Home Health Episodes Spanning Oct. 1 Get CMS Guidance

Home Health Episodes Spanning Oct. 1 Get CMS Guidance

The Centers for Medicare & Medicaid Services (CMS) has addressed Home Health (HH) providers’ anxieties about how to convert to ICD-1o if a patient’s episode of care spans October 1, starting with ICD-9  and finishing with ICD-10 diagnoses.

According to MLN Matters SE1410, CMS addresses the issue by recognizing the following factors for episodes spanning the Oct. 1 implementation:

  • The claim From date (episode start date)
  • The Outcome and Assessment Information Set (OASIS) assessment completion date (OASIS item M0090 date)
  • The claim Through date.

In the case of initial HH episodes beginning and ending before Oct. 1, CMS said the OASIS assessment must be completed within five days of the start of care. The assessment completion date (M0090 date) determines whether the HH Grouper software determining the payment group for the episode will apply ICD-9-CM or ICD-10-CM codes to the episode. In the case where the episode start of care date is before October 1, 2015 and the M0090 date is also before October 1, 2015, ICD-9-CM codes will be used on the OASIS and to determine the payment group code (the Health Insurance Prospective Payment System (HIPPS) code).

For HH claims (type of bill 032x), ICD-10-CM reporting is required based on the claim Through date. On Requests for Anticipated Payment (RAPs), Medicare billing instructions require that the From and Through dates are the same. If the episode begins in September 2015, the From and Through dates on the RAP would report the same date in Sept. These RAPs would report ICD-9-CM diagnosis codes using codes matching the OASIS assessment.

If the HH episode spans into Oct. 2015, CMS explained, the corresponding final claim for the episode will be required to report ICD-10-CM codes. HH claims cannot be split into periods before and after Oct. 1, 2015, so these claims will have claim Through dates of October 1, 2015, or later. The HIPPS code on the final claim must match the HIPPS code reported on the RAP. The HIPPS code on the RAP was based on the ICD-9-CM codes matching the OASIS assessment.

CR 7492 stated that CMS will:

“Allow HHAs to use the payment group code derived from ICD-9-CM codes on claims which span 10/1, but require those claims to be submitted using ICD-10-CM codes.”

This means HH agencies do not have to re-group the episode based the ICD-10-CM codes. But this could result in some inconsistency between the HIPPS code and the ICD-10-CM codes on the claim. CMS will alert medical reviewers at  MACs to ensure  ICD-10-CM codes on these claims are not used in making determinations. CMS will also alert researchers using CMS data files of this inconsistency. The coding used to support the payment of the HIPPS code will be the ICD-9-CM codes used on the RAP, which are stored in the OASIS system.

These same procedures will apply to resumption of care assessments (M0100 = 03) and to recertification (M0100 = 04) and follow-up (M0100 = 05) assessments when the episode start date and the M0090 date on those assessments are both before Oct. 1, 2015 but the episode ends in Oct. 2015 (see table below).

There may be cases  in which episode start before Oct. 1 with OASIS completion dates after implementation,  where the episode start of care date is before Oct. 1, 2015, and, due to the 5 day completion window, the M0090 date is in October 2015. For example, an initial episode with a start of care date of September 28, 2015, could have an M0090 date of Oct. 2, 2015. In these cases, ICD-10-CM codes will be used on the OASIS and to determine the HIPPS code.

The RAP for this example would have From and Through dates of Sept. 28, 2015. As a result, these RAPs would need to report ICD-9-CM diagnosis codes even though ICD-10-CM codes were used on the OASIS assessment.

Because RAPs are not subject to medical review and are replaced in Medicare claims history by the final claim, there is no need to account for adverse impacts in these situations. The ICD-9-CM codes are required for the RAP to be processed. The corresponding final claim for the episode will report ICD-10-CM codes matching the OASIS assessment.

In the case of recertification episodes, the M0090 date can be up to 5 days earlier than the episode start date. A  recertification episode starting on Oct. 2, 2015, could have an M0090 date of September 28, 2015. ICD-9-CM codes are used on the OASIS assessment and will be used to determine the HIPPS code. But in this case, both the RAP and claim will require ICD-10-CM codes since the Through date on both will be after October 1, 2015.

The coding used to support the payment of the HIPPS code will be the ICD-9-CM codes, which are stored in the OASIS system. In these cases, CMS will alert medical reviewers at  MACs and researchers using CMS data files to prevent adverse impacts.

Clear as mud? Here’s a table:

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Type of OASIS Assessment RAP “From/ Through” Dates OASIS M0090 Date/OASIS Version Claim “Through” Date Diagnosis Coding Used on OASIS Diagnosis Coding Used on RAP Diagnosis Coding Used on Claim
Start of Care/Resumption of Care 9/28/2015 9/30/2015OASIS-C 11/26/2015 ICD-9 ICD-9 ICD-10
Recertification 9/28/2015 9/25/2015OASIS-C 11/26/2015 ICD-9 ICD-9 ICD-10
Start of Care/Resumption of Care 9/28/2015 10/2/2015OASIS-C1 11/26/2015 ICD-10 ICD-9 ICD-10
Recertification 10/2/2015 9/28/2015OASIS-C 11/30/2015 ICD-9 ICD-10 ICD-10
Brad Ericson

Brad Ericson

Publisher at AAPC
Brad Ericson, MPC, CPC, COSC, has been publisher for more than nine years. Before AAPC he was at Optum for 13 years and at Aetna Health Plans before that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.
Brad Ericson

About Has 196 Posts

Brad Ericson, MPC, CPC, COSC, has been publisher for more than nine years. Before AAPC he was at Optum for 13 years and at Aetna Health Plans before that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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