Medicare Compliance & Reimbursement

If you’ve seen problems with your home health agency claims re-coding incorrectly this year, you aren’t alone. Medicare is fixing the issue — but not until the fall.

Problem #1: The 2015 HH Pricer currently uses a table that contains incorrect case-mix weights for all HIPPS codes beginning with “4,” the Centers for Medicare & Medicaid Services (CMS) explains in recent MLN Matters article MM9198. “The weights for all codes beginning with ‘4’ are using the weight for the corresponding code that begins with ‘2’ (for example, a claim submitted with HIPPS code 4AFKS is being paid using the weight for 2AFKS),” the agency says.

Solution: CR 9198 “corrects the weight table and instructs [Medicare Administrative Contractors] to adjust claims to correct payments within 60 calendar days of the implementation of CR 9198,” which is Oct. 5, the article says.

Problem #2: An earlier transmittal “contained an error in a table used when HIPPS codes beginning with ‘1’ or ‘2’ are submitted with 20 or more therapy visits and must be re-coded to a HIPPS code beginning with ‘5,’” CMS also says. “If the clinical severity value encoded in the treatment authorization code was a ‘D,’ the claim was recoded into a higher case-mix group in error.”

Solution: CR 9198 corrects the instructions and the re-coding logic in the Pricer, CMS says. “It also instructs MACs to adjust claims to correct payments,” the agency adds.

CR 9198 also requires changes to the HH Pricer to accommodate Types of Bill (TOBs) 32Q and 33Q, the article says. (Reminder: The National Uniform Billing Committee recently created the new TOB frequency code to facilitate the automation of certain requests for re-openings.)

“This frequency code is not currently recognized in the HH Pricer program,” CMS says. “CR 9198 makes the necessary changes to process TOB frequency code ‘Q.’” The HH Pricer “must accommodate TOBs 032Q and 033Q since reopening requests may affect claims which were submitted when TOB 033x was still valid,” the agency adds at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9198.pdf.