Correcting Home Health Oasis Reason Code 37253 Under the Home Health Patient-Driven Groupings Model (PDGM)

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:

  • Have you checked your iQIES verification report to confirm the receipt date was accepted prior to submitting your claim? This is on Page 1 of the report under “Completion Date/Time.”
    • If the OASIS was submitted after the claim, resubmit the claim
  • Have you verified the assessment hasn’t been inactivated?
    •  If the assessment was inactivated, resubmit the assessment
  • Have you verified the reason for assessment (from M0100) is equal to 01, 03, 04 or 05?
  • The assessment completion date reported with occurrence code 50 must match an applicable assessment
    • If the assessment to which the claim is matched is not one with an appropriate reason for assessment, update occ 50 to match the M0090 date of the appropriate assessment
    • If there is no occurrence code 50 on the claim, correct and resubmit
  • Have you verified your provider number, the beneficiary Medicare number and the assessment completion date match on the assessment and claim?
    • If any items do not match, correct the assessment or claim and resubmit
  • Have you verified the MBI reported on the OASIS and claim?
    • If the MBI has changed, verify the MBI in M0063 on the OASIS matches the MBI submitted on the claim

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:

  • Type of Bill (TOB) 0320 indicating the expectation of a full denial for the billing period
  • Occurrence span code 77 with span dates matching the “From” and “Through” dates of the claim, indicating the HHA’s acknowledgment of liability for the billing period
  • Condition code D2, indicating that the HHA is changing the billing for the Health Insurance Prospective Payment System (HIPPS) code to non-covered

Do not use condition code 21 in these instances, since it would result in inappropriate beneficiary liability.

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