RAP Diagnosis Code, Service Date Instructions Change

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  • April 9, 2021
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RAP Diagnosis Code, Service Date Instructions Change

Other claims system glitches fixed, with one still waiting.

The Centers for Medicare & Medicaid Services (CMS) continues to issue new rules to accommodate no-pay Request for Anticipated Payments (RAPs) and Patient-Driven Groupings Model (PDGM).

Principal Diagnosis

CMS has reissued Change Request (CR) 11855 and added a few new instructions about requests for anticipated payments. “For ‘From’ dates on or after January 1, 2021, the RAP may report any valid diagnosis code, in order to facilitate timely submission,” the CR says. “Since these RAPs are not paid, the accurate principal diagnosis code that supports payment is needed only on the claim for the period of care.”

Date of Service

The CR also contains a new instruction on service dates. As usual, home health agencies (HHAs) report on the 0023 revenue code line the date of the first covered visit provided during the initial episodes/periods of care. “For subsequent episodes, the HHA reports on the 0023 revenue code the date of the first visit provided during the episode/period, regardless of whether the visit was covered or non-covered,” the CR states.

However, if “the HHA submitted the corresponding RAP using the first day of the period of care as the service date on the 0023 line,” then “the HHA reports a service date on the 0023 revenue code line that matches the date submitted on the RAP. This is necessary to make sure Medicare systems can correctly match the claim to the RAP during processing,” CMS explains.

“These changes make sure claims successfully match their corresponding RAP,” CMS emphasizes in the accompanying MLN Matters article.

Claims System Errors

RAP instructions aren’t the only things changing. On April 1, three claims system errors were corrected, Medicare Administrative Contractor (MAC) CGS notes on its website.

The fixes were for claims spanning Jan. 1 applying calendar year 2020 rates in error; late RAP penalties not applying to outlier amounts; and late RAP penalties being applied after the Value-Based Purchasing (VBP) adjustment, when the VBP adjustment should be the last calculation.

“Once the correction is implemented, over several weeks CGS will reprocess these claims to correct your payments,” CGS said on the eve of the fixes. “You don’t need to take any action.” MAC Palmetto GBA issued a similar instruction.

Yet another correction is on the horizon, although you can effect it manually on a case-by-case basis right now. “The CWF contains edits that ensure that Medicare pays HH claims in the correct episode or period of care sequence,” CMS says in a recent MLN Matters article. “Currently, these edits bypass LUPA claims,” which was correct in pre-PDGM days. Back then, “if the claim had 4 or fewer visits, it would correctly receive a LUPA payment regardless of whether it was an early or late episode,” CMS recalls.

But under PDGM, LUPA thresholds vary from 1 to 6 visits even among early and late episodes of the same category. “The correct early or late HIPPS code must be assigned before Medicare systems can correctly determine whether a LUPA payment should apply,” the MLN Matters article explains.

Medicare will fix the problem with the July claims system update, it says. Meanwhile, “when HHAs bring such claims to their attention, MACs manually recode affected claims to correct payment,” says the article.

Rebecca Johnson
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Rebecca L. Johnson, BS, is a development editor for AAPC newsletters. She has covered the home health and hospice markets for 20 years.

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