Medicare Explains New Home Health Coding, Payment Policy

Medicare reimbursement information systems recently began comparing two distinct codes on home health agency claims before the claims are paid.

The rule change comes after an extended period of upgrading information systems and testing with the industry. The IT systems are comparing the Health Insurance Prospective Payment System code (HIPPS) on a claim to the HIPPS coded generated by a corresponding Outcomes and Assessment Information Set, known as OASIS.

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According to the Centers for Medicare and Medicaid Services, “OASIS is a group of data elements that represent core terms of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.” The goal of developing OASIS was to measure patient outcomes and support outcome monitoring, clinical assessment, care planning and internal agency activities.

“If the HIPPS code from the OASIS assessment differs, Medicare will use the OASIS-calculated code for payment,” according to guidance available here. “At this time, if no corresponding OASIS assessment is found, the claim will process normally.”

Many home health agencies create software to integrate necessary data entry and grouping functions in their information systems to support the new policy. Agencies without such software or unhappy with a current product can get free grouping software from Medicare.