s limitations Examples: Due to CHF patient ambulates with walker for distances of only 30 before becoming severely dyspneic and weak requiring frequent rest periods Alzheimer s causes the patient to become severely agitated when leaving familiar surroundings of home and requires 24 hour supervision for safety 77 HB Documentation: ICF Examples (cont): Due to COPD patient ambulates with a 4-point cane but is not able to climb/descend stairs without maximum assistance of an adult; all entrances to home have stairs Bilateral foot pain due to diabetic neuropathy becomes severe with ambulation of more than steps; requires wheelchair when leaving the home and this requires maximum assistance of another person Patient underwent a left THR and MD has placed a medical restriction in effect on 7/01/16 patient is not to leave home for 4 weeks following surgery 78 26

27 F2F Supporting Documentation Purpose: To supplement insufficient F2F documentation What & How? HHA information may be incorporated into certifying physician s or the acute/post-acute care facility s medical record for the patient Certifying physician must sign/date Documentation may be info from comprehensive assessment 79 F2F Supporting Documentation: Suggested Elements: Patient Name, MCR # (identifying data) Diagnoses as listed on OASIS/POC Services ordered (SN, PT, SLP, etc..) Supporting OASIS items Narrative/summary of initial OASIS assessment with medical history and description of homebound status Typed name of certifying physician Certification statement Signature/date of certifying physician 80 F2F Supporting Documentation: Admission Narrative: Summary of pertinent diagnoses and medical history resulting in referral to home health care New problem? Exacerbation of previous problem? Post-operative patient: date of surgery and complications Pain: onset and severity Medical restrictions 81 27

28 F2F Supporting Documentation Admission Narrative Include need for specific skilled services i.e. O&A, T&T, therapy needs to restore function or establish maintenance program Structural impairment Functional impairment Activity limitations Environmental, socioeconomic, and/or caregiver barriers to recovery 82 F2F Supporting Documentation Other facility documents (H&P, progress notes, surgical notes, etc..) Anything that supports the need for home care These other forms will need to be signed/dated by certifying physician 83 From NAHC Regulatory Affairs ( Listserv): 1. There is no specific place in the record where the physician following the patient must be identified 2. The certifying physician must attest that an encounter occurred, was related to the primary reason for home care and state the date of the encounter. 3. A certification signed / dated prior to the F2F encounter is not valid 84 28

29 Sample F2F Supporting Documentation, page Sample F2F Supporting Documentation, page Sample Actual F2F Encounter 4/21/

30 : CONNECT The Role of the Case Manager Creates / Submits supplemental documentation with POC to physician to integrate with their records and obtain signature / date for patient chart Ensures all required elements present prior to claim submission (audit tool /checklist) iles/home_health_face_to_face_checklist.pdf/$file/ho me_health_face_to_face_checklist.pdf 88 NO PLAN OF CARE OR CERTIFICATION (11.0%) The services billed were not covered because the home health agency (HHA) did not have the plan of care established and approved by a physician, as required by Medicare, included in the medical records submitted for review; and/or the service(s) billed were not covered because the documentation submitted did not include the physician s signed certification or recertification. 89 NO PLAN OF CARE OR CERTIFICATION Prevention Strategies: Verify the appropriate plan of care (POC) is legibly signed and dated by the physician prior to billing Confirm the plan of care contains all necessary information listed in MBPM Ch Ensure that the signed certification or recertification is submitted when responding to an ADR 90 30

31 NO PLAN OF CARE OR CERTIFICATION Prevention Strategies: The physician certification must include: The home health services were required because the individual was confined to his/her home and needs skilled care A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and The services were furnished while the individual was under the care of a physician 91 NO PLAN OF CARE OR CERTIFICATION Prevention Strategies: The same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible. Submit this information if medical records are requested by the intermediary. 92 NO PLAN OF CARE OR CERTIFICATION Sample certification statement with required elements: I certify that this patient is under my care and that I, or a nurse practitioner, clinical nurse specialist or physician s assistant working with me, had a face-to-face encounter that meets the physician face-to-face encounter requirements, i.e. a visit within 90 days preceding or 30 days after initial visit. Based on my findings, I certify that this patient is confined to the home and needs intermittent nursing care, physical therapy and/or speech therapy. The patient is under my care, and I have initiated the plan of care. The patient will be followed by a physician who will periodically review the plan of care

32 NO PLAN OF CARE OR CERTIFICATION: CONNECT The Role of the Case Manager Build the Plan of Care Ensure POC and certification are present, signed and dated prior to claim submission Verify signatures are acceptable Proactive in Case Conference 94 The Role of the Case Manager ADVOCACY AND ACCURACY 95 ADVOCATE: THE ROLE OF THE CASE MANAGER The Expert: The Medicare Benefit Policy Manual Chapter 7 Qualifying eligibility criteria Elements of the Plan of Care Covered Services Home Health Prospective Payment System (PPS) OASIS Accuracy and Logic 96 32

33 ADVOCATE: THE ROLE OF THE CASE MANAGER Interdisciplinary Team Coordinator: Cost effective, high quality care Coordinates communication with multiple disciplines Building the POC Patient Specific Goals and Interventions Qualifying Skilled Need Case Conference 97 ADVOCATE: THE ROLE OF THE CASE MANAGER Auditor: Qualifications for Home Care F2F Medical Necessity: Skilled Need Home Bound Status Certification / Recert Statement / Plan of Care Documentation OASIS Accuracy: HHRG and Outcomes Accurate Billing RAP / EOE 98 ADVOCATE: THE ROLE OF THE CASE MANAGER Expert Coordinator Auditor For multiple patients at various time points in their episodes of care. For multiple physicians and providers with various modes of communication and home care regulation knowledge. For multiple clinicians at various levels of professional and home care experience

34 Start by doing what s necessary; then do what is possible; and suddenly you are doing the impossible. -Francis of Assisi 100 RESOURCES: CMS > Medicare FFS Compliance Programs Systems/Monitoring-Programs/Medicare-FFS-Compliance- Programs/Overview.html CGS Home Health Top Medical Review Denial Reason Codes (October December 2016 posted 1/17/17) ns.html Conditions of participation title42-vol5-sec pdf CMS>OASIS Submission jennifer.collins@fms-regional.com PHONE: FAX: