An announcement by the Centers for Medicare and Medicaid Services (CMS) in late March reveals that a new billing edit began April 3, 2017, related to OASIS data submission and claims processing.
As a condition for payment identified in the Medicare Home Health Conditions of Participation for Medicare-funded home health episodes, agencies must submit OASIS data within 30 days of completion of the assessment. CMS now requires Medicare Administrative Contractors (MAC) to perform an automated billing edit for all final claims as of April 1, 2017, and after. This billing edit will identify if timely OASIS assessment data is on file with the Quality Information Evaluation System (QIES), and if not, the final payment will be denied.
Medicare systems validate that the Health Insurance Prospective Payment System (HIPPS) code on a home health claim matches the HIPPS code calculated by the OASIS data submitted to QIES. If the HIPPS codes do not match, the HIPPS from the OASIS assessment is used for payment.
Until this new billing edit, action was not taken on claims that did not have a matching OASIS assessment in QIES. However, the Office of Inspector General (OIG) recommended that Medicare strengthen its enforcement of OASIS as a condition of payment to deter improper payment and fraudulent billing practices. This information was published in a series of Medicare Learning Network (MLN) Matters articles from April 2015 to present.
Beginning April 1, 2017, for the final claim to be denied, the assessment must be both missing and past due. This includes the Start-of-Care, Recertification, and certain Resumption-of-Care assessments.
When denying the claim, the following messages will appear on the remittance:
- Group Code of CO
- Claim Adjustment Reason Code 272
Before submitting a claim to the MAC, an agency’s billing processes should ensure the OASIS assessment has completed processing and was successfully accepted in the QIES database. This can be verified by review of the OASIS Agency Final Validation Report or OASIS Submitter Final Validation Report. There is no need to contact your software vendor, MAC or the QIES Technical Support Office (QTSO) help desk for these billing issues. The validation report contains the information needed to ensure the OASIS was accepted, including date of receipt and any fatal or warning errors encountered. Processes may require communication between the provider’s billing office and the staff that submits the OASIS to CMS.
Agencies should ensure, prior to submission of the final claim and the OASIS assessment, that the following information is correct, as these items are used to match claims and assessments:
- HHA 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
For more information on the new auto-denial billing audit, please refer to the following articles:
- Denial of Home Health Payments When Required Patient Assessment Is Not Received (MLN Matters Number: MM9585)
- Denial of Home Health Payments When Required Patient Assessment Is Not Received – Additional Information (MLN Matters Number: SE17009)
