Nursing home

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9585 to address the Office of Inspector General’s recommendation that Medicare strengthen its enforcement of Outcome and Assessment Information Set (OASIS) submission as a condition of home health (HH) payment. The OASIS is the clinical assessment of patient characteristics which determines the Health Insurance Prospective Payment System (HIPPS) code and establishes the expected episode payment. CMS policy requires the OASIS to be submitted within 30 days of completing the patient assessment.

In April 2015, CMS began the initial phase of enforcement by using the claims-OASIS interface to compare the HIPPS code calculated by OASIS data submitted to the Quality Improvement Evaluation System (QIES) with the HIPPS code submitted on the final claim to the Medicare Administrative Contractor. If the two HIPPS codes don’t match, the HIPPS code calculated using OASIS data is used for determining payment to the provider. Currently, there’s no penalty if a corresponding OASIS assessment can’t be found in QIES.

However, effective April 1, 2017, CR 9585 requires an automated denial of HH final claims when the OASIS assessment for the episode hasn’t been received in QIES. If the OASIS assessment isn’t present in QIES on receipt of the HH final claim, and the claim’s receipt date is more than 40 days after the assessment completion date, then Medicare will automatically deny the claim and no payment will be made to the provider. Although regulation requires the OASIS to be submitted within 30 days of the patient assessment, the CMS edit will initially allow 40 days to assist with circumstances where the patient is discharged early or the OASIS assessment is transmitted near the same day as the claim. The number of days allowed may be amended by a future CR.

As in the initial enforcement phase, payment for those episodes where an OASIS was submitted to QIES will be based on the HIPPS code calculated by the submitted OASIS data if it’s different than the HIPPS code submitted on the final claim. The OASIS-calculated HIPPS code may be further recoded for therapy services provided as well as episode timing.

The HIPPS code submitted on the claim, the OASIS-calculated HIPPS code and the Pricer recoded HIPPS code will be reported in the Medicare Direct Data Entry (DDE) system as defined in the fields below.

Field in DDE





HHA-submitted HIPPS code



OASIS-calculated HIPPS code



Pricer recoded HIPPS code

When the OASIS isn’t present in QIES, the OASIS-calculated HIPPS code will be recorded as “ZZZZZ,” and the claim will be denied. Denied claims also will return group code CO and Claim Adjustment Reason Code 272.

While standard Medicare appeals processes will be available, claims denied for this reason likely will be difficult to win in appeals since the technical requirements for transmitting OASIS data prior to billing HH final claims weren’t met. It’s critical processes are in place to consistently transmit OASIS data prior to billing HH claims to avoid unnecessary denials. Providers are encouraged to contact their billing software vendors—and any other third-party vendors used for OASIS submission—to identify automated workflow safeguards that can help prevent unnecessary claim denials.

Contact your BKD advisor for additional information.

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