How to Bill RAPs and Claims to Avoid Pitfalls
Between now and the implementation date of October 1, 2015, for ICD-10-CM, home health agencies have many important processes to re-evaluate. For example, coder productivity is expected to decline by 54.4 – 69 percent following implementation, according to the American Health Information Management Association (AHIMA). The loss in efficiency will likely cause a “log jam” for billing.
Agencies not prepared for this productivity loss and the related temporary billing changes, could face an overwhelming decline in reimbursements from payers post ICD-10-CM implementation. Agencies that anticipate change and adjust their processes accordingly will be better positioned to survive financially.
In a recently revised article from the Centers for Medicare & Medicaid Services (CMS), home health agencies are instructed on how billing home health episodes will be accomplished after the implementation of ICD-10-CM. There are three factors that will determine how ICD-10-CM will be used in billing Requests for Anticipated Payments (RAPs) and final claims that span the implementation date. These factors are:
- The claim “from” date (episode start date)
- MOO90: OASIS-C1 assessment completion date
- The claim “through” date (episode end date)
Depending on the three factors above, the RAP and final claim will be processed using either ICD-9-CM codes, ICD-10-CM codes, or a combination of both. CMS gives agencies several examples of how billing is to be done post ICD-10-CM. Let’s look at the scenarios:
Scenario 1: Admissions with Episode and MOO90 Completion dates before October 1, 2105:
In this scenario, let’s use a start of care date of September 28, 2015. The “from” date would be September 28, 2015. The MOO90 date would also be September 28, 2015. The “through” date would be November 26, 2015. In this scenario, the agency would code the RAP and the OASIS-C1 in ICD-9-CM codes. HIPPS code will be generated using ICD-9-CM case mix groupers. The final claim will be required to use ICD-10-CM codes according to CMS. Although doing so would possibly generate a different HIPPS code, CMS has said that they will use the ICD-9-CM generated HIPPS that is stored in the Assessment Submission and Processing (ASAP) system OASIS system for payment in this case.
Scenario 2: Admissions with Episode date before October 1, 2015, and MOO90 Completion date after October 1, 2015:
In this scenario, let’s also use the start of care date September 28, 2015. The “from” date would be September 28, 2015. The MOO90 date could be up to October 2, 2015. The “through” date would still be November 26, 2015. In this scenario, the agency would code the RAP in ICD-9-CM dates, because on RAPs, the “from” and “through” dates would both be September 28, 2015. The OASIS-C1 would be coded using ICD-10-CM codes, because MOO90 is after October 1, 2015. The final claim will be required to use ICD-10-CM codes.
Scenario 3: Admissions with Episode and MOO90 Completion dates after October 1, 2015:
For this scenario, all the dates fall after the implementation date of October 1, 2015. Therefore, the RAP, the Final Claim, and the OASIS-C1 will all be coded using ICD-10-CM codes.
Scenario 4: Recertifications with Episode date before October 1, 2015, and MOO90 completion date after October 1, 2015:
For this scenario, let’s say the patient is due for re-certification on October 2. The clinician has a five-day window of September 28- October 2 to complete the OASIS-C1 assessment and gather information from the physician and other clinicians, if applicable. The OASIS-C1 will need to be coded in ICD-10, as will the final claim. However, the RAP will need to be coded in ICD-9-CM.
Scenario 5: Recertifications with Episode date after October 1, 2015, and MOO90 completion date after October 1, 2015:
In this scenario, again, the re-certification window can be up to or even after the October 1 implementation date. However, if the episode date and OASIS-C1 completion date is on or after October 1, 2015, the RAP, final claim and OASIS-C1 will all be coded using ICD-10-CM. However, if the OASIS-C1 completion date is prior to October 1, then the process is a little different. Let’s look at this scenario:
Scenario 6: Recertification with Episode date after October 1, 2015, and MOO90 completion date before October 1, 2015, and episode through date after October 1, 2015:
In this last scenario, the episode starts after October 1, 2105. Therefore, the RAP and final claim will be billed using ICD-10-CM codes. However, the OASIS-C1 completion date will use ICD-9-CM codes because it was completed before October 1, 2015.
As you can see from the examples above, the OASIS-C1 code set decision is based on the MOO90 date. However, the RAP and final claim is based on the “From” and “Through” dates.
Now that CMS is using the ASAP system for OASIS submission, final claim HIPPS codes are being matched with the OASIS-C1 generated HIPPS codes. If there is a disparity, the HIPPS generated by the OASIS-is used to generate and adjust final claim payment. Implementation of ICD-10-CM throws a bit of a wrinkle into this system, because in some cases the OASIS-C1 will be submitted to ASAP in ICD-9-CM code set with resulting HIPPS codes generated from ICD-9-CM case mix, while final claims are submitted in ICD-10-CM with resulting HIPPS codes in ICD-10-CM case mix.
CMS has stated that it “will advise medical reviewers at the Medicare Administrative Contractors (MACs) to ensure that the ICD- 10-CM codes on these claims are not used in making determinations”. This means that HHAs do not have to re-group, or split, the episode bills based the ICD-10-CM codes. Claims will be based on the episode start date and associated OASIS-C1 code set used. For those episodes that begin before October 1, 2015, claims will be paid using the ICD-9-CM case mix generated HIPPS codes. For episodes that begin on or after October 1, 2015, claims will be paid using ICD-10-CM case mix generated HIPPS codes.
For more information on the billing process for home care claims following ICD-10-CM implementation, see CMS’s website: www.cms.gov.
REFERENCES:
CMS:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1504.pdf
http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1410.pdf
