A system error following a change request effective April 1, 2025, is causing certain home health claims to be erroneously returned to providers, says Mary Carr, vice president of regulatory affairs at The Alliance for Care at Home.
The issue has been noted when dementia is the primary diagnosis, Carr says. This is an error within the CMS system and Medicare Administrative Contractors (MACs) are being instructed to apply a workaround to these claims, she says.
CR 13992, most recently dated April 25, 2025, included an update to the Integrated Outpatient Code Editor (IOCE). The change was primarily meant to apply to other settings, but CMS noted in the CR that it also should apply to “limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness.”
The issue is that — instead of applying it in these rare circumstances — the CMS system is applying this edit across the board for home health providers when using dementia as the primary diagnosis, Carr says.
Since hospices do not use dementia as a primary diagnosis, they shouldn’t see an impact on hospice claims being inappropriately rejected, Carr says.
As of May 9, there had been no claim error updates or instructions provided from any of the three MACs.