Home Health & Hospice Week

You can’t skip checking the final validation report.

If you missed a change related to the OASIS matching edit this summer, you may be giving yourself extra work for nothing.

Effective April 1, the HHH Medicare Administrative Contractors began editing claims for an OASIS matching record. If the claim is submitted more than 40 days after admission and there is no matching OASIS file, the claim is denied with extremely limited appeal options.

However, a few ways to win an appeal of an OASIS matching denial do exist. Agencies can produce proof that a matching OASIS file was indeed in the system, generally with a final validation report. Or if the beneficiary’s HICN is incorrect (often due to a patient’s spouse dying), agencies can submit the corrected one.

Before: The hitch was that once a claim got caught up in the OASIS matching edit, medical reviewers would scour the entire claim for the usual eligibility issues such as medical necessity, homebound status, face-to-face, etc. “Reason code 37253 is an automated denial, which results in a full review of the claim and all supporting documentation must be available to determine if payment can be made on the claim,” MAC Palmetto GBA explained in an article about the edit on its website earlier this summer (see Eli’s HCW, Vol. XXVI, No. 23).

After: However, in its July Home Health Open Door Forum, the Centers for Medicare & Medicaid Services said it had requested from the MACs that they require only the validation report for OASIS matching edit denials. Accordingly, CGS issued an article in late July stating “that it is not necessary to submit the full medical record when appealing the denial for reason code 37253.” Likewise, Palmetto issued an article omitting the requirement for full documentation of the claim. (National Government Services never did require documentation beyond the validation report for these types of denials, says billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville.)

Double-Check These 4 Matching Fields

Scaling back the review of claims denied due to the OASIS matching edit is “absolutely” helpful for those appeals, notes M. Aaron Little with BKD in Springfield, Missouri. “Requiring a full ADR was ridiculous,” Gaboury contends.

Bottom line: Now, “the only ones that have appeal rights are ones that something on the OASIS [that] doesn’t match something on the claim,” Gaboury summarizes. “All others are denials with no appeal rights, and rightfully so.”

That makes it crucial that you check that your OASIS file was accepted by the system — Every. Single. Time., industry veterans urge.

And you must be able to produce a copy of the final validation report to send in with your appeal, if the claim gets denied erroneously.

In the July forum, CMS responded to a question by saying that a simple claim reopening for a mismatch between the claim and OASIS fields wouldn’t be permitted, notes the National Association for Home Care & Hospice. HHAs must go through the appeal process, even if they just need to change a simple data item.

Thus, to avoid resource-draining appeals for technical errors, agencies must ensure the accuracy of these four items that the edit uses to match claims with their OASIS files, NAHC notes:

1. HHA CMS Certification Number (OASIS item M0010)
2. Beneficiary Medicare Number (M0063)
3. Assessment Completion Date (M0090)
4. Reason for Assessment (M0100) equal to 01, 03 or 04.

Timing: And remember, agencies must perform the checks of these items prior to submitting the claim to avoid a denial, NAHC advises.

One of the most common data-matching problems occurs when a beneficiary’s spouse dies and her Medicare number changes, experts say. The HIC number’s suffix changes to a “D,” Palmetto notes in its revised article about the edits.

How it happens: “When a patient’s Medicare records reflect a corrected HIC number, the Fiscal Intermediary Standard System (FISS) will automatically cross-reference the claim to the correct HIC number and process the claim accordingly,” Palmetto explains. On the other hand, “the QIES will process the OASIS with the HIC number that was initially transmitted. Therefore … when the system was searching for the OASIS, no OASIS was found with the ‘D’ suffix,” Palmetto gives in one of its denial examples.

Palmetto offers these additional tips for avoiding OASIS matching edit denials:

• When fatal errors show up on your OASIS validation report, fix them and resubmit the OASIS (checking for acceptance) before billing the final claim.
• When nonfatal errors show up on your OASIS validation report, investigate them and correct them when appropriate.
• Check that the patients Medicare HIC Number submitted on the OASIS matches the HIC Number that was submitted and/or processed on the claim by reviewing the remittance advice and/or checking claim page one of the Direct Data Entry (DDE) system.
• Periodically review patients’ eligibility records. Changes to a HICN will be reflected on page one of HIQA or HIQH in the “CORRECT” field.

Note: See articles on the denials, including more advice for avoiding them, at www.palmettogba.com/palmetto/providers.nsf/Docs/Providers~JM Home Health and Hospice~Learning Education~Job Aids for Palmetto and at www.cgsmedicare.com/hhh/pubs/news/2017/0717/cope3949.html for CGS.