Home Health Changes for Disaster Claims and Certain Adjustments

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

CMS has posted MLN Matters Number: MM13020 (3 pages) relating to Change Request 13020

When disaster conditions (such as hurricane or wildfire) make submission of OASIS assessments impossible, Medicare may issue a waiver indicating OASIS submission is waived. In this case, HHAs should report condition code DR on their claim to show billing under the waiver. Since the OASIS assessment can’t be submitted, the HHA can’t report occurrence code 50 to show the assessment completion date. We’ll accept claims without occurrence code 50 if condition code DR is present.

When you’re unable to submit a start of care OASIS for an admission period of care, submit the Health Insurance Prospective Payment System (HIPPS) code weighted closest to 1. For a period of continuing care, if you’re unable to submit a follow-up OASIS, carry forward the last HIPPS code generated from the previous OASIS.

If as a result of disaster conditions, we relax OASIS submission timeframes, submit claims without condition code DR as soon as you send the OASIS. In this case, we require matching OASIS assessment information and the occurrence code 50 date to make sure Medicare pays the claim correctly.

HH&H MACs report that HHAs submitted claims with condition code DR (indicating disaster related) during the COVID-19 PHE. If such claims aren’t matched to a corresponding OASIS assessment in the Internet Quality Improvement Evaluation System (iQIES), the claims aren’t returned to the provider. This is because the condition code DR causes the claims-assessment matching edit to be bypassed, assuming the condition code represents a waiver of assessment reporting requirements is in effect. Currently, such claims are then suspended by other edits and require manual workarounds to process.

No waiver of OASIS reporting has occurred during the current PHE, so condition code DR isn’t needed on these claims.

A case-mix methodology adjusts the 30-day payment rate based on characteristics of the patient and their corresponding resource needs (for example, diagnoses, functional impairment level, and other factors). We adjust the 30-day period payment rate by a case-mix method based on information from home health claims, other Medicare claims, and data elements from the OASIS. The claims information and OASIS data elements are used to group 30-day periods of care into their case-mix groups. The home health grouper determines the home health resource groups using HIPPS codes generated from OASIS assessment items.

An OASIS is completed at the start of care (SOC), transfer to or discharge from an inpatient facility, or any significant change in condition resulting in a new plan of care. Flexibility regarding timeframes for completion and submission of the OASIS is only granted through emergency declaration blanket waivers for health care providers.

Upon emergency declaration and waiver implementation, when you’re unable to submit a SOC OASIS for an admission period of care, submit the HIPPS code weighted closest to 1. For a period of continuing care, when you’re unable to submit a follow-up OASIS, use the last HIPPS code generated from the previous OASIS.