Home Health & Hospice Week

Double-check your software if you’re seeing billing mismatches.

If Medicare’s OASIS-HIPPS code matching edit has been slowing your cash flow since April 1, you need to tighten up your billing procedures.

Recap: Since that date, the Centers for Medicare & Medicaid Services bases your payment on the OASIS responses you submit rather than the HIPPS code on your reimbursement claim (see Eli’s HCW, Vol. XXIV, No. 12). The Medicare claims system matches up claims with their corresponding OASIS records. “If the matching process determines that the OASIS-calculated HIPPS code is different from the one submitted on the claim, the OASIS-calculated HIPPS code will be used for payment,” CMS says in MLN Matters article SE1504.

Exception: “If an OASIS assessment corresponding to the claim is not found, the claim will process normally at this time,” CMS says in the MLN Matters article.

Submitting the OASIS prior to the claim has been a condition of payment since 2010, says OASIS expert Lisa Selman-Holman of Selman-Holman & Associates, Code Pro University and CoDR — Coding Done Right in Denton, Texas. It appears that CMS just now worked out a way of checking, she says.

CMS is simply enforcing something that has not previously been enforced, agrees Arlene Maxim of A.D. Maxim Consulting, A.D. Maxim Semi-nars and The National Coding Center in Troy, Mich. CMS likely is conducting this new cross-check because recent medical reviews have uncovered significant inconsistencies between the HIPPS paid and the actual HIPPS supported by OASIS documentation, she says.

Keep Claims Clean By Checking Validation Reports

The first step to figuring out whether your claims are in danger is to determine what might cause inconsistencies with the HIPPS codes you report.

One cause for HIPPS codes that don’t match between the OASIS and the claim is a software issue, Maxim says. If the software vendor you use to submit final claims hasn’t updated their product to CMS requirements, your reimbursement could suffer. If you suspect this is a problem in your agency, contact your vendor and ask them to make certain their product is up-to-date with all CMS rules.

Tip: Monitor the final validation report you receive after submitting the OASIS. If you find that this report comes back to your agency with a HIPPS code that isn’t the same as the code you submitted to the MAC, you’ll need to adjust the claim to match the code on the FVR, Maxim says.

Be sure to use this information to backtrack and investigate the problem so you can fix the source and prevent future mismatches, adds Selman-Holman.

Bottom line: The best step you can take to avoid claim/OASIS discrepancies is to be careful to produce “clean claims” from the beginning, Maxim says. With ICD-10 coding just around the corner, this won’t be the only issue you’ll need to consider when entering a correct HIPPS code. v

Note: The article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1504.pdf