Reason Code 37253

Description
This reason code is assigned when there is no corresponding OASIS assessment found in Medicare’s systems related to the claim.

Resolution
Before submitting your claim and the OASIS assessment, ensure the following OASIS items are correct. These items are used to match the claim with the OASIS assessment.

• Home health agency (HHA) CMS Certification Number (CCN) (OASIS item M0010)
• Beneficiary Medicare Number (OASIS item M0063)
  • Changes to a beneficiary’s Medicare Beneficiary Identifier (MBI) may affect the match. If an HHA becomes aware of a change to the MBI via the MBI lookup tool (in Palmetto GBA’s eServices) and uses the new MBI on their claim (required) when the prior MBI was used on the OASIS, that will cause the claim to be returned. In these cases, HHAs should update item M0063 on the OASIS and then resubmit the claim.
• Assessment Completion Date (OASIS item M0090)
• Reason for Assessment (OASIS Item M0100) equal to 01, 03 or 04

In addition, before submitting the final claim, it is important that you ensure the OASIS assessment has completed processing and was successfully accepted into the Internet Quality Improvement & Evaluation System (iQIES). Verify this by reviewing the OASIS Agency Final Validation Report or OASIS Submitter Final Validation Report for the submission which included the assessment. These reports will provide information that confirms the assessment's receipt, the date of receipt, and any fatal or warning errors encountered.

If your claim is in the Return to Provider (RTP) file (T B9997), review the OASIS and claim and correct any errors to ensure they match.

Note: Before you resubmit (F9) the claim out of the RTP file, be sure to take the following action.

Delete the 0023 Revenue Code Line

• Key the letter "D" in the first position of the 0023 revenue code
• Press the Home key on your keyboard so that your cursor is placed in the upper right-hand corner of the screen (the Page field)
• Press Enter. The revenue code line(s) with the letter "D" will be removed, and FISS will automatically reorder the remaining revenue code lines

To Add the 0023 Revenue Code Line

• Re-key the same 0023 revenue code line information that was deleted under the 0001 revenue code line
• Press the Home key on your keyboard so that your cursor is placed in the upper right-hand corner of the screen (the Page field)
• Press Enter and FISS will automatically reorder the revenue code lines
• Press F9 to allow the claim to continue processing

If you believe there are no errors and the OASIS was successfully accepted into the iQIES database, please contact the QIES/iQIES Service Center. The Service Center is available 8 a.m. to 8 p.m. (ET) Monday through Friday by phone: 888–477–7876 (Select Option 1) or email: iqies@cms.hhs.gov.

If there is no error and it is determined the claim did not meet the condition of payment, submit a claim for denial using the following coding elements:

• Type of bill 0320, which indicates the expectation of a full denial
• Occurrence Span Code 77 with span dates matching the “From” and ”Through” dates of the claim to indicate acknowledgement of liability for the billing period
• Condition Code D2 indicating the change in billing the HIPPS code to non-covered
• Condition Code 20
• Do not use condition code 21

Beneficiary Retroactive Entitlement Beyond 24 Months
Every Medicare home health claim requires a corresponding OASIS assessment to be present in the internet Quality Improvement Evaluation System (iQIES). iQIES accepts assessments for up to 24-months from the assessment date. In rare cases, a retroactive entitlement decision may extend back beyond this 24-month period. Each 60-day assessment that cannot be submitted to iQIES because of the 24 month limit may correspond to up to two Medicare claims for 30-day periods of care.

To process the claims for these older dates of service, a workaround to the OASIS matching requirement must be applied by the home health and hospice Medicare Administrative Contractor (MAC). The below actions will allow the claims to process without a corresponding OASIS.

• HHA are to submit the untimely claims with a note in the Remarks field of the claims saying "OASIS over 24 months" in addition to any note typically required for retroactive entitlement cases
• The MAC will confirm the dates of service are over 24 months from the occurrence code 50 date on the claim and bypass the OASIS edit

References

• MLN Matters® Article MM11272: Home Health (HH) Patient-Driven Groupings Model (PDGM) — Additional Manual Instructions (PDF)
• MLN Matters® Article SE17009: Denial of Home Health Payments When Required Patient Assessment Is Not Received — Additional Information (PDF)