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Home Health 2021 Billing One Month In: Lessons Learned


The implementation of major 2021 billing changes is underway and home health organizations are adapting to new operations to stay compliant and manage revenue.

One month into 2021, organizations have already learned some tips on succeeding with no-pay Requests for Anticipated Payment (RAPs), claim submission and the use of a KX modifier.

The No-Pay RAP

RAPs are still taking an average of three to five days to be moved into a “paid” status in Direct Data Entry (DDE). During this time, billers should track the movement of the claim to ensure final acceptance in the Common Working File (CWF).

Two common instances in which RAPs will not be accepted are due to the core-based statistical area (CBSA) codes on claims and reason codes received in error.

Value Code 61 – CBSA Code

With the introduction of the no-pay RAP, organizations have begun to see issues with RAPs in “Return to Provider” (RTP) status. The first issue recognized was the rejection of RAPs due to the CBSA code, or value code 61, not being present. Although no longer required by CMS, organizations were still seeing RAPs being rejected or in RTP status for this reason. An intuitive revenue cycle management (RCM) software can correct for this by reintroducing the patient’s actual CBSA code into the claim.

However, the Centers for Medicare and Medicaid Services (CMS), advised Medicare Administrative Contractors (MACs) to use CBSA value code 10180 as a placeholder for RAPs submitted without a CBSA code to prevent future RAPs from being in RTP status.

Reason Code W7216

The second issue recognized by CMS was the RTP reason code W7216. On January 27, 2021, CMS stated this issue will be resolved in an April 2021 release. RAPs with this reason code should process appropriately until this update.

For RAPs with a billing period in 2021, it is suggested that organizations continue RAP submission and keep records of submission dates with screenshots for any RAPs that might RTP for this reason.

A KX modifier will most likely be needed on the associated final claim for these RAPs to request an exception to the timely filing penalty. Billers should include remarks on each affected claim, along with the KX modifier to minimize the risk of receiving an Additional Documentation Request (ADR).

Each MAC may request additional documentation prior to releasing payment if remarks included are not sufficient for research.

Reason Code 37253

As Medicare systems have been updated to reflect the 2021 billing changes, an issue impacting finals appeared as well.

CMS has released information regarding reason code 37253, which states that a submitted claim has no associated OASIS submitted to the Internet Quality Improvement and Evaluation System (iQIES).

CMS resolved this issue, effective January 26, and has concluded that MACs did not receive OASIS file responses from iQIES between January 4 and January 8. Currently, no provider action is necessary to resubmit these claims. Claims with this reason code in RTP status should automatically be processed for review and payment and removed from RTP status.

Other Lessons Learned

Billers must be vigilant in reviewing the progress of submitted RAPs for acceptance by CMS. Using a HIPAA-compliant RCM software to track processing for RAPs will minimize penalties due to timeliness. Organizations should also modify internal recovery billing processes to ensure claims in RTP status are reviewed regularly.

Becoming familiar with each MAC’s website and claims issues log is a great way to stay up to date on the latest issues and resolutions.

For more lessons learned on the new billing requirements, register for this free webinar with Axxess, BlackTree and Home Health Care News.

Axxess Home Health is a home health software with up-to-date features that are fully compliant with new Medicare regulations to help organizations succeed.

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