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Printed Date: 9/22/2015
This article discusses how to correct claims, if applicable, that edit for reason code 37253 under the Home Health Patient-Driven Groupings Model (PDGM). Claims with a “FROM” date of January 1, 2020, and later, were processed under PDGM guidelines. For claims with a “FROM” date of December 31, 2019, and earlier, please view the article titled “Correcting Home Health Oasis Reason Code 37253 Under the Home Health Prospective Payment System (HH PPS) ” to correct claims processed under HH PPS guidelines.
An essential step in ensuring the information on a home health claim matches the Outcome and Assessment Information Set (OASIS) supporting the home health agency’s (HHA) billing is the Internet Quality Improvement and Evaluation System (iQIES) OASIS/claim data match. If there is no matching assessment found in iQIES when a claim is submitted, the HHA’s claim will be returned with reason code 37253.
Under PDGM, there are several areas that need to be verified to help correct/avoid this error. If your claim processed under the Home Health Prospective Payment System (HH PPS), please see the article titled “Correcting Home Health Oasis Reason Code 37253 Under the Home Health Prospective Payment System (HH PPS)” for the correction information under HH PPS.
If a PDGM claim gets returned for this reason code, please use the following questions as a checklist to ensure all areas have been verified and corrected:
Please note that it is not appropriate to send an insurance denial (with condition code 21) when a claim is assigned the 37253 reason code. Submitting the claim with condition code 21 would result in inappropriate beneficiary liability. You must follow the steps outlined above to correct the RTP in order for the claim to process correctly.
Please refer to the CMS Special Edition article SE20010 (PDF, 83 KB): “Ensure Required Patient Assessment Information for Home Health Claims” for more information.
Also, in MLN Matters Number MM11272 (PDF, 236 KB), CMS added guidance for HHAs in case the MAC returns a claim because there is no corresponding OASIS assessment in Medicare’s systems related to the claim. In such cases, the HHA may correct any errors in the OASIS or claim information to ensure a match and then resubmit the claim. If there was no error and the HHA determines the claim did not meet the condition of payment, the HHA may bill for denial using the following coding:
Do not use condition code 21 in these instances, since it would result in inappropriate beneficiary liability.
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Last Updated: 08/03/2020