Home Health & Hospice Week

Plus: Other claims system glitches fixed, with one still waiting.

The Centers for Medicare & Medicaid Services continues to issue new rules to accommodate no-pay RAPs and PDGM.

CMS has reissued Change Request 11855 and added a few new instructions about requests for anticipated payment. “For ‘From’ dates on or after January 1, 2021, the RAP may report any valid diagnosis code, in order to facilitate timely submission,” the CR says. “Since these RAPs are not paid, the accurate principal diagnosis code that supports payment is needed only on the claim for the period of care.”

The CR also contains a new instruction on service dates.

Same: “For initial episodes/periods of care, the HHA reports on the 0023 revenue code line the date of the first covered visit provided during the episode/period. For subsequent episodes, the HHA reports on the 0023 revenue code the date of the first visit provided during the episode/period, regardless of whether the visit was covered or non-covered,” the CR states, as it did originally.

Change: However, if “the HHA submitted the corresponding RAP using the first day of the period of care as the service date on the 0023 line,” then “the HHA reports a service date on the 0023 revenue code line that matches the date submitted on the RAP. This is necessary to make sure Medicare systems can correctly match the claim to the RAP during processing,” CMS explains.

“These changes make sure claims successfully match their corresponding RAP,” CMS emphasizes in the accompanying MLN Matters article at www.cms.gov/files/document/mm11855.pdf.

RAP instructions aren’t the only things changing. On April 1, three claims system errors were corrected, HHH Medicare Administrative Contractor CGS notes on its website.

The fixes were for claims spanning Jan. 1 applying CY 2020 rates in error; late RAP penalties not applying to outlier amounts; and late RAP penalties being applied after the Value-Based Purchasing (VBP) adjustment, when the VBP adjustment should be the last calculation.

“Once the correction is implemented, over several weeks CGS will reprocess these claims to correct your payments,” CGS said on the eve of the fixes. “You don’t need to take any action.” HHH MAC Palmetto GBA issued a similar instruction.

Yet another correction is on the horizon, although you can effect it manually on a case-by-case basis right now.

Old way: “The CWF contains edits that ensure that Medicare pays HH claims in the correct episode or period of care sequence,” CMS says in a recent MLN Matters article. “Currently, these edits bypass LUPA claims,” which was correct in pre-Patient-Driven Groupings Model days. Back then, “if the claim had 4 or fewer visits, it would correctly receive a LUPA payment regardless of whether it was an early or late episode,” CMS recalls.

New way: But under PDGM, LUPA thresholds vary from 1 to 6 visits even among early and late episodes of the same category. “The correct early or late HIPPS code must be assigned before Medicare systems can correctly determine whether a LUPA payment should apply,” the MLN Matters article explains.

Medicare will fix the problem with the July claims system update, it says. Meanwhile, “when HHAs bring such claims to their attention, MACs manually recode affected claims to correct payment,” says the article at www.cms.gov/files/document/mm12085.pdf.