The day has come that many agencies are going to be surprised by and that many have feared. A long standing federal regulation requires the transmission and acceptance of the SOC or FollowUp (Recert) OASIS assessment, used in creation of the HIPPS code on the claim, at the ASAP database as a condition of payment.
Prior to 2012 the Medicare claims processing system was unable to enforce compliance with this requirement because the system that maintained OASIS data and the system that processes claims were not linked. This weakness was identified and addressed with Change Request (CR) 7760, which required the FISS systems to develop a file exchange interface between their claim processing systems and the Quality Information Evaluation System (QIES). That work was completed for the home health claims processing system in late 2014 and the initial implementation of this validation, as announced in MLN Matters article SE1504), went into effect April 1, 2015.
Since April 2015 the claims processing system has been comparing the HIPPS code on the final claim to the HIPPS code from the SOC or Recert OASIS associated with the episode and using the HIPPS code from the OASIS to process the claim if the two were not the same. Until now, if there is no OASIS found in ASAP the claims processing system uses the HIPPS code on the final claim to calculate payment. As announced in MLN Matters article MM9585 full implementation of CR 7760 has arrived and will begin in April 2017.
As mentioned above, submission of an OASIS is a condition of payment for all home health episodes. Regulation requires the OASIS be transmitted within 30 days of completion (M0090). Typically, by the time a final claim is billed, that 30 day time period will have expired. Beginning April 3, 2017, when processing final claims, if an OASIS is not found in the QIES system and the date of the claim is more than 30 days after the assessment completion date Medicare will fully deny the episode. The Medicare remittance advice will report a group code of CO and a claim adjustment reason code of 272 for these denials.
Many agencies believe that their software system will protect them from denials with this issue. That is pretty much impossible. The majority, if not all, home health software systems, that have edits for not allowing the final to release until the OASIS has been transmitted, are actually releasing the final when the OASIS transmission file is EXPORTED from the software. The agency must confirm that the file was transmitted and accepted at the ASAP database and the Final Validation report is the only way to ensure that this has occurred. This step should be added to the agency PreBill Audit for all Medicare episodes. Please do not assume that this does not impact your agency without verifying that you have a process in place to check the validation reports.