For Home Care agency collectors there has been a seemingly never-ending saga of research, in many cases, to ensure that the agency was paid appropriately by Medicare. At the core of much of this lies the reality of the claims processing system not adequately communicating claim adjustments to the provider. If the clinician states, on the OASIS, that there will be 15 therapy visits, but only 10 are represented on the claim, this requires re-coding/re-pricing of the claim and a change to the HIPPS code. Prior to now, the HIPPS code change was not reflected in claim detail screen in DDE nor has it been reflected as changed on the detail option of the electronic remittance advice.

CMS issued Change Request (CR) 8950, Transmittal 3151dated December 17, 2014. This replaced Transmittal 3104, dated 11/6/14, which was rescinded. The effective date was April 1, 2015 with an implementation date of April 6, 2015. This CR includes requirements that the HIPPS codes that are changed, based on validation with QIES data/OASIS, that are not currently displayed to providers on Direct Data Entry (DDE) screens or on the electronic remittance advices, will be displayed appropriately following claims processing.

In addition to the HIPPS code being appropriately reflected, this CR also includes confirmation of the Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) combination that will be reflected on the electronic remittance advices so that agencies know for sure that the claim has been adjusted.

The Phase III Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) EFT & ERA Operating Rule Set was implemented by January 1, 2014 as required by the Affordable Care Act of 2010. In order to be compliant with Medicare Operating Rules, claims processing must use remittance advice code combinations that are included in the list developed by CAQH CORE.

In 2012, Change Request (CR) 7760 began the implementation of a process to validate HIPPS codes against the assessment records submitted to the Quality Improvement Evaluation System (QIES). This process will be expanded to Home Care and skilled nursing facility claims in the future. CR 7760 only required Medicare systems to apply RARC N69 to claims re-coded based on QIES data.

The current CR seeks to correct the oversight of not having code pairs assigned for these Home Care adjustments. Approved code pairs for RARC N69 have not yet been assigned by CAQH CORE. Until a code pair is assigned, Medicare will pair RARC N69 with a CARC that also does not have any CORE-approved pairing. Medicare systems will apply CARC 186 with RARC N69 in both the situation of therapy visit adjustments and re-coding due to the timing question not being validated.

Following is the link to the transmittal:Transmittal 3151