Home Health & Hospice Week

But there are 6 reasons the new edit may not be as bad as you think.

If you miss your OASIS submission deadline and your corresponding final claim gets denied by a new OASIS-checking edit, you can probably kiss that money goodbye forever.

Reminder: Last October, the Centers for Medicare & Medicaid Services issued a transmittal detailing a new edit under which home health agencies’ final claims will deny if there is no corresponding OASIS file submitted for the claim (see Eli’s HCW, Vol. XXVI, No. 39-40).

In the Feb. 8 Medicare Home Health Open Door Forum, a CMS official listed many features that will soften the edit’s impact:

1. The edits will not apply to Requests for Anticipated Payment, only End of Episode claims.

2. The filing date of the OASIS assessment doesn’t matter, as long as the OASIS is present when the edit checks the claim. In other words, a late-filed OASIS won’t stop your claim as long as that OASIS file is in the system when the edit runs.

3. The edit has a two-step check process. First, it will check to see if the OASIS is present, a CMS staffer explained in the Feb. 8 call. If it is present, the claim continues to process normally. If the OASIS is not present, the edit then checks whether the OASIS assessment is overdue. If the OASIS isn’t late, the claim will process normally even though the OASIS is missing.

4. The edit will count three types of assessments toward the requirement — Start of Care, Resumption of Care, or Recertification assessments.

5. HHAs will get a little extra leeway when CMS first implements this edit April 1. “While the regulation requires the assessment to be submitted within 30 days, the initial implementation of this edit will allow 40 days,” says MLN Matters Article MM9545.

6. Correcting an already submitted OASIS assessment won’t trigger the edit, the CMS staffer said in a forum last November (see Eli’s HCW, Vol. XXV, No. 42).

Appeal Success Unlikely

If you do submit a claim and it fails this edit and denies, you technically have the right to appeal the denial, the CMS official said in the Feb. 8 call. But he doesn’t put much stock in your chance of success, he said in response to a question.

While “mechanically those claims could be appealed, I don’t know what grounds you’d be appealing on if the assessment wasn’t received within the time frame set in the regulation,” the CMS source told an agency caller.

Note: The transmittal implementing this edit is online at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3629CP.pdf.