Eli's Hospice Insider

Published on Thu Mar 23, 2017 PDF

Payment reform billing tangle continues.

It may not be a shocker that yet another fix for a hospice reform payment-related problem didn’t work.

The problem: “The unsolicited adjustment” for End of Life SIA payments “did not auto create when the subsequent claim was billed with the discharge equal to deceased (patient status 40, 41, 42) and the DOD occurred within the 1st days of the subsequent month,” HHH Medicare Administrative Contractor National Government Services explains on its website. “Also, retractions of the EOL SIA payment occurred on hospice unsolicited adjustment records during a period of a few weeks in September 2016.” These were part of the many reimbursement glitches that dogged hospices’ claims after payment reform took effect in January 2016.

The solution: As the Centers for Medicare & Medicaid Services said in its Feb. 8 Home Health Open Door Forum, “the correction to both issues was installed to production on 1/3/2017,” the MAC says. “NGS is awaiting [CMS’] direction on resumption of mass adjustment for these claims. In the interim, providers are advised that they may now adjust any SIA payment issue claims.”

Another problem: But hospices that tried to resubmit those claims, as well as claims for Routine Home Care tier mistakes, “have run into processing issues linked to a FISS edit that has been incorrectly returning FY2017 claims with certain CBSA codes that were not valid during FY2016 (but these CBSA codes are valid for FY2017),” the National Association for Home Care & Hospice says. “CMS has directed the MACs to turn this edit off to allow for reprocessing of hospice claims.”

If you resubmit a fiscal year 2017 claim and it’s returned with Reason Code 36458, “the provider should contact the MAC as this is an indication that the edit has not been turned off,” NAHC adds. Meanwhile, an April systems release will attempt to fix the CBSA edit problems.