Agencies soon could see more automated rejections as CMS updates its claims processing system to correct a pandemic-era blind spot that was requiring manual review by Medicare Administrative Contractors (MACs).
During the pandemic, some agencies have submitted claims with condition code DR, indicating “disaster related,” according to CR 13020.
Claims should be matched to an OASIS assessment when processed, CMS notes. If not, they’re returned to the provider. When the DR condition code is attached to a claim, the system bypasses the requirement for a matching OASIS, because the system assumes the condition code represents a waiver of assessment reporting requirements is in effect.
“No waiver of OASIS reporting has occurred during the current PHE, so condition code DR is not needed on these claims,” CMS states in the change request.
So, CMS is clarifying billing instructions to specify the correct situation for reporting condition code DR and modifying the claims processing system to ensure that claims process correctly without manual intervention from the MACs when condition code DR is present.
The following guidance has been added to Chapter 10 §40.2 of the Claims Processing Manual:
As a result of disaster conditions (such as hurricane or wildfire) that render submission of OASIS assessments impossible, Medicare may issue a waiver indicating OASIS submission is waived. In this case, HHAs should report condition code DR on their claim to indicate billing under the waiver. Since the OASIS assessment cannot be submitted, the HHA cannot report occurrence code 50 to show the assessment completion date. Claims without occurrence code 50 will be accepted if condition code DR is present.
When a provider is unable to submit a start of care OASIS for an admission period of care, they should submit the HIPPS code weighted closest to 1. For a period of continuing care, when a provider is unable to submit a follow-up OASIS, they should carry forward the last HIPPS code generated from the previous OASIS.
If as a result of disaster conditions, OASIS submission timeframes are relaxed, HHAs should submit claims without condition code DR as soon as the OASIS was submitted. In this case, matching OASIS assessment information and the occurrence code 50 date are required to ensure Medicare pays the claim accurately.
Second change targets adjustment coding
CMS made a second change to the payment system to address a home health billing error with CR 13008.
In this change request, to be implemented July 3, 2023, CMS is trying to address an issue in which original claims were being submitted with a cross-reference document control number (XREF DCN), something that is only supposed to appear on adjustment claims.
The following guidance has been added to Chapter 1 §130.1 of the Claims Processing Manual:
The ICN/DCN of an associated claim shall only be reported on adjustments. The MAC shall return to the provider any original claim reporting information in this field.