Homecare: Automatic Denials

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.pdf

Kevin Harrington, MATS, MSHA, RHIA, CHP  Full-Time Faculty at Saint Joseph's College