How to Bill RAPs and Claims to Avoid Pitfalls
Between now and the implementation date of October 1, 2015, for ICD-10-CM, home health agencies have many important processes to re-evaluate. For example, coder productivity is expected to decline by 54.4 鈥� 69 percent following implementation, according to the American Health Information Management Association (AHIMA). The loss in efficiency will likely cause a 鈥渓og jam鈥� for billing.
Agencies not prepared for this productivity loss and the related temporary billing changes, could face an overwhelming decline in reimbursements from payers post ICD-10-CM implementation. Agencies that anticipate change and adjust their processes accordingly will be better positioned to survive financially.
In a recently revised article from the Centers for Medicare & Medicaid Services (CMS), home health agencies are instructed on how billing home health episodes will be accomplished after the implementation of ICD-10-CM. There are three factors that will determine how ICD-10-CM will be used in billing Requests for Anticipated Payments (RAPs) and final claims that span the implementation date. These factors are:
- The claim 鈥渇rom鈥� date (episode start date)
- MOO90: OASIS-C1 assessment completion date
- The claim 鈥渢hrough鈥� date (episode end date)
Depending on the three factors above, the RAP and final claim will be processed using either ICD-9-CM codes, ICD-10-CM codes, or a combination of both. CMS gives agencies several examples of how billing is to be done post ICD-10-CM. Let鈥檚 look at the scenarios:
Scenario 1: Admissions with Episode and MOO90 Completion dates before October 1, 2105:
In this scenario, let鈥檚 use a start of care date of September 28, 2015. The 鈥渇rom鈥� date would be September 28, 2015. The MOO90 date would also be September 28, 2015. The 鈥渢hrough鈥� date would be November 26, 2015. In this scenario, the agency would code the RAP and the OASIS-C1 in ICD-9-CM codes. HIPPS code will be generated using ICD-9-CM case mix groupers. The final claim will be required to use ICD-10-CM codes according to CMS. Although doing so would possibly generate a different HIPPS code, CMS has said that they will use the ICD-9-CM generated HIPPS that is stored in the Assessment Submission and Processing (ASAP) system OASIS system for payment in this case.
Scenario 2: Admissions with Episode date before October 1, 2015, and MOO90 Completion date after October 1, 2015:
In this scenario, let鈥檚 also use the start of care date September 28, 2015. The 鈥渇rom鈥� date would be September 28, 2015. The MOO90 date could be up to October 2, 2015. The 鈥渢hrough鈥� date would still be November 26, 2015. In this scenario, the agency would code the RAP in ICD-9-CM dates, because on RAPs, the 鈥渇rom鈥� and 鈥渢hrough鈥� dates would both be September 28, 2015. The OASIS-C1 would be coded using ICD-10-CM codes, because MOO90 is after October 1, 2015. The final claim will be required to use ICD-10-CM codes.
Scenario 3: Admissions with Episode and MOO90 Completion dates after October 1, 2015:
For this scenario, all the dates fall after the implementation date of October 1, 2015. Therefore, the RAP, the Final Claim, and the OASIS-C1 will all be coded using ICD-10-CM codes.
Scenario 4: Recertifications with Episode date before October 1, 2015, and MOO90 completion date after October 1, 2015:
For this scenario, let鈥檚 say the patient is due for re-certification on October 2. The clinician has a five-day window of September 28- October 2 to complete the OASIS-C1 assessment and gather information from the physician and other clinicians, if applicable. The OASIS-C1 will need to be coded in ICD-10, as will the final claim. However, the RAP will need to be coded in ICD-9-CM.
Scenario 5: Recertifications with Episode date after October 1, 2015, and MOO90 completion date after October 1, 2015:
In this scenario, again, the re-certification window can be up to or even after the October 1 implementation date. However, if the episode date and OASIS-C1 completion date is on or after October 1, 2015, the RAP, final claim and OASIS-C1 will all be coded using ICD-10-CM. However, if the OASIS-C1 completion date is prior to October 1, then the process is a little different. Let鈥檚 look at this scenario:
Scenario 6: Recertification with Episode date after October 1, 2015, and MOO90 completion date before October 1, 2015, and episode through date after October 1, 2015:
In this last scenario, the episode starts after October 1, 2105. Therefore, the RAP and final claim will be billed using ICD-10-CM codes. However, the OASIS-C1 completion date will use ICD-9-CM codes because it was completed before October 1, 2015.
As you can see from the examples above, the OASIS-C1 code set decision is based on the MOO90 date. However, the RAP and final claim is based on the 鈥淔rom鈥� and 鈥淭hrough鈥� dates.
Now that CMS is using the ASAP system for OASIS submission, final claim HIPPS codes are being matched with the OASIS-C1 generated HIPPS codes. If there is a disparity, the HIPPS generated by the OASIS-is used to generate and adjust final claim payment. Implementation of ICD-10-CM throws a bit of a wrinkle into this system, because in some cases the OASIS-C1 will be submitted to ASAP in ICD-9-CM code set with resulting HIPPS codes generated from ICD-9-CM case mix, while final claims are submitted in ICD-10-CM with resulting HIPPS codes in ICD-10-CM case mix.
CMS has stated that it 鈥渨ill advise medical reviewers at the Medicare Administrative Contractors (MACs) to ensure that the ICD- 10-CM codes on these claims are not used in making determinations鈥�. This means that HHAs do not have to re-group, or split, the episode bills based the ICD-10-CM codes. Claims will be based on the episode start date and associated OASIS-C1 code set used. For those episodes that begin before October 1, 2015, claims will be paid using the ICD-9-CM case mix generated HIPPS codes. For episodes that begin on or after October 1, 2015, claims will be paid using ICD-10-CM case mix generated HIPPS codes.
For more information on the billing process for home care claims following ICD-10-CM implementation, see CMS鈥檚 website:.
REFERENCES:
AHIMA:
CMS: