Home Health Coding and OASIS Expert

Watch out for medical review.

If you’ve noticed a change in the way your claims are processing since April 1, you may have been caught up in a new CMS initiative.

As of 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.

New way: 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 an MLN Matters article.

Submitting the OASIS prior to the claim has been a condition of payment since 2010, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates, Code Pro University and CoDR — Coding Done Right in Denton, Texas. It appears that CMS just now got a way of checking, she says.

CMS is simply enforcing something that has not previously been enforced, agrees Arlene Maxim, RN, founder of A.D. Maxim Consulting, A.D. Maxim Seminars, 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.

Prediction: This rule is likely to cause yet another flurry of Medical reviews, Maxim says.

Keep Your Claims Clean

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.

No OASIS? No Problem — For Now

“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.

But don’t expect that exception to last for long. “Submission of an OASIS assessment for all HH episodes of care is a condition of payment,” CMS notes in the article. “CMS plans to use the claims matching process to enforce this condition of payment in the earliest available Medicare systems release. At that time, Medicare will deny claims when a corresponding assessment is past due in the QIES but is not found in that system.”

An OIG report a couple of years ago recommended that CMS deny claims when the OASIS wasn’t submitted or was submitted late, Selman-Holman points out. At the time, CMS said they had no way to determine whether the OASIS was submitted past the 30 days or whether it was on time but had to be corrected and reflected a later date, Selman-Holman says. CMS wanted to encourage correction so they declined the OIG recommendation. “Makes me wonder if they’ve got that fixed with the ASAP system.”

Just how long it will take CMS to begin denying claims with no OASIS is unclear. The requirement to match OASIS records with HIPPS claims was actually contained in a 2012 transmittal. CMS spent 2013 testing the matching process for inpatient rehab facilities (IRFs), then implementing it for IRFs in 2014. CMS began testing the matching process for HHAs last year.

Watch for: “CMS will provide notice to HHAs as soon as possible after we determine the implementation date” for the edits that will deny claims with no matching OASIS records, the agency adds in the MLN Matters article.

In the meantime, this will likely be a way to filter claims for medical review, Maxim warns. “No match means a review. The OIG is watching this, so it can’t be good news.”

More information, including how to identify payment adjustments due to matching errors, is in the article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1504.pdf.