Home Health Claims: New Grouper Edits

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant ā€“ Briggs Healthcare

CMS posted Transmittal 11714 – Change Request 12924 on November 18, 2022. This Change Request contains no new policy. It improves the implementation of existing policies.

The Home Health (HH) Grouper program contains various data validity edits that ensure consistent and accurate data is used when calculating payment groups on HH claims. Of these edits, currently only Grouper return code 05 (principal diagnosis not assigned to a clinical group) causes HH claims to be returned to the provider. Grouper return code 03 (other principal diagnosis code error) is not returned to the provider. In some cases, this causes processing problems. Additionally, the edit identifies various error conditions that may be helpful to providers in improving claims accuracy. The requirements below revise Original Medicare systems to return claims with these errors, using a combination of Grouper return code 03 and Grouper validity flag information that identifies specific error conditions, to create new Fiscal Intermediary Shared System (FISS) reason codes that describe the errors to providers.

When a Notice of Admission (NOA) is submitted indicating the beneficiary transferred from another home health agency (HHA) and the NOA From date falls within the HH period of care of the previous HHA, the End date of the previous period is truncated to allow the transfer. Change Request 12790 corrected a problem that occurred if a transfer NOA is submitted in error and subsequently canceled. It ensured that Medicare systems restore the previous period’s End date when a transfer NOA is canceled. It did not address the possibility that a claim corresponding to the previous period may have been paid a partial period payment adjustment in error. The requirements below create a new IUR that will be sent by the Common Working File (CWF) to identify these claims and trigger FISS to adjust those claims to restore full payment for the period of care.

MLN Matters Number: MM12924 Revised was posted on November 18, 2022 as well.