(Medicare Claims Processing Manual)

10.1.15 - Payment Adjustments - Partial Period Payment Adjustment  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Both transfer situations and discharge and readmission to the same agency in a 30- day period result in shortened periods of care.  In such cases, payment will be pro- rated.    Partial period payment adjustments occur as a result of the two following situations:   a. When a patient has been discharged and readmitted to home care within the same 30 -day period of care; or   b. When a patient transfers to another HHA during a 30- day period of care.   Both situations are indicated on the claim by reporting a Patient Discharge Status code of 06.  Based on the presence of this code, Pricer calculates a partial period payment adjustment to the claim.  This is a proportional payment amount based on the number of days of service provided, which is the total number of days counted from and including the day of the first billable service to and including the day of the last billable service, divided by 30.  The contractor shall use the following remittance advice messages and associated codes when paying partial period payment adjustments under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: B20  RARC: N120  MSN: N/A  10.1.16 - Payment When Death Occurs During an HH PPS Episode /Period  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  If a beneficiary dies during a period of care, full payment will be made for the period, including payment adjustments applicable to given services actually delivered prior to death.  However, there is one exception.  Partial period payment adjustments wil l not apply to the claim, because no more home care can be delivered in the 30 -day period.  The Statement Covers Period through date on the claim in which the beneficiary died should be the date of death.  Such claims may be submitted earlier than the 30th day of the period of care.   10.1.17 - Payment Adjustments - Low Utilization Payment Adjustments (LUPAs)  (Rev. 10919, Issued:08- 06-21, Effective:01 -01-22, Implementation: 01- 03-22)  If an HHA provides fewer than the threshold of visits specified for the periods HHRG, they will be paid a standardized per visit payment.  Such payment adjustments are called Low Utilization Payment Adjustments (LUPAs).   On LUPA claims, nonroutine supplies will not be reimbursed in addition to the visit payments, since total annual supply payments are factored into all payment rates.  If the claim for the LUPA is later adjusted such that the number of visits is equal to or  greater than the threshold for the HHRG, payments will be adjusted to an HHRG basis, rather than a visit basis.   If the LUPA period is the first in a sequence of adjacent periods or is the only period of care the beneficiary received, Medicare will make an additional add -on payment.  Medicare will add to these claims an amount calculated from a factor established in regulation.  This additional payment will be reflected in the payment for the earliest dated revenue code line representing a home health visit for skilled nursing, physical therapy, occupational therapy (after January 1, 2022), or speech- language pathology.  One criterion that Medicare uses to determine whether a LUPA add -on payment applies is that the claim Admission Date matches the claim From Date.  HHAs should take care to ensure that they submit accurate admission dates, especially if claims are submitted out of sequence.  Inaccurate admission dates may result in Medicare systems returning LUPA claims where an add -on payment applies, but the add- on was paid inappropriately on a later dated period in the same sequence.   Additionally, Medicare systems may return to the provider LUPA claims if the claim meets the criteria for a LUPA add -on payment but it contains no qualifying skilled service.  In these cases, the HHA may add the skilled visit to the claim if it was omitted  in error and re -submit the claim.  Otherwise, the HHA may only re -submit the claim using condition code 21, indicating a billing for a denial notice.   10.1.18  RESERVED   10.1.19 - Payment Adjustments  Applying OASIS Assessment Items to Determine HIPPS Codes  (Rev. 12306; Issued: 10- 19-23; Effective:01 -24-24; Implementation:01 -24-24)  Submission of an OASIS assessment is a condition of payment for HH periods of care.  OASIS reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary.  Under the HH PDGM, matching a claim to the OASIS assessment is required to process each home health claim.    During claims processing, the quality system, known as the Internet Quality Improvement and Evaluation System (iQIES), provides the claims system (FISS), with the OASIS items used for payment grouping under the PDGM. The HIPPS code is calculated by Medicares Grouper program with FISS.   Because payment grouping cannot occur without the OASIS information, if the OASIS assessment is not found in the quality syste m upon receipt of a claim, Medicare systems will return the HH claim.   The only exception to this is when a disaster -related waiver of OASIS submission is in effect.  In this case, the HHA reports condition code DR on the claim and does not report occurrence 50 (the assessment submission date) because no OASIS was submitted.  The claim -OASIS matching process is bypassed and the provider -submitted HIPPS code is used for payment.  In any other case, when occurrence code 50 is reported a matching assessment must be found in order for the claim to process.   There are steps an HHA can take to make sure a claim matches to the OASIS assessment successfully.   Ensuring the Claim Matches an OASIS Assessment   Before submitting an HH claim, HHAs should ensure the OASIS assessment has completed processing and was successfully accepted into iQIES. HHAs can verify this by reviewing their OASIS Final Validation Report (FVR).   If a claim is submitted and Medicare systems do not find the matching assessment, the claim is Returned to the Provider (RTP). Typically, there is no need to call the iQIES help desk for assistance in resolving this.   HHAs should take the following steps:   1. Double -check the FVR to confirm the receipt date shows the OASIS was accepted by iQIES before you submitted your claim. This date is shown on Page 1 of the report, in the field labeled, Completion Date/Time. Also, ensure that the assessment has not be en inactivated.   If the OASIS was submitted after the claim, resubmit the claim   If the assessment was inactivated, resubmit the assessment.   2. Ensure the assessment is one that is used for determining payments. The Reason for Assessment (RFA) (OASIS Item M0100) must be equal to 01, 03, 04, or 05.   If the claim matches an assessment that is for another reason, update the occurrence code 50 date on the claim to correspond to the M0090 date of the applicable assessment and resubmit the claim.   3. Ensure you have submitted occurrence code 50 on any claims, reporting the assessment completion date (item M0090) as the associated date   If the occurrence code is missing, update the claim and resubmit it.   4. Check the items Medicare systems use to match the claim and OASIS, making sure that they are the same on both submissions. These are:   Your CMS Certification Number (OASIS item M0010)   Beneficiary Medicare Number (OASIS item M0063)   Assessment Completion Date (OASIS item M0090)  If any of these items do not match, correct the claim or the assessment, then resubmit.   Note : Changes to a beneficiarys Medicare Beneficiary Identifier (MBI) can affect the match. If an HHA becomes aware of a change to the MBI via the MBI look -up tool and uses the new MBI on their claim when the prior MBI was used on the OASIS, that will cause t he claim to be returned. In these cases, HHAs should update item M0063 on the OASIS and then resubmit the claim.   If a claim with correct and matching information continues to RTP, the HHA should reach out to their MAC and provide:   The claim document control number (DCN)   The validation reports Page 1, showing the Completion Date/Time the batch of OASIS assessments was received   The validation reports page for the OASIS assessment in question, showing the RFA, Medicare Number, and M0090 date   Any other information requested by the MAC to confirm the matching OASIS  The MAC shall use this information to research the issue.  When a Matching OASIS is Found  When the OASIS assessment if found, answers to the OASIS items used in PDGM case -mix scoring are returned to the claims system and stored on the claim record.  This information is displayed on a screen in the claims system, so the HHA can refer to it. Medicare systems combine OASIS items and claims data (period timing, inpatient discharge, diagnoses) and send them to HH Grouper program (see section 80). The Grouper -produced HIPPS code replaces the provider -submitted HIPPS code on the claim and is used f or payment.  The system -calculated HIPPS code may be re -coded by medical reviewers, based on their review of the documentation supporting the claim.  In this case, the medical reviewer indicates changes to the OASIS information on the claim screen where it is displayed .  The original OASIS item information is in a column marked OA, the medical reviewers changes are recorded in a column marked MR.   The revised OASIS information will be sent to the HH Grouper and a new HIPPS will be used for payment.  This HIPPS code will be recorded in the APC -HIPPS field.  This code will match the code on the electronic remittance advice.   When an OASIS Assessment Has Not Been Submitted   If there was no error and the condition of payment was not met, the HHA may bill for denial using the following coding:    Type of Bill (TOB) 0320 indicating the expectation of a full denial for the billing period,   Occurrence span code 77 with span dates matching the From/Through dates of the claim, indicating the HHAs acknowledgment of liability for the billing period, and   Condition code D2, indicating that billing for the Health Insurance Prospective Payment System (HIPPS) code is changed to non-covered.   Condition code 21 must not be used in these instances, since it would result in inappropriate beneficiary liability.   The contractor shall use the following remittance advice messages and associated codes when processing billings for denial under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 272  RARC: N211  MSN: 41.17   When OASIS Assessments Cannot Be Submitted Within 24 Months  A Medicare beneficiary's entitlement date may sometimes be approved or changed retroactively.  Frequently, these cases result in services becoming covered for dates of service that are beyond the Medicare timely filing limit.  Retroactive entitlement is an established exception to the timely filing pe riod, so these claims may be submitted for payment (see Pub. 100- 04, chapter 1, section 70.7.2).  iQIES accepts assessments for up to 24 months from the assessment date.  In rare cases, a retroactive entitlement decision may extend back beyond this 24 month period.  Each 60-day assessment that cannot be submitted to iQIES because of the 24 month limit may correspond to up to 2 Medicare claims for 30- day periods of care.   To process the claims for these older dates of service, HHAs should contact their MAC to alert them to the situation and request any special instructions for the timing and coding of the claims.  In addition to any other special instructions, the HHA shall  submit the claims with a note in the Remarks field saying "OASIS over 24 months."   Upon receipt of the claims, the HH&H MAC shall take the following actions: