A home health billing rejection issue is leading to significant frustration and needs to be addressed.
On April 25th, 2025, CMS issued Change Request 13992 to update the Outpatient Code Editor. This update intended to release diagnosis codes that could no longer be used as primary in many outpatient settings, but it excluded home health. It clearly states that home health services under the Prospective Payment System (PDGM) were not to be impacted.
However, that has not been the case. We’ve observed home health claims being placed in T status— Returned to Provider (RTP) status—due to these edits, particularly for diagnosis codes starting with F03, which are dementia-related codes.
This is a error. CMS has confirmed the issue with the Outpatient Code Editor and is providing guidance to the Medicare MACs this week on a workaround to ensure these claims are processed and paid correctly.
This is not a coding mistake. Your coding team has not used these diagnosis codes in error, and your EMR system has not failed to alert you. The issue stems solely from a claims processing error within the system, which CMS is responsible for resolving.
HPS stands ready to support your agency with any of your home health billing needs. Please don’t hesitate to reach out to us.
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