5FNOA - Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted
The services billed were not covered because the appropriate OASIS was not located in the State repository for to support the HIPPS code billed on the claim. The provider should ensure that the OASIS that generated the HIPPS code for the claim is submitted to the state repository and submitted with the medical records in response to an ADR.
To Prevent this Denial
Under the HHPPS and under PDGM, an OASIS is a regulatory requirement. If the home health agency does not submit the appropriate OASIS or if the appropriate OASIS cannot be located in the repository, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services. Submission of the hardcopy of the OASIS with requested documentation allows for validation of OASIS entries to the repository.
For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:
- Code of Federal Regulations, 42 CFR — Sections 484.20, 484.55 and 484.250
- CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 10.1, 10.9 (PDF)
- Change Request 6982
- CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 18.104.22.168 (PDF)
- Outcome and Assessment Information Set Implementation Manual
- Responding to a Home Health Additional Documentation Request (ADR)