Home Health & Hospice Week

Get ready for another claims processing hurdle to block your way to Medicare payment.

The Centers for Medicare & Medicaid Services is implementing edits to validate HIPPS codes against assessment data for three post-acute providers: home health agencies, inpatient rehab facilities, and skilled nursing facilities.

First up are IRFs, whose validation edits went into place Oct. 1. CMS plans to implement HHA and SNF edits on future dates "to be determined," the agency notes in MLN Matters Article No. MM7760.

Why? "Currently, the [Fiscal Intermediary Shared System] does not have access to the assessment databases," CMS notes in the article. "This inability to validate the submitted Health Insurance Prospective Payment System (HIPPS) code(s) against the associated assessment creates significant payment vulnerability for the Medicare program."

How it will work: If the HIPPS codes on the claim and in the QIES OASIS assessment database agree, Medicare will release the claim for processing, CMS explains. If not, the MAC will use the assessment to generate a new HIPPS code. If there is no corresponding assessment file in the database, the system will return the claim to provider, CMS says in revised Transmittal No. 2495 (CR 7760).

"Although a date has not yet been determined for implementing this process for home health claims, agencies should be make certain to take necessary steps to be prepared for this," warns the National Association for Home Care & Hospice.

Tip: "Agencies that use outside vendors rather than HAVEN to generate HIPPS codes should verify the HIPPS codes that their software generates against HAVEN prior to submitting claims," NAHC advises.

Resources: The transmittal is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2495CP.pdf and the MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7760.pdf.