CMS issued Change Request (CR) 13543 on 04/11/24 with Subject Line: Additional Enforcement of Required County Codes on Home Health Claims

While the stated purpose noted on this CR was to create an edit in the original Medicare systems to ensure required county codes are reported on all home health claims, other interesting tidbits were included.

This CR was stated to also make makes clarifications to home health billing instructions regarding Notice of Admission timeliness exceptions, charge reporting for telehealth visits and diagnosis code reporting.

We are going to focus on the diagnosis code reporting.  Interestingly, as noted on page 20 of the CR, for ICD-10 Coding updates, the HH Grouper logic uses the “from” date rather than the “through” date when updates are made to the code set and will map the new code back to the predecessor code to correctly determine the case-mix scoring and the HIPPS code for the claim.  As stated below, the diagnosis code used for payment grouping are determined from claim coding rather than the OASIS assessment.  That being said, the claim and OASIS diagnosis codes are note expected to match in all cases. Please see below for a portion of the CR or here is the link for full access:  https://www.cms.gov/files/document/r12577cp.pdf

Updated information from the CR in red:

The following instructions apply to both Principal and Other Diagnosis Code reporting.

• Diagnosis coding and claim dates:

Diagnosis codes that reflect the patient’s condition as of the start of a period of care (the claim From date)

are reflected on the claim for the current period of care. Diagnosis codes that reflect a change in the

patient’s condition during a period of care should be reflected on the claim for the next period.

ICD diagnosis codes are updated each year on October 1 and April 1. While the claim describes the

patient’s condition as of the From date, if the claim Through date spans across an ICD update, the codes

that are valid after the update are reported on the claim.

For example, the HHA submits a claim spanning September 15, 2023 to October 14, 2023, for a patient that

has Parkinson’s Disease as a secondary diagnosis, The code in effect on September 15, 2023 is G20

(Parkinson’s Disease) but effective October 1, the code that applies to the patient’s condition changed to

G20.C (Parkinsonism, unspecified). The G20.C code is reported on the claim.

The version of the HH Grouper logic applied to each claim is determined is based on the claim From

date. In the case of a claim with a From date of September 15, 2023 and Through date of October 14, 2023,

the Grouper applies the logic and codes in effect for dates of service before September 30, 2023 and not the

logic and codes effective October 1. When a diagnosis code changes as describe above, the HH Grouper

maps the new code back to its predecessor code to correctly determine the case-mix scoring and the HIPPS

code for the claim (e.g. maps G20.C back to G20 and uses the G20 code to assign the HIPPS code).

Claim and assessment diagnosis codes:

The diagnosis codes used for payment grouping are determined from claim coding rather than the OASIS

assessment. As a result, the claim and OASIS diagnosis codes are not expected to match in all cases.

Typically, the codes will match between the first claim in an admission and the start of care (Reason for

Assessment –RFA 01) assessment and claims corresponding to recertification (RFA 04) assessments.

Second 30-day claims in any 60-day period will not necessarily match the OASIS assessment. When

diagnosis codes change between one 30-day claim and the next, there is no absolute requirement for the

HHA to complete an ‘other follow-up’ (RFA 05) assessment to ensure that diagnosis coding on the claim

matches to the assessment. However, the HHA would be required to complete an ‘other follow-up’ (RFA 05)

assessment when such a change would be considered a major decline or improvement in the patient’s health

status.