At the beginning of April, CMS issued key updates and clarifications regarding home health claim processing. The changes were issued through Change Request 13543.
This Change Request/Transmittal brought a number of clarifications to the Medicare Claims Processing Manual. One key item involves the county code. It’s been a long-time standard practice to include the FIPS code on claims to indicate the county where the patient was treated. However, some systems weren’t reporting this code, which prompted CMS to require a new edit to ensure that the FIPS code appears on the claim.
The next item to address is the Notice of Admission (NOA), which must be submitted and accepted by the Medicare Administrative Contractor (MAC) within five days of the start of care. However, sometimes the NOA encounters issues that cause it to enter “Return to Provider” or “T” status. This Change Request includes a clarification for resolving late NOAs that enter “T” status, provided the original submission was within the required filing window.
To qualify for an exception when dealing with a late NOA, you must correct the error within two business days. If the necessary correction requires canceling the NOA, the cancellation must also be completed within two business days. A new NOA must be issued within two business days of the cancellation processing, as well.
It’s important to understand that a change to a Notice of Admission cannot be made whenever you like, with the expectation that an exception request will go through without issues. To increase your chances of a successful outcome, keep a close eye on your NOAs and double-check their accuracy before you send them in initially. This approach helps ensure that your NOAs are correct from the start and reduces the risk of problems later on.
Diagnosis coding, which is a critical area, included in the Change Request. ICD-10 codes are updated each year — not on a calendar basis — but every year on October 1. Minor adjustments can occasionally happen in April, but the most significant changes always happen in October.
In past years, there have been major issues fighting claim rejections related to diagnosis coding. These issues occurred when the codes used for completing the OASIS and plans of care were completed prior to the effective date of the new code, but then became outdated when new codes took effect on October 1. As a result, claims that were submitted could later end up in “T” status due to invalid diagnosis codes, causing them to be denied. This led to extensive efforts to correct and resubmit the claims, creating a frustrating cycle for providers.
This update clarifies that if the “from” date on a claim is earlier than the effective date of a new diagnosis code, the claim will be accepted with the old code. Claims processing will use the “from” date to determine which set of codes to accept and process. This should reduce complications due to code changes and streamline claim processing.
An example provided is if the start date for a 30-day period is September 15, and then ICD-10 codes change on October 1. When you submit that first 30-day claim, the “from” date is September 15, so that claim will be processed using the old codes, not the new ones. This is a significant development, and one we hope works as intended. Ideally, the claims processing systems will be updated to align with this guidance, ensuring it’s not just a manual update but an automatic process that takes effect by October 1.
Should you need any assistance with claims processing, Healthcare Provider Solutions is here to help, please don’t hesitate to reach out to us.
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