Agencies facing denials based on a system error around dementia coding will soon be able to resubmit those claims for processing.
 
The misapplication of a change request effective April 1, 2025, has caused some home health claims to be returned to the provider (RTP) in error. This has been a particular issue when dementia is listed as the primary diagnosis.
 
The change request for the Integrated Outpatient Code Center (IOCE) was meant to apply to home health agencies in rare circumstances when the agency is not paid under the Home Health Prospective Payment System (HHPPS). Instead, the edit is impacting home health providers broadly, causing the RTP for reason code W7113, an unacceptable principal diagnosis.
 
A message dated May 21, 2025, from Palmetto GBA instructs agencies affected by this error to return their RTP claims for processing on or after June 2, 2025. “If the claims are resubmitted prior to June 2, they and new claims affected by this issue will suspend until June 2 when the fix is implemented,” Palmetto notes. 
 
See the Palmetto claims processing alert at https://palmettogba.com.
Read the CMS change request involved at https://www.cms.gov.