CMS to Begin Matching OASIS With Claims
February 4, 2015 12:31 PM
Beginning on April 1, 2015, Medicare systems will compare the Health Insurance Prospective Payment System (HIPPS) code on a Medicare home health claim to the HIPPS code generated by the corresponding Outcomes and Assessment Information Set (OASIS) assessment before the claim is paid. If the HIPPS code from the OASIS assessment differs, Medicare will use the OASIS-calculated HIPPS code for payment.
Previously, the transmission of assessment data and the submission of claims were entirely separate processes. The Fiscal Intermediary Shared System (FISS), which processes all Original Medicare home health claims, did not have access to the quality data repository. As a result, FISS could not validate the submitted HIPPS code against the associated OASIS assessment.
The Centers for Medicare & Medicaid Services (CMS) has planned for several years to create a file exchange interface with the national quality data repository to provide the infrastructure needed to validate HIPPS codes against OASIS assessments. During 2014, the Medicare Administrative Contractors (MACs) successfully began testing the home health OASIS and claim matching process.
Home health agencies (HHAs) are not required to make any changes to their billing systems.
Claims will be suspended temporarily during processing to allow for the file exchange between FISS and QIES. The claims will be suspended with FISS reason code 37071 in status/locations SMFRX0-SMFRX4. This will occur during the 14 day payment floor period and should not delay payments to HHAs.
CMS states that if no corresponding OASIS assessment is found the claim will process normally. However, CMS expects that will change in the near future. HHAs have been required to submit the OASIS assessment as a condition for payment since 2010, but due to the system’s inability to match the OASIS with the claim, CMS was not able to enforce the requirement through an automatic process.
To view the article, please click here.