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Claims Processing Issues Log
Please reference this page for confirmed system-related claims processing issues before you contact the Provider Contact Center. Click on the description of the issue to view detailed information and check back often for updates that are posted when they become available.
Closed issues remain on the active log for approximately 60 days before they are moved to the resolved issues archive list at the bottom of the page.
If you still have questions please contact the Provider Contact Center or use one of our self-service tools.
Date Reported |
Description of Issue |
10.16.2023 |
FISS is aware some claims suspended to status/location (S/LOC) S MCABL without a reason code assigned. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health & Hospice |
N/A |
N/A |
|
Updates |
|
MAC Action |
CGS will provide updates when available. |
Provider Action |
No provider action is required at this time. |
Proposed Resolution |
A resolution is pending further research. |
|
08.08.2023 |
Some home health claims returned to the provider (RTP’d) with reason code 32103 due to an NPI Crosswalk issue. This issue occurs when an historical termination date is incorrectly applied in FISS after an application finalizes in PECOS under a current, active enrollment record. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
32103 |
N/A |
|
Updates |
|
MAC Action |
We will provide updates when available. |
Provider Action |
You may continue to submit NOAs (TOB 32A) to meet the timely filing requirement, but don’t submit claims or correct/resubmit any NOAs or claims that RTP until the issue is resolved. |
Proposed Resolution |
A resolution is pending further research. |
|
08.02.2023 |
Home Health claims returned to provider (RTP’d) with reason code W7072 in error. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
HH TOB 34X |
W7072 |
Claims submitted between January 1 – June 30, 2023 Revenue codes 042X, 043X, 044X CPT codes 98980 and/or 98981 |
|
Updates |
|
MAC Action |
|
Provider Action |
You may F9/resubmit claims that RTP’d in error. |
Proposed Resolution |
A system update was implemented with the July 2023 quarterly release. |
|
08.01.2023 |
Some HH Claims Receiving Reason Code 19963 in Error |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
19963 |
|
|
Updates |
CGS is aware of some home health claims receiving Reason Code 19963 in error. This is occurring when the Notice of Admission (NOA) has gone offline to OB9997 st/loc. We are researching this issue and working with CMS/FISS. We will update providers as more information becomes available. |
MAC Action |
This issue has been identified and is currently in research. |
Provider Action |
Ensure claim is editing in error as described as some claims will appropriately edit for RC 19963. |
Proposed Resolution |
|
|
07.17.2023 |
Hospice Reason Code W7048 Revenue Codes Without HCPCS Codes |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Resolved |
Hospice |
W7048 |
|
08.03.2023 |
Updates |
Since the July 2023 System Release, Medicare has seen an increase in hospice claims editing for reason code (RC) W7048. This reason code states one or more visit revenue codes were reported on the claim without the required corresponding HCPCS code. RC W7048 has been firing incorrectly for revenue codes 0250 (non-injectable prescription drugs), 0290 and/or 0294 (infusion DME and drugs), which do not require HCPCS codes.
August 3, 2023, Update: RC W7048 has been firing incorrectly for revenue codes 029X (infusion DME and drugs), which do not require HCPCS codes. Additionally, claims are being incorrectly RTP with W7048 when GIP 656/Q5006 is reported on a claim with lines with a visit RC 055x, 056x, or 057x date inside the GIP dates if they do not have corresponding visit HCPCS. Revenue code 0250 was removed from this issue as it was not affected by it. Visit revenue codes require a corresponding HCPCS code. More information on which revenue codes require HCPCS in claims may be found in section 30.3 - Data Required on the Institutional Claim to A/B MAC (HHH), of the Medicare Claims Processing Manual, Chapter 11 - Processing Hospice Claims. For example, if a hospice reports revenue code 055x (Skilled Nursing), HCPCS code G0299 or G0300 must be reported with it. Claims will be returned to the provider (RTP) with W7048 if they reported revenue code 055x without that HCPCS, regardless of the level of hospice care provided. |
MAC Action |
Within 10 business days of this update, the MACs shall suspend hospice claims that edit for RC W7048 to bypass the edit and release them back in to processing. MACs will apply the above workaround until the October 2023 Integrated Outpatient Code Editor (IOCE) is implemented for hospice claims, which will update the logic for RC W7048 to correct the issue. |
Provider Action |
Hospices who have had claims returned with RC W7048 since July 1, 2023, should return them for processing so they may bypass RC W7048. If a hospice had a claim(s) RTP prior to July 1, 2023, ensure the correct HCPCS codes were applied to the claim. |
Proposed Resolution |
See above. |
|
03.29.2023 |
Service Intensity Add-On (SIA) Payments Not Applying to Previous Month |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Hospice |
|
|
|
Updates |
A service intensity add-on (SIA) payment will be made for in person social worker visits and nursing visits provided by a registered nurse (RN), when provided during routine home care in the last seven days of life. When a patient is discharged deceased on a claim within the first six days of a month, CMS' system is to perform a look back on the prior month's claim to identify if there were SIA eligible services provided within the last seven days of life and if there are, a system-initiated adjustment would occur. The look back is currently not occurring.
More information on SIA payments and how they applied to claims may be found in section 30.2.2 – Service Intensity Add-on (SIA) Payments, of the Medicare Claims Processing Manual . |
MAC Action |
This issue has been identified and is currently in research. |
Provider Action |
|
Proposed Resolution |
The maintainers are researching. |
|
02.24.2023 |
Some Home Health (329) claims with Condition Code 47 received Reason Code U538F |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
U538F |
Condition Code 47 |
|
Updates |
|
MAC Action |
|
Provider Action |
|
Proposed Resolution |
The maintainers are researching. |
|
01.11.2023 |
Some Home Health Claims Editing for Reason Code 31755 |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
31755 |
|
|
Updates |
Some home health claims are being returned for Reason Code 31755. The majority of the claims being returned are provider billing errors and need to be corrected with the information provided in the "Provider Action" section of this article. However, Medicare is still receiving claims for January 2022 that used the artificial admit date that have a different 0023 vs first visit date. We are researching what action to take on these claims.
Please see the below additional information as to why Reason Code 31755 was reactivated and why.
As of January 3, 2023, reason code 31755 has been reactivated per CMS instructions. This means the revenue code 0023 line-item date of service must match the date of service for the first home health visit on the claim. |
MAC Action |
The issue is being researched. |
Provider Action |
Home health agencies need to ensure that:
- For initial periods of care, the HHA reports on the 0023 revenue code line the date of the first covered visit provided during the period.
- For subsequent periods, the HHA reports on the 0023 revenue code the date of the first visit provided during the period, regardless of whether the visit was covered or non-covered.
Many of the subsequent period claims are reporting the first day of the period rather than the first visit date, which are being correctly returned to the provider. Providers should correct the date and resubmit the claim. See page 61 of Chapter 10 - Home Health Agency Billing for more information.
No additional provider action is needed at this time. We will provide an update as soon as it is available. |
Proposed Resolution |
|
|
08.02.2022 |
Home Health claims submitted with condition code DR (disaster related) during the COVID-19 public health emergency that are not matched to a corresponding OASIS assessment in iQIES cannot finalize. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
N/A |
Condition Code DR |
|
Updates |
|
MAC Action |
CGS will remove condition code DR from affected claims to allow them to return to provider (RTP) with reason code 37253 correctly and include the following message in the Remarks field on claim page 07: DR condition code not needed. Removed so provider can submit matching OASIS. |
Provider Action |
Condition Code DR is not required since there is no waiver of OASIS reporting in place during the COVID-19 PHE.
If a claim RTPs per the MAC Action section above, submit the missing OASIS assessment and resubmit the claim. |
Proposed Resolution |
|
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