OASIS Alert

Published on Fri Feb 20, 2004 PDF

M0245 is a claim form oddball.

If you thought something was missing from your claim form, you were right.

Are you still trying to figure out where OASIS diagnosis codes fit on RAPs and final claims? You're not alone. But a CMS transmittal may ensure prompt payment by making it easier to complete claims accurately.

The Centers for Medicare & Medicaid Services' Jan. 16 Transmittal No. 61 - a revision to the Internet-Only Manual (IOM) on Medicare Claims Processing (Pub. 100-04) - addresses field locations on claim forms for primary and secondary diagnoses as well as for M0245. (IOMs replaced the HIM 11 last fall.)

Problem: As of Oct. 1, 2003, the Health Insurance Portability and Accountability Act required diagnosis coding on OASIS assessments to follow official guidelines for ICD-9 coding. CMS added M0245 to the OASIS assessment when HIPAA required agencies to report a non-paying diagnosis V code in M0230, bumping a case mix payment code. Agencies can put that bumped payment diagnosis code in M0245 and still capture the associated reimbursement for the condition (see Eli's OASIS Alert, Vol. 4, No. 7).

But M0245 has frustrated clinicians and billers alike. Once coders unraveled the mysteries of this payment diagnosis, billers couldn't find a place to put it on the request for anticipated payment or the claim form.

Solution: Check these three parts of your claims processing:

1. Field 67 must match OASIS M0230. And as required, the principal diagnosis code entered in Field 67 must follow the official guidelines for ICD-9 coding, CMS explains in the transmittal. This includes using all five digits of the diagnosis code when available and not replacing missing digits with "0."

2. Look to coding guidelines for sequence. If a manifestation code is part of the primary diagnosis, the sequence of the first two codes follows ICD-9 guidelines. The sequence should be the same in M0230/240 of the OASIS assessment and in Field 67/68 of the submitted claim.

3. M0245 does not have a corresponding field on the claim. Payment diagnoses M0245 (a) and (b) "are not directly reported in any field of the claim form," CMS instructs. The only time these codes will appear on the claim form is if coding guidelines require them to be reported in M0240. In that case, they will also appear in Fields 68 to 75 (Other Diagnoses).