evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
Upon receipt of the claims, the HH&H MAC shall take the following actions:    When the untimely claims are suspended to check for exception requests, confirm the dates of service are over 24 months from the occurrence code 50 date on the claim.   Temporarily turn off the edit that triggers the iQIES finder file, process the affected claims without sending them to iQIES, then turn the edit back on.   Use the manual recoding process to copy the provider submitted HIPPS code from the 0023 revenue code into the recoded HIPPS code field and set the payment indicator (IND) field to P so the claim bypasses the home health Grouper.  Monitor the claims for any Common Working File recoding edits that may apply and update first position of the HIPPS code on the claims as necessary to resolve the edits.   10.1.20 - RESERVED  (Rev. 2230, Issued: 05- 27-11, Effective: 08 -28-11, Implementation: 08- 28-11)  10.1.21 - Payment Adjustments - Outlier Payments  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  HH PPS payment groups are based on averages of home care experience.  When cases lie outside expected experience by involving an unusually high level of services in 30-day periods of care, Medicare claims processing systems will provide outlier payments in addition to the case -mix adjusted payment.  Outlier payments can result from medically necessary high utilization in any or all of the service disciplines.   Outlier determinations are made by comparing:    The estimated cost for a period of care, calculated as the sum of the products of number of units of each discipline on the claim and each wage -adjusted national standardized per unit rate for each discipline (1 unit = 15 minutes); with   The sum of the period payment and a wage -adjusted standard fixed loss threshold amount.
(Medicare Claims Processing Manual)
 The sum of the period payment and a wage -adjusted standard fixed loss threshold amount.  If the estimated cost is greater than the wage adjusted and case- mix specific payment amount plus the wage adjusted fixed loss threshold amount, a set percentage (the loss sharing ratio) of the amount by which the estimated cost exceeds the sum will be pai d to the HHA as an outlier payment.  Units considered for outlier payment are subject to a limit of 32 units (8 hours), summed across the six disciplines of care, per date of service.   For rare instances when more than one discipline of care is provided and there is more than 8 hours of care provided in 1 day, the cost associated with the care provided during that day will be calculated using a hierarchical method based on the cost per unit per discipline.  The discipline of care with the lowest associated cost per unit will be discounted in the calculation of cost in order to cap the estimation of cost at 8 hours of care, summed across the six disciplines, per day.   The outlier payment is a payment for an entire period, and therefore carried only at the claim level on the paid claim.  It is not allocated to specific lines of the claim.   HHAs do not submit anything on their claims to be eligible for outlier consideration.  The outlier payment shall be included in the total payment for the claim on a remittance, but it will be identified separately on the claim using value code 17 with an associated dollar amount representing the outlier payment. Outlier payments will also appear on the electronic remittance advice in a separate segment.    Outlier payments made to each HHA are subject to an annual limitation.  Medicare systems ensure that outlier payments comprise no more than 10 percent of the HHAs total HH PPS payments for the year.  Medicare systems track both the total amount of HH PPS payments that each HHA has received and the total amount of outlier payments that each HHA has received.  When each HH PPS claim is processed, Medicare systems compare these two amounts and determine whether the 10 percent has currently been met.  If the limitation has not yet been met, any outlier amount is paid normally.   If the limitation has been met or would be exceeded by the outlier amount calculated for the current claim, other HH PPS amounts for the claim are paid but any outlier amount is  not paid.  Partial outlier payments are not made.
(Medicare Claims Processing Manual)
The contractor shall use the following remittance advice messages and associated codes when not paying outlier amounts under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 119  RARC: N/A  MSN: N/A  Since the payment of subsequent claims may change whether an HHA has exceeded the limitation over the course of the timely filing period, Medicare systems conduct a quarterly reconciliation process.  All claims where an outlier amount was calculated but not paid when the claim was initially processed shall be reprocessed to determine whether the outlier has become payable.  If the outlier can be paid, the claim is adjusted to increase the payment by the outlier amount.  Additionally, if any HHAs are found t o have been overpaid outlier during the quarterly reconciliation process, claims are adjusted to recover any excess payments.  These adjustments appear on the HHAs remittance advice with a type of bill code that indicates a contractor -initiated adjustment (TOB 032I) and the coding that typically identifies outlier payments.  This quarterly reconciliation process occurs four times  per year, in February, May, August and November.   10.1.22 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  10.1.23 - Changes in a Beneficiarys Payment Source  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  1. Payment Source Changes From Medicare Advantage (MA) Organization to Original Medicare.
(Medicare Claims Processing Manual)
1. Payment Source Changes From Medicare Advantage (MA) Organization to Original Medicare.   If a Medicare beneficiary is covered under an MA Organization during a period of home care, and subsequently decides to change to Original Medicare coverage, a new start of care OASIS assessment must be completed that reflects the date of the beneficiarys change to this pay source.  This is required any time the payment source changes to Original Medicare.  With that assessment, an NOA may be sent to  Medicare to open an HH PPS admission period.  HHAs are advised to verify the patients payer source on a regular basis when providing services to a patient with an MA Organization payer source to avoid the circumstance of not having an OASIS to be used to determine the payment group, or having the patient discharged without an OASIS assessment.  If a follow -up assessment is used to generate a new start of care assessment, CMS highly recommends, but does not require, a discharge OASIS assessment be done.   While this is not a requirement, conducting a paper discharge at the point where the patients change in insurance coverage occurred will provide a clear endpoint to the patients episode of care for purposes of the individual HHAs outcome -based quality reports.  Otherwise, that patient will not be included in the HHAs quality measure statistics.  It will also keep that patient from appearing on the HHAs roster report (a report the HHAs can access from the OASIS system that is helpful for tracking OASI S start of care and follow -up transmissions) when the patient is no longer subject to OASIS data collection.   In cases where the patient changes from MA coverage to Original Medicare coverage, the patients overall Medicare coverage is uninterrupted.  This means an HH PPS period of care may be billed beginning on the date of the patients Original Medicare coverag e.  Upon learning of the change in MA election, the HHA should submit an NOA using the date of the first visit provided after the Original Medicare effective date as the from date.  The OASIS assessment performed most recently after the change in electio n is used to produce a HIPPS code for the first claim in the new admission period.
(Medicare Claims Processing Manual)
If a new start of care (SOC) OASIS assessment was not conducted at the time of the change in pay source, a correction to an existing OASIS assessment may be necessary to change the reported payer source.  The HHA should correct the existing OASIS assessmen t conducted most closely after the new start date.  If more than one 30- day period has elapsed before the HHA learns of the change in payer source, this procedure can be applied to the additional periods.  If the patient is still receiving services, the HH A must complete the routine follow -up OASIS assessments (RFA4) consistent with the new start of care date.  In some cases, HHAs may need to inactivate previously transmitted assessments to reconcile the data collections with the new dates.   2. Payment Source Changes From Original Medicare to MA Organization  In cases where the patient elects MA coverage during an HH PPS period of care, the period will end and be proportionally paid according its shortened length (a partial period payment adjustment).  The MA Organization becomes the primary payer upon the MA enrollment date.  The HHA may learn of the change after the fact, for instance, upon rejection of their claim by Medicare claims processing systems.  The HHA must resubmit this claim indicating a transfer of payer source using patient status code 06, and reporting only the visits provided under the fee -for-service eligibility period.  The claim through date and the last billable service must occur before the MA enrollment date.  If the patient has elected to move from Original Medicare to an MA Organizatio n and is still receiving skilled services, the HHA should indicate the change in payer source on the OASIS at the next assessment time point.   3. Payment Source Changes Involving Medicaid   There may be cases where a patient eligible for both Medicare and Medicaid is receiving home health services covered under Medicaid and the patient experiences a change in status that allows their home health services to meet coverage criteria for Original Medicare.  In these cases, a new start of care OASIS assessment must be completed that reflects the date of the beneficiarys change to this pay source.  This is required any time the payment source changes to Original Medicare.  With that assessment, an NOA may be sent to Medicare to open an HH PPS admission period.  The OASIS guidance provided above for changes from Medicare Advantage to Original Medicare apply in this case also.