Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
On March 16, 2021, CMS issued Transmittal 10596/Change Request 12085. This Change Request revises Common Working File home health period sequence edits to no longer exclude low utilization payment adjustment claims.
EFFECTIVE DATE: January 1, 2020 – Claim “From” dates on or after this date.
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: July 6, 2021
- GENERAL INFORMATION A. Background: The Common Working File (CWF) contains edits that ensure home health (HH) claims are paid in the correct episode or period of care sequence. Currently, these edits bypass low utilization payment adjustment (LUPA) claims. Before the implementation of the Patient-Driven Groupings Model (PDGM), this bypass was correct. If the claim had 4 or fewer visits, it would correctly receive a LUPA payment regardless of whether it was an early or late episode.
Under the PDGM, the early or late Health Insurance Prospective Payment System (HIPPS) codes for a period of care can have different LUPA thresholds, ranging from 1 to 6 visits. The correct early or late HIPPS code must be assigned before Medicare systems can correctly determine whether a LUPA payment should apply. In some cases, incorrect payments result if Medicare systems bypass period of care sequence edits for LUPA claims.
MACs are manually recoding the affected claims to correct payments, when providers bring the issue to their attention. This Change Request corrects CWF editing to remove the LUPA bypass for HH claims with From dates on or after January 1, 2020. Once this correction is implemented, manual recoding will no longer be necessary.
Additionally, Medicare Administrative Contractors (MACs) have reported cases where CWF is sending unsolicited response to trigger partial period payment adjustments on claims that have no covered visits. These adjustments cannot be processed through the HH Pricer, so this Change Request also makes changes to FISS to no longer send these unsolicited responses to the Pricer.
B. Policy: This Change Request contains no new policy. It corrects the implementation of existing policy.
[Above bolding added by this author.]