Payment Codes to be Matched to Patient Assessments

Home Health Billing Update.

Beginning on April 1, 2015, Medicare systems will compare the Health Insurance Prospective Payment System (HIPPS) code on a Medicare home health claim to the HIPPS code generated by the corresponding Outcomes and Assessment Information Set (OASIS) assessment before the claim is paid. If the HIPPS code from the OASIS assessment differs, Medicare will use the OASIS-calculated HIPPS code for payment.

For now, if no corresponding OASIS assessment is found the claim will process normally, however providers should be reminded that submission of an OASIS assessment for all Home Health episodes of care is a condition of payment. If the OASIS is not found during medical review of a claim, the claim is denied. The Office of Inspector General (OIG) is recommending that the Medicare program use this claims matching process to further enforce the condition of payment in the future and CMS.

CMS plans to use the claims matching process to enforce this condition of payment in the earliest available Medicare systems release. At that time, Medicare will deny claims when a corresponding assessment is past due in the QIES but is not found in that system. CMS will provide notice to HHAs as soon as possible after they determine an implementation date.

Update Your Billing Staff: Steps to Take Now

While CMS has said that Home Health providers do not need to make any changes to their home health billing system at this time, please make sure your billing staff is aware that Home Health PPS claims will be suspended temporarily during processing to allow for the file exchange between FISS and QIES. The claims will be suspended with FISS reason code 37071 in status/locations SMFRX0-SMFRX4. This will occur during the 14 day payment floor period and should not delay payments to home health providers.

The full Medlearn matters article can be accessed here.