Home Health & Hospice Week

Tip: 3 words in the remarks section probably isn’t going to win back your rightful reimbursement.

Submitting a late no-pay RAP starts chipping away at your episode payment quickly. But not every late RAP must carry a financial penalty.

Reminder: Home health agencies can request an exception to the late request for anticipated payment penalty in four circumstances, the Centers for Medicare & Medicaid Services allows: fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA’s ability to operate; an event that produces a data filing problem due to a CMS or Medicare Administrative Contractor systems issue that is beyond the control of the HHA; a newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC; and other circumstances determined by the MAC or CMS to be beyond the control of the HHA.

To request an exception, an agency must report the KX modifier on the final claim with the HIPPS code on the revenue code 0023 line, HHH MAC CGS explains. “When requesting an exception, home health agencies should provide sufficient information in the ‘Remarks’ section of the final claim. This allows the CGS Claims department to research the exception request,” the MAC advises.

Heed These Exception Examples

But what exactly qualifies as a CMS or MAC system issue, or “other circumstances … beyond the control of the HHA,” that will convince your MAC to lift the penalty? CGS is giving agencies some clues with a new “Examples of Denied/Granted RAP Exception Requests” webpage.

For example: CGS granted an exception when an HHA submitted “RAP was billed timely on 1/9/21 please reconsider,” the MAC relates. Upon review, the CGS claims department found “the RAP was submitted timely but went to the Return to Provider (RTP) file with reason code U538I,” the new webpage details. “Since it was corrected/rebilled within 2 business days, the exception was granted.”

Another example: CGS turned down an exception request when an agency submitted “billing software issue” in the remarks section, but did not back that up with any specifics in the initial filing nor upon request.

Followup can be essential to your request’s success, CGS emphasizes. “If the information is not sufficient, CGS will request additional documentation,” it says.

Instead of just submitting “late due to system issue” in the remarks field, “explain what system issue affected the submission of the RAP,” CGS counsels. “Was it a FISS issue, or an issue with your home health agency’s system, or a vendor system issue? Refer to the Claims Processing Issues Log and reference the specific issue, when applicable,” the MAC urges.

Note: More examples and advice are on the CGS website online at https://cgsmedicare.com/hhh/education/materials/rap_exception.html.