With the increasing trend of patient care being delivered it
the home, and many health care organizations looking at vertical integration
into home care, this topic of Home Care can be of assistance to healthcare administrators.
Centers for Medicare & Medicaid Services (CMS) directed
Medicare Administrative Contractors (MACs) to start the process of doing an
automatic denial of Home Health Prospective Payment System (HHPPS) claims. This
process will be automatic when there are some conditions for payment that are
not met in the claims submission process, specifically if the patient
assessment data is not met.
If the claim is submitted without OASIS Assessment information the claim will
be denied.
This information must be submitted within
30 days of completion. For the most part, this window of 30 days will have
elapsed by the time the 60 day Plan of Care/Episode for HHPPS is completed. Now
when the claim is submitted, for dates of service after April 1, 2017. Medicare
claims processing will now look for the corresponding OASIS assessment is
present in the Quality Information and Evaluation System (QIES).
If the criteria of the assessment is not found and the date
of the claim is more than 30 days after the assessment completion date that is
reported on the claim, Medicare will deny the claim. With that said, in the
beginning however, Medicare will allow for 40 days.
In the information that Medicare sends back to the agency
the following codes:
- Group Code of CO
- Claim Adjustment Reason Code 272
The home health agency can do some things to avoid
unnecessary denials. Before submitting the claim the home health agency should
check to see if the OASIS assessment has been completed and accepted in the
QIES National Database. The home health agency can also verify by reviewing
their OASIS Agency Final Validation Report to OASIS.
Basically, the home health agency should ensure prior to the
submission of the OASIS assessment and the claim and that the following is
correct:
- Home Health CMS Certification Number (OASIS item M0010)
- Beneficiary Medicare Number (OASIS item M0063)
- Assessment Completion Date (OASIS item M0090)
- Reason for Assessment (OASIS Item M0100) equal to 01, 03, or 04
Most importantly, accuracy of home health agency claims
information is essential to prevent claim denials.
For more information on various Home Health Prospective
Payment initiatives at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17009.pdfKevin Harrington, MATS, MSHA, RHIA, CHP Full-Time Faculty at Saint Joseph's College
