Under the Patient-Driven Groupings Model (PDGM), matching the claim to the OASIS is more important than ever, and CMS has issued an MLN Matters article to help agencies get it right.
For several years, Medicare systems have checked for a corresponding OASIS once the final home health claim was received. This step is designed to ensure the claim meets federal requirements that an oasis assessment is a condition of payment. It also served to validate the Health Insurance Prospective Payment System (HIPPS) code on the claim and in the assessment system.
If the claim and OASIS do not match, the claim is Returned to the Provider with reason code 37253.
CMS provides the following steps to make sure OASIS assessments match the claim:
1. Double-check the OASIS final validation report 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 been 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 PDGM payments. The Reason for Assessment (RFA) (OASIS Item M0100) must be equal to 01, 03, 04, or 05. Note that RFA 05 is new to the matching process with PDGM.
  • 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 PDGM claims, reporting the assessment completion date (item M0090) as the associated date. This code is new with the PDGM.
  • 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.
Related link: Learn more about the process and read the full MLN Matters article at https://www.cms.gov/files/document/se20010.pdf.