Billing:
Use Correct Year's Diagnosis Codes On Claims Spanning Oct. 1
Published on Thu Oct 07, 2004
You'll face delayed reimbursement if you mix up your fiscal year ICD-9 codes. Quick Test: If a home health episode begins prior to Oct. 1 and ends on or after that date, do you use 2004 or 2005 diagnosis codes on the RAP and final claim?
Home health agencies that thought they knew the answer aren't so sure now that HIPAA has eliminated the 90-day grace period for adopting new ICD-9 codes.
But agencies should do what they've always done since the prospective payment system began, recommend regional home health intermediaries Palmetto GBA and Cahaba GBA in advice posted to their Web sites.
Answer: When dates of service begin prior to Oct. 1, you should use 2004 diagnosis codes on both the request for anticipated payment and the final claim, confirms billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN. That rule goes even if you submit the RAP and claim after Oct. 1, points out consultant M. Aaron Little with BKD in Springfield, MO.
"The principal diagnosis code reported in FL 67 must match the primary diagnosis code reported on M0230 of the OASIS assessment, and in item 11 on the CMS-485 form (Plan of Care)," Palmetto tells agencies.
If the first date of service is Oct. 1 or after, you should use the newly updated 2005 ICD-9 codes on the RAP and claim, explains consultant Lynda Dilts-Benson with Reingruber & Co. in St. Petersburg, FL (for a list of new codes HHAs are likely to encounter, see Eli's HCW, Vol. XIII, No. 20, p. 154).
Failure to follow either of those procedures could result in returned claims you'll have to correct, notes Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, TX. And if you don't keep on top of your RTP'd claims online, the delays could sap your agency of much-needed cash flow.
Loophole: You may get lucky if you goof up and use a 2004 code on the RAP and a 2005 code on the final claim when the episode spans Oct. 1, however. "The claims system will accept both the new 2005 codes and the discontinued 2004 codes on final claims spanning October 1, 2004," Palmetto acknowledges, even though you are supposed to match the codes.
An exception to the RAP-final claim matching requirement applies to significant changes in condition. On claims that reflect a SCIC adjustment, "the principal diagnosis code should correspond to the OASIS that produced the [HIPPS] code on the latest dated 0023 revenue code line," Palmetto instructs. In other words, the claim should reflect the primary diagnosis on the OASIS that sparked the SCIC.
