Module 1, Topic 1
In Progress

Day 1: Final – Type of Bill 329

Petria September 3, 2020

FINAL CLAIM: TYPE OF BILL 329

Once the 30 day period of care is complete, HHAs can bill the final claim to Medicare. Upon adjudication, Medicare will pay the remaining amount of 80 percent.

Final Claim – PDGM

  • FL 6 on UB04 Statement Covers Period up to 30 days
  • The from and through date will cover all dates of service on the final claim
  • The from date must match the from date submitted on the corresponding RAP for the period
  • If the patient discharges or transfers before the 30 day period, report the through date as the date of discharge
    Mostly, status codes should be 01 or 20; hardly ever 06

 

 

Final Claim Fields MUST match the active RAP

  • From Date
  • Admit Date
  • HIPPS code
  • First Billable Visit

(if not your claim will RTP & be entered into “T” status)

 

 

FINAL CLAIMS

Occurrence code 50 – “Assessment Date”

  • Required on all final claims, not on RAPs
  • If this code is missing, the claim will be returned, RTP
  • Report the assessment completion date (OASIS item M0090) for the start of care, resumption of care, recertification or other follow-up OASIS that occurred most recently before the claim “From” date
  • This date will be used to match to the OASIS record in iQIES

Treatment authorization codes are no longer required on all HH final claims

 

 

Code of Federal Regulations (CFR)

Per the Code of Federal Regulations (CFR) at 42 CFR 484.210(e), submission of an Outcome and Assessment Information Set (OASIS) assessment for all Home Health (HH) final claims are a condition of payment for HHAs effective for claims with dates of service on or after April 1, 2017.

 

 

OASIS Agency Final Validation Report or OASIS Submitter Final Validation Report

HHA should ensure the OASIS assessment has completed processing and was successfully accepted into the QIES National Database by reviewing their OASIS Agency Final Validation Report or OASIS Submitter Final Validation Report
This will require communication between the provider’s billing office and their clinical staff that submits the OASIS to CMS.
HHAs should ensure, prior to submission of the OASIS assessment and the claim, that the following information is correct:

  • HHA CMS Certification Number (OASIS item M0010)
  • Beneficiary Medicare Number (OASIS item M0063)
  • Assessment Completion Date (OASIS item M0090)
  • Reason for Assessment (OASIS Item M0100) equal to 01, 03 or 04

These items will be used to match claims and assessments, so accuracy of submission can help prevent claim denials.

 

 

Claims Denied When an OASIS Assessment Has Not Been Submitted

  • OASIS reporting regulations require the OASIS to be transmitted within 30 days of completion.
    Medicare systems will check whether the corresponding OASIS assessment is present in the Quality Information and Evaluation System (QIES).
  • If the OASIS assessment is not found AND the receipt date of the claim is more than 30 days after the assessment completion date reported on the claim, Medicare systems will deny the HH claim. While the regulation requires the assessment to be submitted within 30 days of completion, the initial implementation of this process will allow 40 days.
  • Medicare systems will check for assessments used to determine the HIPPS code on the claim (Start of Care, Recertification and certain Resumption of Care assessments).

For the claim to be denied, the assessment must be both missing AND past due.

 

 

Final Claims

Services that begin in 2020 will be handled under PDGM.

  • Required for each 30-day payment period
    • – Not required to be billed sequentially
  • Required to have corresponding RAP in “paid” status
    • – Subject to 14-day payment floor
    • – Paid full claim amount less recoupment of RAP 20% payment
    • – Subject to payment recoding & adjustments, if applicable
    • –OASIS validation required
  • Claims for, SOC, ROC or recertification, 30-day payment periods subject to OASIS validation

 

 

Occurrence Code

  • (Required)
    • Code 50 will be used to designate the OASIS completion date for the assessment associated with claim.
  • (Conditional)
    • Code 55 is required when there is a Date of Death needed because the Patient Discharge Status Code indicates death (20 – expired).
  • (Optional)
    • Code 61 together with the applicable date will be used to designate a hospital discharge within 14 days of admission
    • Code 62 and the discharge date will be used for all post-acute care discharges from a SNF, IRF, LTCH, or IPF
  • Two new occurrence codes to support the admission source category of the PDGM (Community vs. Institutional)
    Occurrence code 61 – “Hospital Discharge Date”
    ‒  Reported, but not required, on final claims. Not reported on RAPs
    ‒  Reported on admission claims AND continuing claims, if applicable
    ‒  Report the discharge date (“Through” date) of an inpatient hospital admission that ended within 14 days of the “From” date of the HH period of care.
    ‒  Claims with hospital discharges within 14 days are grouped into “Institutional” payment groups
  • Occurrence code 62 – “Other Institutional Discharge Date”
    ‒  Reported, but not required, on final claims. Not reported on RAPs
    ‒  Reported ONLY on admission claims, if applicable

    • Claim “From” and “Admission” date match
  • Report the discharge date (“Through” date) of a skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), long term care hospital (LTCH) or inpatient psychiatric facility (IPF) stay that ended within 14 days of the “From” date of the HH period of care.
  • Admission claims with other institutional discharges within 14 days are grouped into “Institutional” payment groups
  • Report only one occurrence code 61 or 62 on a claim. If two inpatient discharges occur during the 14 day window, report the later discharge date.
  • Claims with both occurrence code 61 and 62 will be returned
  • Claims with more than one occurrence code 61 or more than one occurrence code 62 will be returned

 

 

What happens if an HHA is not aware of an institutional discharge when they submit the claim?

  • If the inpatient claim has been processed by Medicare before the HH claim is received, Medicare systems will identify it and group the HH claim into an institutional payment group automatically
  • If the inpatient claim has not been processed yet when the HH claim is received, Medicare systems will group the HH claim into a community payment group
  • When the inpatient claim is processed later, Medicare systems will automatically adjust the paid HH claim and pay it using an institutional payment group instead

 

 

Value Code 85

  • Implemented on January 7, 2019, requires home health rural add-on payments to vary based on the county in which the service was furnished.  As a result, a new value code (VC) 85, is effective January 1, 2019.  VC 85 is defined as “County Where Service is Rendered.”
  • On all Requests for Anticipated Payments (RAPs) and home health Final claims with dates of service on or after January 1, 2019, providers must report VC 85.
  • If the VC 85 is invalid or are missing from the billing transactions (RAP or Final claim), they will be moved to Return to Provider (RTP)