The Home Health (HH) Grouper program has various data validity edits that make sure it uses consistent and accurate data when calculating payment groups on HH claims. Of these edits, currently only a principal diagnosis not assigned to a clinical group causes HH claims to be returned to the provider. Other principal diagnosis code errors aren’t returned to the provider. In some cases, this causes processing problems.

New edits will identify various error conditions helpful to providers in improving claims accuracy. If the diagnosis coding issues are identified, CMS returns the claim to the provider for correction.

These new Grouper edits apply to Types of Bill 032X (except 032A, 032D, and 0320). With this process, the U.S. Centers for Medicare & Medicaid Services (CMS) may return some claims to you with 1 of the following messages:

  • Unacceptable primary diagnosis, not reportable as primary
  • Manifestation code not reportable as primary diagnosis
  • Unspecified diagnosis code not acceptable as primary diagnosis
  • External cause of injury code not reportable as primary diagnosis
  • Primary diagnosis identified as a code first code with condition present
  • Primary diagnosis code is not valid for claim dates or is blank

Revised Processing of Some NOAs
When you send CMS an NOA indicating the patient transferred from another Home Health Agency (HHA) and the NOA From date falls within the HH period of care of the previous HHA, CMS truncates the End date of the previous period to allow the transfer.

CR 12790 corrected a problem that occurs if you send CMS a transfer NOA in error and then cancel it. That CR makes sure Medicare systems restore the previous period’s End date when a transfer NOA is canceled. It doesn’t address the possibility that a claim corresponding to the previous period may have been paid a partial period payment adjustment in error. CR 12924 creates a process to identify these claims and to adjust them to restore full payment for the period of care.

This is effective for claims processed on or after April 1, 2023.

Source: U.S. Centers for Medicare & Medicaid Services (CMS)

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