Home Health & Hospice Week
Claims System Fix For LUPA Glitch Leads To Errors
A new claims system edit may be kicking out claims in error. On the other hand, it may be kicking out claims because you’re billing unallowable occupational therapy visits.
“The July 2015 system release included the addition of reason code (RC) 37249 to ensure appropriate payment is made on low utilization payment adjustment (LUPA) claims,” HHH Medicare Administrative Contractor CGS says in a message to providers. “RC 37249 was implemented to ensure that LUPA claims (4 or fewer visits), that are for the first episode in a sequence of adjacent episodes, or is the only episode of care, include a skilled service (skilled nursing (SN), physical therapy (PT), or speech-language pathology (SLP) on the claim. Occupational therapy (043X) visits are only covered when preceded by an intermittent SN (055X), PT (042X), or SLP (044X) visit.”
The problem: “Claims that receive RC 37249 will be sent to Return to Provider (RTP) (status/location T B9997). However, CGS has determined that some claims are being sent to RTP with RC 37249 in error. This issue has been reported to the system maintainer.”
The solution: “At this time, if you feel your claim is in RTP with RC 37249 in error, please contact the home health and hospice Provider Contact Center (PCC),” CGS advises. “The Customer Service Representative will make a referral to the Claims department. If the Claims department determines that it went to RTP in error, the claim will be released to continue processing.”
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