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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 |
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 |
|
|
06.22.2022 |
Some home health claims received a partial episode payment (PEP) adjustment in error. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
|
Patient discharge status code 06; Reason Code 37184 |
|
Updates |
04.24.2023 – This issue continues to affect initial claim submissions, type of bill (TOB) 329. However, provider submitted adjustment claims, TOB 327, have been successful in issuing full period payments, if applicable.
10.06.2022 – A system fix will be implemented on April 3, 2023. Please reference MM12924 for additional information. |
MAC Action |
|
Provider Action |
Providers may submit adjustments (TOB 327) for claims that received incorrect partial period payment adjustments. Before submitting an adjustment, please ensure the partial period payment was incorrect by reviewing the reasons a partial payment would occur in the “Issue Description” section of this article below.
Providers will have to update the patient status codes on the adjustments, as this issue changed the original code to 06, causing the partial period payment. The adjustments should include condition code D9 and remarks “INCORRECT PARTIAL PERIOD PAYMENT ADJUSTMENTS”. CGS will bypass timely filing for claims past timely filing affected by this issue. |
Proposed Resolution |
Some home health claims are receiving incorrect partial period payment adjustments when the below situations are not present.
Partial period payment adjustments should only occur as a result of the following situations:
- When a patient has been discharged and readmitted to home care within the same 30-day period of care; or
- When a patient transfers to another HHA during a 30-day period of care, or
- In cases where the patient elects Medicare Advantage (MA) coverage during an HH PPS period of care.
These situations are indicated on the claim by reporting a Patient Discharge Status code of 06. Based on the presence of this code, the Pricer calculates a partial period payment adjustment to the claim. |
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