Medicare and Reimbursement for Falls-Related Services
Medicare pays for services that are considered medically necessary and reasonable. While there is no single benefit, provider, or procedure for falls, clinicians treating older adults with symptoms predisposing them to falls could receive Medicare-reimbursement and/or incentive (PQRI) payment if the services they provide are medically necessary, reasonable, and billed appropriately.
Physician Quality Reporting Initiative
Physician Quality Reporting Initiative can help practitioners identify people at risk for falls who might be in need of follow-up services.
The Tax Relief and Health Care Act of 2006 authorized the establishment of a physician quality reporting system, which CMS has called the Physician Quality Reporting Initiative (PQRI). The first reporting period was for services provided between July 1, 2007-December 31, 2007.
Eligible professionals, including physicians, nurse practitioners, physician assistants, occupational and physical therapists, and other practitioners providing services that are paid under the Medicare Physician Fee Schedule voluntarily reported on a set of quality measures through the Medicare claims they submitted. Professionals who successfully reported on measures were eligible for incentive payments.
The Medicare, Medicaid, and SCHIP Extension Act of 2007 authorized the continuation of the PQRI for 2008 and 2009, and provided greater flexibility in reporting and the opportunity for eligible professionals to receive higher incentive payments. For more information, please visit: http://www.cms.hhs.gov/pqri/
The PQRI presents an opportunity for providers to screen patients for falls risk and provide follow-up care if medically necessary and reasonable. "Screening for future fall risk" is a 2008 PQRI measure and is described as follows:
Percentage of patients aged 65 years and older who were screened for future fall risk (patients are considered at risk for future falls if they have had 2 or more falls in the past year or any fall with injury in the past year) at least once within 12 months.
For more information on the specifications for reporting this measure, go to: http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage
Hospital-Acquired Conditions (Present on Admission) Reporting Initiative
The Deficit Reduction Act of 2005 required the Secretary to identify conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. CMS can revise the list of conditions from time to time, as long as it contains at least two conditions.
For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule, CMS included 10 categories of conditions that were selected for the Hospital Acquired Conditions (HAC) payment provision. The list includes Falls and Trauma, please visit: http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage
Falls V-code
The Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) developed a V code to identify older adults who have fallen and are predisposed to recurrent falls. A V code is a type of diagnostic code used to describe a status rather than a specific condition. V codes are most frequently used as secondary diagnoses on a claim, but in some cases may be listed as the principal diagnosis.
The code, V15.88, indicates that the older adult may benefit from a fall risk evaluation and management of fall risk(s). This V-code may be useful for providing further justification of medical necessity and reasonableness for evaluation and management services for time-intensive activities, such as medication review and adjustment, either provided as a result of a falls risk screening conducted as part of the PQRI or not.
Qualification of the Medicare V code 15.88 is based upon the presence and documentation of at least one of the following:
- Recent history of falls in last 6-12 months*
- Health-related falls risk factors*
- Health behaviors related to falls*
*Documentation qualifies for use of Medicare V code 15.88, which is a secondary ICD-9 code to be used with principal ICD- 9 codes. Check with your local Medicare claims processing contractor to find out whether the falls V code can be used as a principal diagnosis on claims.
An ICD-9 code is required for all professional claims, e.g., physicians, non-physician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologist, ambulatory surgical centers (ASCs), and for all institutional claims.