In Home Health there has been an edit in place that required the date on the HIPPS code line of a claim to match the first billable visit on the claim. In the past, under 60-day payment methodology, that was not that big of a deal. In 2021, after having switched to PDGM model and Requests for Anticipated Payment (RAP) required every 30-days, the edit would not work on subsequent periods of care, and so they put a hold on that edit in 2021. Now they are convinced that the edit should be reactivated, since RAPs are no longer an issue, and they did so on January 3, 2023, with no warning. In fact, the notifications, from CGS specifically, were dated January 6, saying that CMS stated they would be reactivated on January 3. Then we have another situation where Palmetto GBA has identified that there could be an issue with claims in this edit because of the artificial start date that was required with claims that had crossover periods into 2022, when the Notice of Admission (NOA) began.   

We have also identified that NGS has not made an official announcement regarding this edit being reinstated in January. Healthcare Provider Solutions, as a billing entity for agencies all over the nation, has a few hundred claims that have hit T status (Returned to Provider) because of this edit with CGS and Palmetto GBA, but we do not have any with NGS. However, we have had reports from agencies in the NGS coverage area that they have several that have been hitting T status with reason code 31755.   

We have also identified a difference in the language on the three Medicare MAC websites. Both CGS and Palmetto GBA state the language in the original wording of the regulation, which states that the HIPPS code line date must match the first billable visit on the claim. That would include even subsequent 30-day periods, recertifications, subsequent 30-day periods in a recertification, and so on. While it is not a big deal at the Start of Care because 99.9%, if not 100% of the time, the date on the HIPPS code line is going to match the Start of Care date and the first billable visit. That is not typically an issue at all, but in the subsequent periods, the from and through date, on the 30-day claim are to reflect the first day of the 30-day period, and that is required. Based on this edit and regulation, the HIPPS code line date should match the first billable visit in that period. Typically, in subsequent periods, the EMR systems have that HIPPS code line match the beginning of the billing period, which does not necessarily coincide with a visit.   

The difference in CGS and Palmetto versus NGS is that the CGS and Palmetto GBA wording states that the HIPPS code line must match the first visit on the claim. NGS says that the HIPPS code line must have a date that matches a visit in the 30-day period, it does not say that it must match the first billable visit on the claim. Obviously, there is still some clarification that must be worked out with this edit. We know that all Medicare MACs have stated that you simply are going to need to change that date on the HIPPS code line to reflect the first billable visit date on the claim and it will reprocess and pay.   

We know one large EMR system that stated they have an update this week that should reconcile the situation. We are hoping that that is true, but until that point, to avoid T status claims, make sure that date on the HIPPS code line matches the first billable visit on the claim, regardless of what 30-day payment period you are in. In addition, if you are not checking that before you bill the claim, you will need to make the correction in DDE or in your clearing house, if it allows for that, so that the claim can reprocess and pay.   

HPS has Billing Specialists that can assist, if needed. Don’t hesitate to let us know.