10.1.19.3 – Adjustments of Episode Payment – Validation of HIPPS Codes (Rev. 3629, Issued: 10-27-16, Effective: 04-01-17, Implementation: 04-03-17)

Recoding Based on OASIS-calculated HIPPS Codes

The HIPPS code calculated based on the OASIS assessment for an episode is reported on the HH RAP and claim. HHAs may calculate the HIPPS code using CMS-provided Grouper software or with their own software that recreates CMS grouping logic.  When the OASIS assessment is submitted to the Medicare quality system, the HIPPS code is independently calculated using the CMS-provided Grouper program.

When processing the claim for an episode, Medicare systems compare the provider-submitted HIPPS code with the HIPPS code calculated based on the assessment information in the quality system. If the codes do not match, the OASIS-calculated HIPPS code is used for payment.

 Medicare systems display the OASIS-calculated HIPPS code in Direct Data Entry (DDE) in a field named “RETURN-HIPPS1.”  When the OASIS-calculated HIPPS code is used for payment, the code in this field will match the code on the electronic remittance advice.  In other cases, the HIPPS code in this field will match what the HHA submitted on their claim.

The OASIS-calculated HIPPS code may be re-coded further by Medicare systems. The OASIS-calculated HIPPS code will be sent to the HH PPS Pricer program which may change the code based on changes in therapy services (see section 10.1.19.1) or whether the claim is for an early or later episode (see section 10.1.19.2).  In this case, the Pricer re-coded HIPPS code will be used for payment and will continue to be recorded in the APC-HIPPS field.  This code will match the code on the electronic remittance advice.  HHAs will be able to recognize this case because there will be three HIPPS codes on the claim record in DDE:

Field in DDE DDE Map Represents
HCPC MAP171E HHA-submitted HIPPS code
RETURN-HIPPS1 MAP171E OASIS-calculated HIPPS code
APC-HIPPS MAP171A Pricer re-coded HIPPS code

The OASIS-calculated HIPPS code may also be re-coded by medical reviewers, based on their review of the documentation supporting the claim. In this case, the HIPPS code determined by medical review will be used for payment and will be recorded in the APC-HIPPS field.  This code will match the code on the electronic remittance advice.

When an OASIS Assessment Has Not Been Submitted

Submission of an OASIS assessment is a condition of payment for HH episodes of care. OASIS reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary.  In most cases, this 30 day period will have elapsed by the time a 60 day episode of HH services is completed and the final claim for that episode is submitted to Medicare.  If the OASIS assessment is not found in the quality system upon receipt of a final claim for an HH episode and the receipt date of the claim is more than 30 days after the assessment completion date, Medicare systems will deny the HH claim.

The contractor shall use the following remittance advice messages and associated codes when denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.

Group Code: CO CARC: 272 RARC: N/A MSN: 41.17

Federal Register / Vol. 81, No. 235 / Wednesday, December 7, 2016 / Rules and Regulations

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of Inspector General

42 CFR Parts 1001 and 1003

RIN 0936–AA06

Medicare and State Health Care Programs: Fraud and Abuse;

Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements

AGENCY: Office of Inspector General (OIG), HHS.

ACTION: Final rule.

SUMMARY: In this final rule, OIG amends the safe harbors to the anti-kickback statute by adding new safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. The OIG also amends the civil monetary penalty (CMP) rules by codifying revisions to the definition of ‘‘remuneration,’’ added by the Balanced Budget Act (BBA) of 1997 and the Patient Protection and Affordable Care Act, Public Law 111–148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010 (ACA). This rule updates the existing safe harbor regulations and enhances flexibility for providers and others to engage in health care business arrangements to improve efficiency and access to quality care while protecting programs and patients from fraud and abuse.

DATES: These regulations are effective on January 6, 2017.

FOR FURTHER INFORMATION CONTACT: Heather L. Westphal, Office of Counsel to the Inspector General, (202) 619– 0335.

 

…Page 88408

  1. Local Transportation. As used in section 1128B of the Act, ‘‘remuneration’’ does not include free or discounted local transportation made available by an eligible entity (as defined in this paragraph (bb)):
  1. To Federal health care program beneficiaries if all the following conditions are met:
  1. The availability of the free or discounted local transportation services—
  1. Is set forth in a policy, which the eligible entity applies uniformly and consistently; and
  2. Is not determined in a manner related to the past or anticipated volume or value of Federal health care program business;
  1. The free or discounted local transportation services are not air, luxury, or ambulance-level transportation;
  2. The eligible entity does not publicly market or advertise the free or discounted local transportation services, no marketing of health care items and services occurs during the course of the transportation or at any time by drivers who provide the transportation, and drivers or others arranging for the transportation are not paid on a per beneficiary-transported basis;
  3. The eligible entity makes the free or discounted transportation available only:
  1. To an individual who is:
  1. An established patient (as defined in this paragraph (bb)) of the eligible entity that is providing the free or discounted transportation, if the eligible entity is a provider or supplier of health care services; and
  2. An established patient of the provider or supplier to or from which the individual is being transported;
  1. Within 25 miles of the health care provider or supplier to or from which the patient would be transported, or within 50 miles if the patient resides in a rural area, as defined in this paragraph (bb); and
  2. For the purpose of obtaining medically necessary items and services.
  1. The eligible entity that makes the transportation available bears the costs of the free or discounted local transportation services and does not shift the burden of these costs onto any Federal health care program, other payers, or individuals; and
  1. In the form of a ‘‘shuttle service’’ (as defined in this paragraph (bb)) if all of the following conditions are met:
  1. The shuttle service is not air, luxury, or ambulance-level transportation;
  2. The shuttle service is not marketed or advertised (other than posting necessary route and schedule details), no marketing of health care items and services occurs during the course of the transportation or at any time by drivers who provide the transportation, and drivers or others
  3. The eligible entity makes the shuttle service available only within the eligible entity’s local area, meaning there are no more than 25 miles from any stop on the route to any stop at a location where health care items or services are provided, except that if a stop on the route is in a rural area, the distance may be up to 50 miles between that that stop and all providers or suppliers on the route; and
  4. The eligible entity that makes the shuttle service available bears the costs of the free or discounted shuttle services and does not shift the burden of these costs onto any Federal health care program, other payers, or individuals.
  5. Note to paragraph (bb): For purposes of this paragraph (bb), an ‘‘eligible entity’’ is any individual or entity, except for individuals or entities (or family members or others acting on their behalf) that primarily supply health care items; ‘‘established patient’’ is a person who has selected and initiated contact to schedule an appointment with a provider or supplier to schedule an appointment, or who previously has attended an appointment with the provider or supplier; ‘‘shuttle service’’ is a vehicle that runs on a set route, on a set schedule; ‘‘rural area’’ is an area that is not an urban area, as defined in this rule; and ‘‘urban area’’ as: (a) A Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA), as defined by the Executive Office of Management and Budget; or (b) the following New England counties, which are deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98–21, 42 U.S.C. 1395ww (note)): Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island.